Longitudinal study of changes in greenness exposure, physical activity and sedentary behavior in the ORISCAV-LUX cohort study.

BACKGROUND: Greenness exposure has been associated with many health benefits, for example through the pathway of providing opportunities for physical activity (PA). Beside the limited body of longitudinal research, most studies overlook to what extent different types of greenness exposures may be associated with varying levels of PA and sedentary behavior (SB). In this study, we investigated associations of greenness characterized by density, diversity and vegetation type with self-reported PA and SB over a 9-year period, using data from the ORISCAV-LUX study (2007-2017, n = 628). METHODS: The International Physical Activity Questionnaire (IPAQ) short form was used to collect PA and SB outcomes. PA was expressed as MET-minutes/week and log-transformed, and SB was expressed as sitting time in minutes/day. Geographic Information Systems (ArcGIS Pro, ArcMap) were used to collect the following exposure variables: Tree Cover Density (TCD), Soil-adjusted Vegetation Index (SAVI), and Green Land Use Mix (GLUM). The exposure variables were derived from publicly available sources using remote sensing and cartographic resources. Greenness exposure was calculated within 1000m street network buffers around participants' exact residential address. RESULTS: Using Random Effects Within-Between (REWB) models, we found evidence of negative within-individual associations of TCD with PA (ß = - 2.60, 95% CI - 4.75; - 0.44), and negative between-individual associations of GLUM and PA (ß = - 2.02, 95% CI - 3.73; - 0.32). There was no evidence for significant associations between greenness exposure and SB. Significant interaction effects by sex were present for the associations between TCD and both PA and SB. Neighborhood socioeconomic status (NSES) did not modify the effect of greenness exposure on PA and SB in the 1000 m buffer. DISCUSSION: Our results showed that the relationship between greenness exposure and PA depended on the type of greenness measure used, which stresses the need for the use of more diverse and complementary greenness measures in future research. Tree vegetation and greenness diversity, and changes therein, appeared to relate to PA, with distinct effects among men and women. Replication studies are needed to confirm the relevance of using different greenness measures to understand its' different associations with PA and SB.

Childhood obesity's influence on socioeconomic disparities in young adolescents' mental health.

PURPOSE: We investigated whether socioeconomic inequalities in young adolescents' mental health are partially due to the unequal distribution of childhood obesity across socioeconomic positions (SEP), i.e. differential exposure, or due to the effect of obesity on mental health being more detrimental among certain SEPs, i.e. differential impact. METHODS: We studied 4660 participants of the Generation R study, a population-based study in the Netherlands. SEP was estimated by mother's education and household income at age five of the child. We estimated the contribution of the mediating and moderating effects of high body fat percentage to the disparity in mental health. This was done through a four-way decomposition using marginal structural models with inverse probability of treatment weighting. RESULTS: Comparing children with the least to most educated mothers and the lowest to highest household income, the total disparity in emotional problems was 0.98 points (95%CI:0.35-1.63) and 1.68 points (95%CI:1.13-2.19), respectively. Of these total disparities in emotional problems, 0.50 points (95%CI:0.15-0.85) and 0.24 points (95%CI:0.09-0.46) were due to the differential exposure to obesity. Obesity did not contribute to disparities in behavioural problems. CONCLUSION: Addressing the heightened obesity prevalence among children in low SEP families may reduce inequalities in emotional problems in early adolescence.

Tunneling, cognitive load and time orientation and their relations with dietary behavior of people experiencing financial scarcity - an AI-assisted scoping review elaborating on scarcity theory.

BACKGROUND: The concept of a financial scarcity mindset has raised much attention as an explanation for poor decision-making and dysfunctional behavior. It has been suggested that financial scarcity could also impair dietary behavior, through a decline in self-control. Underlying cognitive mechanisms of tunneling (directing attention to financial issues and neglecting other demands), cognitive load (a tax on mental bandwidth interfering with executive functioning) and time orientation (a shift towards a present time horizon, versus a future time horizon) may explain the association between financial scarcity and self-control related dietary behavior. The current scoping review gathers recent evidence on how these mechanisms affect dietary behavior of people experiencing financial scarcity. It builds on a theoretical framework based on insights from behavioral economics and health psychology. METHODS: A literature search was executed in six online databases, which resulted in 9.975 papers. Search terms were tunneling, cognitive load and time orientation, financial scarcity, and dietary behavior. Screening was performed with ASReview, an AI-ranking tool. In total, 14 papers were included in the scoping review. We used PRISMA-ScR guidelines for reporting. RESULTS: Limited evidence indicates that a scarcity mindset could increase tunneling, through attentional narrowing on costs of food, which then directly impacts dietary behavior. A scarcity mindset involves experiencing financial stress, which can be understood as cognitive load. Cognitive load decreases attentional capacity, which could impair self-control in dietary choices. Financial scarcity is related to a present time orientation, which affects dietary choices by shifting priorities and decreasing motivation for healthy dietary behavior. CONCLUSIONS: A scarcity mindset affects dietary behavior in different ways. Tunneling and a shift in time orientation are indicative of an attentional redirection, which can be seen as more adaptive to the situation. These may be processes indirectly affecting self-control capacity. Cognitive load could decrease self-control capacity needed for healthy dietary behavior because it consumes mental bandwidth. How a changing time orientation when experiencing financial scarcity relates to motivation for self-control in dietary behavior is a promising theme for further inquiry.

Why we struggle to make progress in obesity prevention and how we might overcome policy inertia: Lessons from the complexity and political sciences.

Despite evidence for the effectiveness of policies that target obesogenic environments, their adoption remains deficient. Using methods and concepts from complexity and political science (Stock-and-Flow analysis and Punctuated Equilibrium Theory) and a qualitative literature review, we developed system maps to identify feedback loops that hinder policymaking on mitigating obesogenic environments and feedback loops that could trigger and sustain policy change. We found numerous self-reinforcing feedback loops that buttress the assumption that obesity is an individual problem, strengthening the biomedical and commercial weight-loss sectors' claim to "ownership" over solutions. That is, improvements in therapies for individuals with obesity reinforces policymakers' reluctance to target obesogenic environments. Random events that focus attention on obesity (e.g., celebrities dismissing soda) could disrupt this cycle, when actors from outside the medical and weight-loss sector (e.g., anti-weight stigma activists) successfully reframe obesity as a societal problem, which requires robust and politically relevant engagement with affected communities prior to such events taking place. Sustained prioritization of policies targeting obesogenic environments requires shared problem ownership of affected communities and nonhealth government sectors, by emphasizing cobenefits of policies that target obesogenic environments (e.g., ultraprocessed food taxation for raising revenue) and solutions that are meaningful for affected communities.

Untangling the complex implementation process of community-based health promotion: a multiple-case study in the Netherlands.

Community-based programmes are a widely implemented approach for population health promotion. Due to the context-dependent and dynamic nature of these programmes, evaluating their implementation is challenging. Identifying key events in the implementation process in evaluation could enable us to support future implementation, while acknowledging the complexity of real-world implementation. We studied the nationwide implementation of the Dutch Healthy Youth, Healthy Future (JOGG) approach, a community-based programme for childhood overweight prevention. The aims of our study were (i) to gain insights into the implementation process of the JOGG approach, and (ii) to identify key events that influenced said process. In nine communities, we conducted interviews (n = 24) with coordinators and stakeholders involved in the implementation of the JOGG approach and collected documents on the programme's implementation. We applied the analytical tool 'Critical Event Card' to identify key events in the implementation process. Results showed that in 5-10 years of implementing the JOGG approach, communities have undergone different phases: preparation, upscaling, resource mobilization, integration with other policy initiatives and adaptation of the implementation strategy. Key events influencing the implementation process included national policy developments (e.g. new health programmes), framing of the JOGG approach in local policy, staff turnover and coordination teams' experiences and actions. Furthermore, changes in implementation were often triggered by the destabilization of the implementation process and linked to opportunities for change in the policy process. The identified key events can inform future implementation of the JOGG approach as well as other community-based health promotion programmes.

Do financial constraint and perceived stress modify the effects of food tax schemes on food purchases: moderation analyses in a virtual supermarket experiment.

OBJECTIVE: To investigate whether financial constraint and perceived stress modify the effects of food-related taxes on the healthiness of food purchases. DESIGN: Moderation analyses were conducted with data from a trial where participants were randomly exposed to: a control condition with regular food prices, an sugar-sweetened beverage (SSB) tax condition with a two-tiered levy on the sugar content in SSB (5-8 g/100 ml: €0·21 per l and ≥8 g/100 ml: €0·28 per l) or a nutrient profiling tax condition where products with Nutri-Score D or E were taxed at a 20 percent level. Outcome measures were overall healthiness of food purchases (%), energy content (kcal) and SSB purchases (litres). Effect modification was analysed by adding interaction terms between conditions and self-reported financial constraint or perceived stress in regression models. Outcomes for each combination of condition and level of effect modifier were visualised. SETTING: Virtual supermarket. PARTICIPANTS: Dutch adults (n 386). RESULTS: Financial constraint or perceived stress did not significantly modify the effects of food-related taxes on the outcomes. Descriptive analyses suggest that in the control condition, the overall healthiness of food purchases was lowest, and SSB purchases were highest among those with moderate/high levels of financial constraint. Compared with the control condition, in a nutrient profiling tax condition, the overall healthiness of food purchases was higher and SSB purchases were lower, especially among those with moderate/high levels of financial constraint. Such patterns were not observed for perceived stress. CONCLUSION: Further studies with larger samples are recommended to assess whether food-related taxes differentially affect food purchases of subgroups.

Public support for smoke-free private indoor and public outdoor areas in the Netherlands: A trend analysis from 2018-2022.

INTRODUCTION: In addition to smoke-free policies in indoor public and workplaces, governments increasingly implement smoke-free policies at beaches, in parks, playgrounds and private cars ('novel smoke-free policies'). An important element in the implementation of such policies is public support. In the context of the ambition of the Netherlands to reach a smoke-free generation by 2040, we investigated temporal changes in public support for novel smoke-free policies. METHODS: We analyzed annual cross-sectional questionnaires in a representative sample of the Dutch population from 2018 to 2022. Multivariable logistic regression was applied to model public support for each smoke-free policy area as a function of time (calendar year), smoking status, gender, and socioeconomic status. Interaction terms were added for time with smoking status and with socioeconomic status. RESULTS: A total of 5582 participant responses were included. Between 2018 and 2022, support increased most for smoke-free policies regarding train platforms (+16%), theme parks (+12%), beaches (+10%), and terraces (+10%). In 2022, average support was higher than 65% for all categories of smoke-free places and highest for private cars with children (91%). Regression analyses indicated significant increases in support over time within each category of smoke-free places (adjusted odds ratio, AOR between 1.09 and 1.17 per year), except smoke-free private cars with children (AOR=0.97; 95% CI: 0.89-1.05). Regardless of smoking status, support was high for places where children often go. CONCLUSIONS: Support for novel smoke-free places in the Netherlands is high and increasing, in particular for places frequented by children. This indicates the potential to implement such measures in the Netherlands.

Socio-economic inequalities in smoking and drinking in adolescence: Assessment of social network dynamics.

AIMS: We investigated whether (1) adolescents selected friends with a similar socio-economic status (SES), (2) smoking and alcohol consumption spread in networks and (3) the exclusion of non-smokers or non-drinkers differed between SES groups. DESIGN: This was a longitudinal study using stochastic actor-oriented models to analyze complete social network data over three waves. SETTING: Eight Hungarian secondary schools with socio-economically diverse classes took part. PARTICIPANTS: This study comprised 232 adolescents aged between 14 and 15 years in the first wave. MEASUREMENTS: Self-reported smoking behavior, alcohol consumption behavior and friendship ties were measured. SES was measured based upon entitlement to an income-tested regular child protection benefit. FINDINGS: Non-low-SES adolescents were most likely to form friendships with peers from their own SES group [odds ratio (OR) = 1.07, 95% confidence interval (CI) = 1.02-1.11]. Adolescents adjusted their smoking behavior (OR = 24.05, 95% CI = 1.27-454.86) but not their alcohol consumption (OR = 1.65, 95% CI = 0.62-4.39) to follow the behavior of their friends. Smokers did not differ from non-smokers in the likelihood of receiving a friendship nomination (OR = 0.98, 95% CI = 0.87-1.10), regardless of their SES. Alcohol consumers received significantly more friendship nominations than non-consumers (OR = 1.16, 95% CI = 1.01-1.33), but this association was not significantly different according to SES. CONCLUSIONS: Hungarian adolescents appear to prefer friendships within their own socio-economic status group, and smoking and alcohol consumption spread within those friendship networks. Socio-economic groups do not differ in the extent to which they encourage smoking or alcohol consumption.

Association of Neighborhood Deprivation and Depressive Symptoms With Epigenetic Age Acceleration: Evidence From the Canadian Longitudinal Study on Aging.

BACKGROUND: Neighborhood deprivation and depression have been linked to epigenetic age acceleration. The next-generation epigenetic clocks including the DNA methylation (DNAm) GrimAge, and PhenoAge have incorporated clinical biomarkers of physiological dysregulation by selecting cytosine-phosphate-guanine sites that are associated with risk factors for disease, and have shown improved accuracy in predicting morbidity and time-to-mortality compared to the first-generation clocks. The aim of this study is to examine the association between neighborhood deprivation and DNAm GrimAge and PhenoAge acceleration in adults, and assess interaction with depressive symptoms. METHODS: The Canadian Longitudinal Study on Aging recruited 51 338 participants aged 45-85 years across provinces in Canada. This cross-sectional analysis is based on a subsample of 1 445 participants at baseline (2011-2015) for whom epigenetic data were available. Epigenetic age acceleration (years) was assessed using the DNAm GrimAge and PhenoAge, and measured as residuals from regression of the biological age on chronological age. RESULTS: A greater neighborhood material and/or social deprivation compared to lower deprivation (b = 0.66; 95% confidence interval [CI] = 0.21, 1.12) and depressive symptoms scores (b = 0.07; 95% CI = 0.01, 0.13) were associated with higher DNAm GrimAge acceleration. The regression estimates for these associations were higher but not statistically significant when epigenetic age acceleration was estimated using DNAm PhenoAge. There was no evidence of a statistical interaction between neighborhood deprivation and depressive symptoms. CONCLUSIONS: Depressive symptoms and neighborhood deprivation are independently associated with premature biological aging. Policies that improve neighborhood environments and address depression in older age may contribute to healthy aging among older adults living in predominantly urban areas.

Climate distress, climate-sensitive risk factors, and mental health among Tanzanian youth: a cross-sectional study.

BACKGROUND: Climate change threatens youth mental health through multiple mechanisms, yet empirical studies typically focus on single pathways. We explored feelings of distress over climate change among Tanzanian youth, considering associations with climate change awareness and climate-sensitive risk factors, and assessed how these factors relate to mental health. METHODS: Tanzanian youth (aged 18-23 years) from a cluster randomised controlled trial in Mbeya and Iringa regions of Tanzania were interviewed between Jan 25, and March 3, 2021, and included in this cross-sectional study. A threshold of at least 10 on the ten-item Centre for Epidemiological Studies Depression Scale was used to classify symptom severity indicative of depression. Regardless of climate change awareness, respondents were asked about their feelings of distress on climate change using inclusive language (changing weather patterns or changing seasons). We estimated rate differences in climate change distress (slight or moderate or extreme vs none) by youth characteristics, extent of climate awareness, and climate-sensitive livelihoods (eg, agriculture, tending livestock) and climate-sensitive living conditions (eg, food or water insecurity), using generalised linear models. We compared depression prevalence by extent of climate change distress and climate-sensitive living conditions. FINDINGS: Among 2053 youth (1123 [55%] were male and 930 [45%] were female) included in this analysis, 946 (46%) had reported any distress about climate change. Distress was higher among female, more educated, more religious, older youth, and those working in extreme temperatures. Adjusting for climate awareness-a factor strongly associated with climate distress-helped to explain some of these associations. Depression was 23 percentage points (95% CI 17-28) higher among youth who had severe water insecurity than those who did not. Similarly, youth who had severe food insecurity had 23 percentage points higher depression (95% CI 17-28) compared with those who did not. Those reporting climate change distress also had worse mental health-extremely distressed youth had 18 percentage points (95% CI 6-30) higher depression than those reporting none. INTERPRETATION: Living in conditions worsened by climate change and feeling distressed over climate change have mental health implications among young people from low-resource settings, indicating that climate change can impact youth mental health through multiple pathways. FUNDING: Erasmus Trustfonds, Centre for Global Health Inequalities Research, UK's Foreign, Commonwealth, and Development Office, Oak Foundation, UNICEF, UK's Department of International Development, the Swedish Development Cooperation Agency, Irish Aid.

Healthy immigrants, unhealthy ageing? Analysis of health decline among older migrants and natives across European countries.

The probability of having multiple chronic conditions simultaneously, or multimorbidity, tends to increase with age. Immigrants face a particularly high risk of unhealthy ageing. This study investigates the immigrant-native disparities in the speed of age-related chronic disease accumulation, focusing on the number of chronic health conditions; and considers the heterogeneity of this trajectory within immigrant populations by origin and receiving country. We use data from the Survey of Health, Ageing and Retirement in Europe from 2004 to 2020 on adults aged 50 to 79 from 28 European countries and employ both cross-sectional and longitudinal analyses. For longitudinal panel analyses, we use fixed-effects regression models to account for the unobserved heterogeneity related to individual characteristics including migration background. Our results indicate that immigrants report a higher number of chronic conditions at all ages relative to their native-born peers, but also that the immigrant-native differential in the number of chronic conditions decreases from age 65 onwards. When considering differences by origin country, we find that the speed of chronic disease accumulation is slower among immigrants from the Americas and the Asia and Oceania country groups than it is among natives. When looking at differences by receiving country group, we observe that the speed of accumulating chronic diseases is slower among immigrants in Eastern Europe than among natives, particularly at older ages. Our findings suggest that age-related trajectories of health vary substantially among immigrant populations by origin and destination country, which underscore that individual migration histories play a persistent role in shaping the health of ageing immigrant populations throughout the life course.

Is the association between financial scarcity and health behaviours moderated by cultural capital? The GLOBE study.

BACKGROUND: Experiencing financial scarcity taxes cognitive bandwidth. This leaves less capacity to withhold temptations and makes relying on easiest default options more likely. Whether this default option is (un)healthy may depend on the amount of cultural capital acquired during life course. This study examined whether the association between financial scarcity and health behaviours is moderated by cultural capital. METHODS: Self-reported data were used from Dutch adults of the 2014-survey of the GLOBE study (N = 2466). Using linear regression analysis, financial strain (no, some, great) and cultural capital (institutionalized, objectivized, incorporated) were related to body mass index (BMI), alcohol intake, sports participation, cycling and walking, fruit intake and vegetable consumption. The interaction between financial strain and cultural capital was used to assess moderation. RESULTS: Experiencing some financial strain was associated with a higher BMI (0.7 kg/m2) and less sport participation (-31.8 min/week). Great financial strain was associated with less sport participation (-41.4 min/week). Being in the lowest tertile of cultural capital was associated with a higher BMI (1.3 kg/m2), drinking less alcohol (-10.0 units/week), less sport participation (-31.5 min/week) and consuming less fruit (-2.9 pieces/week). Cultural capital had no significant moderating effect on the relationship between financial strain and these health behaviours. CONCLUSION: Financial strain and cultural capital seem associated with different health behaviours. Cultural capital had no moderating effect on the relationship between financial strain and different health behaviours. While financial strain and cultural capital could both be entry points for interventions to improve health behaviour, underlying mechanisms require further attention.

Micro urban spaces and mental well-being: Measuring the exposure to urban landscapes along daily mobility paths and their effects on momentary depressive symptomatology among older population.

The urban environment plays an important role for the mental health of residents. Researchers mainly focus on residential neighbourhoods as exposure context, leaving aside the effects of non-residential environments. In order to consider the daily experience of urban spaces, a people-based approach focused on mobility paths is needed. Applying this approach, (1) this study investigated whether individuals' momentary mental well-being is related to the exposure to micro-urban spaces along the daily mobility paths within the two previous hours; (2) it explored whether these associations differ when environmental exposures are defined considering all location points or only outdoor location points; and (3) it examined the associations between the types of activity and mobility and momentary depressive symptomatology. Using a geographically-explicit ecological momentary assessment approach (GEMA), momentary depressive symptomatology of 216 older adults living in the Ile-de-France region was assessed using smartphone surveys, while participants were tracked with a GPS receiver and an accelerometer for seven days. Exposure to multiple elements of the streetscape was computed within a street network buffer of 25 m of each GPS point over the two hours prior to the questionnaire. Mobility and activity type were documented from a GPS-based mobility survey. We estimated Bayesian generalized mixed effect models with random effects at the individual and day levels and took into account time autocorrelation. We also estimated fixed effects. A better momentary mental wellbeing was observed when residents performed leisure activities or were involved in active mobility and when they were exposed to walkable areas (pedestrian dedicated paths, open spaces, parks and green areas), water elements, and commerce, leisure and cultural attractors over the previous two hours. These relationships were stronger when exposures were defined based only on outdoor location points rather than all location points, and when we considered within-individual differences compared to between-individual differences.

The role of labor market inequalities in explaining the gender gap in depression risk among older US adults.

We aim to investigate to what extent gender inequality at the labor market explains higher depression risk for older US women compared to men. We analyze data from 35,699 US adults aged 50-80 years that participated in the Health and Retirement Study. The gender gap is calculated as the difference in prevalence in elevated depressive symptoms (score ≥ 3 on the 8-item Center for Epidemiological Studies Depression Scale) between women and men. We employ a dynamic causal decomposition and simulate the life course of a synthetic cohort from ages 50-80 with the longitudinal g-formula and introduce four nested interventions by assigning women the same probabilities of A) being in an employment category, B) occupation class, C) current income and D) prior income group as men, conditional on women's health and family status until age 70. The gender gap in depression risk is 2.9%-points at ages 50-51 which increases to 7.6%-points at ages 70-71. Intervention A decreases the gender gap over ages 50-71 by 1.2%-points (95%CI for change: 2.81 to 0.4), intervention D by 1.64%-points (95%CI for change: 3.28 to -0.15) or 32% (95%CI: 1.39 to 62.83), and the effects of interventions B and C are in between those of A and D. The impact is particularly large for Hispanics and low educated groups. Gender inequalities at the labor market substantially explain the gender gap in depression risk in older US adults. Reducing these inequalities has the potential to narrow the gender gap in depression.

Testing conditionality with Bourdieu's capital theory: How economic, social, and embodied cultural capital are associated with diet and physical activity in the Netherlands.

Although Bourdieu's capital theory emphasized that economic, social, and embodied cultural capital interact to shape health behavior, existing empirical research mainly considered separate associations of the three forms of capital. Our aim was to investigate if and how economic, social, and embodied cultural capital are conditional on each other in their associations with adults' diet and physical activity. Cross-sectional, self-reported data from the 2014 GLOBE survey of 2812 adults aged between 25 and 75 years residing in Eindhoven, the Netherlands were used. Step-wise multiple logistic regression models included economic, social, and embodied cultural capital and adjustment for potential confounders. The models estimated odds ratios of main effects and two-way interactions of the forms of capital with fruit consumption, vegetable consumption, sports participation, and leisure time walking or cycling. In the main effects models, embodied cultural capital was consistently positively associated with all outcomes. Social capital was positively associated with sports participation, fruit consumption, and vegetable consumption, and economic capital was positively associated with sports participation and vegetable consumption. In the two-way interaction models, having specific higher levels of both economic and social capital strengthened their positive association with sports participation. No other combinations of capital were conditional on each other. Economic and social capital were conditional on each other in their association with sports participation, so interventions that provide both economic and social support may be especially effective for increasing this type of physical activity. As its association was strong with all outcomes but not conditional on other forms of capital, embodied cultural capital may operate distinctly from economic and social resources. Policy that takes differences in embodied cultural capital into account or changes to the environment that dampen the importance of embodied cultural resources for health behavior may help improve both diet and physical activity.

Public support for smoke-free policies in outdoor areas and (semi-)private places: a systematic review and meta-analysis.

Background: Smoke-free policies are essential to protect people against tobacco smoke exposure. To successfully implement smoke-free policies that go beyond enclosed public places and workplaces, public support is important. We undertook a comprehensive systematic review of levels and determinants of public support for indoor (semi-)private and outdoor smoke-free policies. Methods: In this systematic review and meta-analysis, six electronic databases were searched for studies (published between 1 January 2004 and 19 January 2022) reporting support for (semi-)private and outdoor smoke-free policies in representative samples of at least 400 respondents aged 16 years and above. Two reviewers independently extracted data and assessed risk of bias of individual reports using the Mixed Methods Appraisal Tool. The primary outcome was proportion support for smoke-free policies, grouped according to location covered. Three-level meta-analyses, subgroup analyses and meta-regression were performed. Findings: 14,749 records were screened, of which 107 were included; 42 had low risk of bias and 65 were at moderate risk. 99 studies were included in the meta-analyses, reporting 326 measures of support from 896,016 individuals across 33 different countries. Support was pooled for indoor private areas (e.g., private cars, homes: 73%, 95% confidence interval (CI): 66-79), indoor semi-private areas (e.g., multi-unit housing: 70%, 95% CI: 48-86), outdoor hospitality areas (e.g., café and restaurant terraces: 50%, 95% CI: 43-56), outdoor non-hospitality areas (e.g., school grounds, playgrounds, parks, beaches: 69%, 95% CI: 64-73), outdoor semi-private areas (e.g., shared gardens: 67%, 95% CI: 53-79) and outdoor private areas (e.g., private balconies: 41%, 95% CI: 18-69). Subcategories showed highest support for smoke-free cars with children (86%, 95% CI: 81-89), playgrounds (80%, 95% CI: 74-86) and school grounds (76%, 95% CI: 69-83). Non-smokers and ex-smokers were more in favour of smoke-free policies compared to smokers. Support generally increased over time, and following implementation of each smoke-free policy. Interpretation: Our findings suggested that public support for novel smoke-free policies is high, especially in places frequented by children. Governments should be reassured about public support for implementation of novel smoke-free policies. Funding: Dutch Heart Foundation, Lung Foundation Netherlands, Dutch Cancer Society, Dutch Diabetes Research Foundation and Netherlands Thrombosis Foundation.

Examining neighborhood effects on mental health utilizing a novel two-stage modeling approach.

PURPOSE: Neighborhood conditions may affect health, but health may also determine a preference for where to live. This study estimates the effect of neighborhood characteristics on mental health while aiming to adjust for this residential self-selection. METHODS: A two-step method was implemented using register data from Statistics Netherlands from all residents of the city of Rotterdam relocating within the city in 2013 (N = 12,456). First, using a conditional logit model, we estimated for each individual the probability of relocating to a neighborhood over all other neighborhoods in Rotterdam, based on personal and neighborhood characteristics in 2013. Second, we corrected this selection process in a model investigating the effects of neighborhood characteristics in 2014 on reimbursed anti-depressant or anti-psychotic medication in 2016. RESULTS: Personal and neighborhood characteristics predicted neighborhood choice, indicating strong patterns of selection into neighborhoods. Unadjusted for selection log neighborhood income was associated with reimbursed medication (ß = -0.040, 95% CI = -0.060, -0.020), but the association strongly attenuated after controlling for self-selection into neighborhoods (ß = -0.010, 95% CI = -0.030, 0.011). The opposite was observed for contact with neighbors; unadjusted for self-selection there was no association (ß = -0.020, 95% CI = -0.073, 0.033), but after adjustment increased neighborhood contact was associated with an 8.5% relative reduction in reimbursed medication (ß = -0.075, 95% CI = -0.126, -0.025). CONCLUSIONS: The method illustrated in this study offers new opportunities to disentangle selection from causation in neighborhood health research.

Social inequalities in child development: the role of differential exposure and susceptibility to stressful family conditions.

BACKGROUND: Stressful family conditions may contribute to inequalities in child development because they are more common among disadvantaged groups (ie, differential exposure) and/or because their negative effects are stronger among disadvantaged groups (ie, differential impact/susceptibility). We used counterfactual mediation analysis to investigate to what extent stressful family conditions contribute to inequalities in child development via differential exposure and susceptibility. METHODS: We used data from the Generation R Study, a population-based birth cohort in the Netherlands (n=6842). Mother's education was used as the exposure. Developmental outcomes, measured at age 13 years, were emotional and behavioural problems (Youth Self-Report), cognitive development (Wechsler Intelligence Scale for Children) and secondary education entry level. Financial and social stress at age 9 years were the putative mediators. RESULTS: Differential exposure to financial stress caused a 0.07 (95% CI -0.12 to -0.01) SD worse emotional and behavioural problem -score, a 0.05 (95% CI -0.08 to -0.02) SD lower intelligence score and a 0.05 (95% CI -0.05 to -0.01) SD lower secondary educational level, respectively, among children of less-educated mothers compared with children of more-educated mothers. This corresponds to a relative contribution of 54%, 9% and 6% of the total effect of mother's education on these outcomes, respectively. Estimates for differential exposure to social stress, and differential susceptibility to financial or social stress, were much less pronounced. CONCLUSION: Among children of less-educated mothers, higher exposure to financial stress in the family substantially contributes to inequalities in socioemotional development, but less so for cognitive development and educational attainment.

How theory can help to understand the potential impact of food environment policies on socioeconomic inequalities in diet: an application of Bourdieu's capital theory and the scarcity theory.

Government policies that promote healthy food environments are considered promising to reduce socioeconomic inequalities in diet. Empirical evidence of effects on these inequalities, however, is relatively scarce and, with a few exceptions, tends to be inconclusive. We use two contemporary theories that help to understand socioeconomic inequalities in health and health-related behaviours (Bourdieu's capital theory and Mullainathan and Shafir's scarcity theory) to reason how policies influencing food environments may differentially impact lower and higher socioeconomic groups. In essence, these theories enable us to understand how specific elements of broader daily living conditions (e.g. social practices that lead to habitus formation, material conditions that shape experiences of scarcity) may lead to a greater benefit of certain food environment policies for the healthfulness of diets of lower or higher socioeconomic groups. We conclude that the application of theories on the mechanisms underlying socioeconomic inequalities in health can help to guide future empirical studies in testing theory-based hypotheses on differential effects of policies, and thereby enhance the development of effective policies tackling socioeconomic inequalities in dietary intakes.

Moderators of an intervention on emotional and behavioural problems: household- and school-level parental education.

BACKGROUND: Children of lower-educated parents and children in schools with a relatively high percentage of peers with lower-educated parents (lower parental education schools) are more likely to develop emotional and behavioural problems compared to children in higher-educated households and schools. Universal school-based preventive interventions, such as the Good Behaviour Game (GBG), are generally effective in preventing the development of emotional and behavioural problems, but information about potential moderators is limited. This study examined whether the effectiveness of the GBG in preventing emotional and behavioural problems differs between children in lower- and higher-educated households and schools. METHODS: Using a longitudinal multi-level randomized controlled trial design, 731 children (Mage=6.02 towards the end of kindergarten) from 31 mainstream schools (intervention arm: 21 schools, 484 children; control arm: 10 schools, 247 children) were followed annually from kindergarten to second grade (2004-2006). The GBG was implemented in first and second grades. RESULTS: Overall, the GBG prevented the development of emotional and behavioural problems. However, for emotional problems, the GBG-effect was slightly more pronounced in higher parental education schools than in lower parental education schools (Bhigher parental education schools =-0.281, P <0.001; Blower parental education schools =-0.140, P = 0.016). No moderation by household-level parental education was found. CONCLUSIONS: Studies into universal school-based preventive interventions, and in particular the GBG, should consider and incorporate school-level factors when studying the effectiveness of such interventions. More attention should be directed towards factors that may influence universal prevention effectiveness, particularly in lower parental education schools.