Does partnership diversity in intersectoral policymaking matter for health promoting intervention packages' composition? A multiple-case study in the Netherlands.

Intersectoral policymaking to improve public health includes integrated health promotion (HP) intervention packages that address a variety of health behavior determinants. The involvement of different partners is assumed to be necessary to implement such integrated packages. We examined how partnership diversity was associated with the composition of intervention packages implemented in Dutch municipalities. In a longitudinal multiple-case study (2012-14), we collected questionnaire data among 31 project leaders and 152 intervention implementers in 31 (alliances of) municipalities. Package composition was assessed in terms of intervention strategies, implementation settings and targeted behavioral determinants. Partnership diversity during the adoption and implementation phases was assessed in terms of the actors and sectors, as well as private partners and citizens involved. The association between partnership diversity and package composition was examined using crosstabs. Almost all packages integrated multiple strategies, but mostly education, facilitation and case finding, in multiple, but mostly health and public settings, such as schools. The packages targeted diverse behavioral determinants, although mainly personal and social environmental factors. A variety of partners from multiple sectors was involved, during both adoption and implementation of the packages. However, partners from the health, welfare and education sectors were mostly involved. More partnership diversity, especially during implementation, was associated with more integrated intervention packages. In intersectoral policymaking, investment in diversely composed partnerships seems worthwhile for implementing integrated intervention packages. However, investments in other conditions, like framing health issues and network management, are also needed to make environmental determinants of health behavior the object of HP.

Process evaluation of the healthy primary School of the Future: the key learning points.

BACKGROUND: While schools have potential to contribute to children's health and healthy behaviour, embedding health promotion within complex school systems is challenging. The 'Healthy Primary School of the Future' (HPSF) is an initiative that aims to integrate health and well-being into school systems. Central to HPSF are two top-down changes that are hypothesized as being positively disruptive to the Dutch school system: daily free healthy lunches and structured physical activity sessions. These changes are expected to create momentum for bottom-up processes leading to additional health-promoting changes. Using a programme theory, this paper explores the processes through which HPSF and the school context adapt to one another. The aim is to generate and share knowledge and experiences on how to implement changes in the complex school system to integrate school health promotion. METHODS: The current study involved a mixed methods process evaluation with a contextual action-oriented research approach. The processes of change were investigated in four Dutch primary schools during the development year (2014-2015) and the first two years of implementation (2015-2017) of HPSF. The schools (each with 15-26 teachers and 233-389 children) were in low socio-economic status areas. Measurements included interviews, questionnaires, observations, and analysis of minutes of meetings. RESULTS: Top-down advice, combined with bottom-up involvement and external practical support were key facilitators in embedding HPSF within the schools' contexts. Sufficient coordination and communication at the school level, team cohesion, and feedback loops enhanced implementation of the changes. Implementation of the healthy lunch appeared to be disruptive and create momentum for additional health-promoting changes. CONCLUSIONS: Initiating highly visible positive disruptions to improve school health can act as a catalyst for wider school health promotion efforts. Conditions to create a positive disruption are enough time, and sufficient bottom-up involvement, external support, team cohesion and coordination. The focus should be on each specific school, as each school has their own starting point and process of change. TRIAL REGISTRATION: The study was retrospectively registered in the ClinicalTrials.gov database on 14 June 2016 (NCT02800616).

The Healthy Primary School of the Future: study protocol of a quasi-experimental study.

BACKGROUND: Unhealthy lifestyles in early childhood are a major global health challenge. These lifestyles often persist from generation to generation and contribute to a vicious cycle of health-related and social problems. This design article presents a study evaluating the effects of two novel healthy school interventions. The main outcome measure will be changes in children's body mass index (BMI). In addition, lifestyle behaviours, academic achievement, child well-being, socio-economic differences, and societal costs will be examined. METHODS: In close collaboration with various stakeholders, a quasi-experimental study was developed, for which children of four intervention schools (n = 1200) in the southern part of the Netherlands are compared with children of four control schools (n = 1200) in the same region. The interventions started in November 2015. In two of the four intervention schools, a whole-school approach named 'The Healthy Primary School of the Future', is implemented with the aim of improving physical activity and dietary behaviour. For this intervention, pupils are offered an extended curriculum, including a healthy lunch, more physical exercises, and social and educational activities, next to the regular school curriculum. In the two other intervention schools, a physical-activity school approach called 'The Physical Activity School', is implemented, which is essentially similar to the other intervention, except that no lunch is provided. The interventions proceed during a period of 4 years. Apart from the effectiveness of both interventions, the process, the cost-effectiveness, and the expected legal implications are studied. Data collection is conducted within the school system. The baseline measurements started in September 2015 and yearly follow-up measurements are taking place until 2019. DISCUSSION: A whole-school approach is a new concept in the Netherlands. Due to its innovative, multifaceted nature and sound scientific foundation, these integrated programmes have the potential to form a template for primary schools worldwide. The effects of this approach may extend further than the outcomes associated with well-being and academic achievement, potentially impacting legal and cultural aspects in our society. TRIAL REGISTRATION: The study protocol was registered in the database ClinicalTrials.gov on 14-06-2016 with the reference number NCT02800616 .

Factors influencing perceived sustainability of Dutch community health programs.

We assessed the perceived sustainability of community health programs organized by local intersectoral coalitions, as well as the factors that collaborating partners think might influence sustainability. Semi-structured interviews were conducted among 31 collaborating partners of 5 community health programs in deprived neighborhoods in the southern part of the Netherlands. The interview guide was based on a conceptual framework that includes factors related to the context, the leading organization, leadership, the coalition, collaborating partners, interventions and outcomes. Interviews were recorded, transcribed and content analyzed using NVivo 8.0. Participants in each of the programs varied in their perceptions of the sustainability of the program, but those people collaborating in pre-existing neighborhood structures expressed relatively high faith in their continuation. The participating citizens in particular believed that these structures would continue to address the health of the community in the future. We found factors from all categories of the conceptual framework that were perceived to influence sustainability. The program leaders appeared to be crucial to the programs, as they were frequently mentioned in close interaction with other factors. Program leaders should use a motivating and supportive leadership style and should act as 'program champions'.

Clarifying concepts of food parenting practices. A Delphi study with an application to snacking behavior.

Inconsistencies in measurements of food parenting practices continue to exist. Fundamental to this problem is the lack of clarity about what is understood by different concepts of food parenting practices. The purpose of this study was to clarify food parenting practice concepts related to snacking. A three round Delphi study among an international group of experts (n = 63) was conducted. In the first round, an open-ended survey was used to collect food parenting practice descriptions and concept labels associated with those practices. In the second round, participants were asked to match up descriptions with the appropriate concept labels. The third and final round allowed participants to reconsider how descriptions and concept labels were matched, taking into account the opinions expressed in round two. Round one produced 408 descriptions of food parenting practices and 110 different concept names. Round two started with 116 descriptions of food parenting practices and 20 concept names. On 40 descriptions, consensus regarding the underlying concept name was reached in round two. Of the remaining 76 descriptions, consensus on 47 descriptions regarding the underlying concept name was reached in round three. The present study supports the essential process of consensus development with respect to food parenting practices concepts.

Patterns in bottlenecks for implementation of health promotion interventions: a cross-sectional observational study on intervention-context interactions in the Netherlands.

BACKGROUND: From a complex systems perspective, implementation should be understood as the introduction of an intervention in a context with which it needs to interact in order to achieve its function in terms of improved health. The presence of intervention-context interactions could mean that during implementation particular patterns of crucial interaction points might arise. We examined the presence of - and regularities in - such 'bottlenecks for implementation', as this could create opportunities to predict and intervene in potential implementation problems. METHODS: We conducted a cross-sectional observational study against the background of municipal intersectoral policymaking in the Netherlands. We asked implementers of health promotion interventions to identify bottlenecks by rating the presence and importance of conditions for implementation in a range of intervention systems. We used descriptive statistics to characterize these systems (by their behaviour change method, health theme and implementation setting) and the conditions that acted as bottlenecks. After stratifying bottlenecks by intervention system and the system's characteristics, we tested our hypotheses by comparing the number and nature of the bottlenecks that emerged. RESULTS: More than half of the possible conditions were identified as a bottleneck for implementation. Bottlenecks occurred in all categories of conditions, e.g., relating to the implementer, the intervention, and political and administrative support, and often connected with intersectoral policymaking, e.g., relating to the co-implementer and the co-implementer's organization. Both our hypotheses were supported: (1) Each intervention system came across a unique set of - a limited number of - conditions hampering implementation; (2) Most bottlenecks were associated with the characteristics of the system in which they occurred, but bottlenecks also appeared in the absence of such an association, or remained absent in the presence thereof. CONCLUSIONS: We conclude that intervention-context interactions in integrated health policymaking may lead to both regularities and variations in bottlenecks for implementation. Regularities may partly be predicted by the function of an intervention system, and may serve as the basis for building the capacity needed for the structural changes that can bring about long-lasting health improvements. Variations may point at the need for flexibility in further tailoring the implementation approach to the - mostly unpredictable - problems at individual sites.

Energy, saturated fat and fibre intakes among Dutch children and adolescents at breakfast and implications for educational messages.

The aim of this study was to assess energy, saturated fat and fibre intakes at breakfast among Dutch youngsters aged 10-19 years and the extent to which they meet nutritional value recommendations and the educational messages on food group intake by the Netherlands Nutrition Centre (NNC). A cross-sectional design was used and data were collected through an online questionnaire among 2380 students attending 71 Dutch schools for primary and secondary education. Energy intake at breakfast was, on average, 15.8% of daily recommended energy intake; mean saturated fat intake was 7.5 en% and mean fibre intake 1.0 g per 100 kcal. Of the participants, 67.2% met the saturated fat intake recommendation and 35.3% the fibre intake recommendation. In addition, 25.5% were assessed to have an adequate energy intake based on daily recommended, but not individually measured, age- and gender-specific energy intake. Most participants consumed products from the grains food group, in combination with products from one or two other food groups. Consumption from two or more food groups resulted in less favourable intake. Our study found generally inadequate fibre intake at breakfast as well as an indication of inadequate energy intake at breakfast among Dutch youngsters. The educational message of the NNC to consume at least (wholemeal) bread or another fibre-rich product (cereals) at breakfast seems realistic in terms of compliance and favourable in terms of the resulting nutritional value. The educational message to preferably eat from each of the five main food groups should be reconsidered.

Battling the obesity epidemic with a school-based intervention: Long-term effects of a quasi-experimental study.

BACKGROUND: School-based health-promoting interventions are increasingly seen as an effective population strategy to improve health and prevent obesity. Evidence on the long-term effectiveness of school-based interventions is scarce. This study investigates the four-year effectiveness of the school-based Healthy Primary School of the Future (HPSF) intervention on children's body mass index z-score (BMIz), and on the secondary outcomes waist circumference (WC), dietary and physical activity (PA) behaviours. METHODS AND FINDINGS: This study has a quasi-experimental design with four intervention schools, i.e., two full HPSFs (focus: diet and PA), two partial HPSFs (focus: PA), and four control schools. Primary school children (aged 4-12 years) attending the eight participating schools were invited to enrol in the study between 2015 and 2019. Annual measurements consisted of children's anthropometry (weight, height and waist circumference), dietary behaviours (child- and parent-reported questionnaires) and PA levels (accelerometers). Between 2015 and 2019, 2236 children enrolled. The average exposure to the school condition was 2·66 (SD 1·33) years, and 900 participants were exposed for the full four years (40·3%). After four years of intervention, both full (estimated intervention effect (B = -0·17 (95%CI -0·27 to -0·08) p = 0·000) and partial HPSF (B = -0·16 (95%CI-0·25 to -0·06) p = 0·001) resulted in significant changes in children's BMIz compared to control schools. Likewise, WC changed in favour of both full and partial HPSFs. In full HPSFs, almost all dietary behaviours changed significantly in the short term. In the long term, only consumption of water and dairy remained significant compared to control schools. In both partial and full HPSFs, changes in PA behaviours were mostly absent. INTERPRETATION: This school-based health-promoting intervention is effective in bringing unfavourable changes in body composition to a halt in both the short and long term. It provides policy makers with robust evidence to sustainably implement these interventions in school-based routine.

Product samples stimulate choice of unfamiliar healthful food products.

The purpose of this study was to assess whether the availability of a product sample of an unfamiliar low-fat or fruit and vegetable products stimulates choice for this product among food neophobic young adults. The study had a 2 (experimental vs. control group) by 4 (low-fat bread spread, low-fat cheese, fruit juice, fruit and vegetable juice) between subjects design with a pre-and post-experiment questionnaire. The study was conducted in restaurant rooms of several educational institutions in the Netherlands among a convenience sample of 197 food neophobic young adults aged 17-25 years. A small bite or sip-sized sample of the target product was provided as an intervention. The effect measure was choice of either an unfamiliar healthful food product or a traditional food product. Offering a sample of an unfamiliar healthful food product resulted in 51% of the participants in the experimental group choosing this product vs. 36.4% in the control group. Providing food product samples seems to be a promising strategy in healthy diet promotion programs for food neophobic young adults to increase first-time trial of unfamiliar low-fat and fruit and vegetable products.

Information about the taste stimulates choice of unfamiliar healthful food products.

BACKGROUND: The present study aimed to assess whether taste information about unfamiliar low-fat and fruit and vegetable products leads to more positive taste expectations and stimulates choice for these products. The impact of level of food neophobia on such effects was studied. METHODS: The present study had a two (taste information: yes/no) by four (food products: low-fat cheese/very low-fat margarine spread/fruit juice/fruit and vegetable juice) between subjects design among a convenience sample of 396 university students. Taste information was delivered by means of a poster providing information on the taste of the offered food product. Primary outcome measurements were taste expectations and product choice. Level of food neophobia, appetite level, mood states, usual intake of fruit, vegetables and fat, and demographics were taken into account as potential confounders. RESULTS: Taste information had no effect on taste expectations, although it had a positive effect on choosing unfamiliar healthful products. These effects were not moderated by level of food neophobia. CONCLUSIONS: Offering taste information on unfamiliar healthful products appears to be a promising strategy for increasing the first-time trial of such products, independent of the participants' level of food neophobia.

Implementation of intersectoral community approaches targeting childhood obesity: a systematic review.

The implementation of intersectoral community approaches targeting childhood obesity (IACO) is considered challenging. To help overcome these challenges, an overview of the evidence to date is needed. We searched four databases to identify papers that reported on the determinants of successful implementation of IACOs, resulting in the inclusion of 25 studies. We appraised study quality with the Crowe Critical Appraisal Tool and the Quality Framework; reported implementation outcome indicators were reviewed via narrative synthesis. Quality of included studies varied. The most frequently reported indicators of implementation success were fidelity and coverage. Determinants related to the social-political context and the organization were most often cited as influencing implementation, in particular, 'collaboration between community partners', 'the availability of (human) resources' and 'time available for implementation'. The association between determinants and implementation variability was never explicated. We conclude that although some insights into the effective implementation of IACOs are present, more research is needed. Emphasis should be placed on elucidating the relationship between determinants and implementation success. Research should further focus on developing a 'golden standard' for evaluating and reporting on implementation research. These actions will improve the comparison of study outcomes and may constitute the cumulative development of knowledge about the conditions for designing evidence-based implementation strategies.

The reliability and validity of a Dutch questionnaire on fat consumption as a means to rank subjects according to individual fat intake.

In this paper a short, 25-item, telephone-administered questionnaire, designed to rank individuals according to their dietary intake of fat, is presented. Based on two studies of 52 and 639 men and women, respectively, its relative validity regarding a 7-day diet record and its reproducibility are discussed. A Pearson correlation of 0.59 was observed between fat intake estimated by 7-day diet records and fat score derived from the short questionnaire. Gross misclassification, defined as disagreement between the two fat consumption assessments beyond an adjacent tertile, was 15.4%. A Pearson correlation of 0.71 was calculated by a test-retest procedure. It is concluded that the Dutch short questionnaire on fat consumption is a rapid, simple and inexpensive method that can very well be used in nutrition education research to rank individuals according to their dietary fat intake.

Are awareness of dietary fat intake and actual fat consumption associated?--a Dutch-American comparison.

OBJECTIVES: To compare dietary fat intake, the accuracy of individuals' awareness about their fat intake, and sociodemographic and psychosocial correlates of awareness, in Dutch and American samples of employed adults. A discrepancy between objective dietary intake data and subjective self-evaluation of dietary fat consumption has been recognized in the past and might undermine healthy diet promotion interventions, and this is important because people who believe that their diets are healthful are less likely to be interested in making changes. Further, international comparisons have not been examined to date. DESIGN: Data collected for the baseline surveys of the 'Healthy Bergeijk' study in the Netherlands and the 'Working Well Trial' in the United States were compared. SUBJECTS: Working adults from a Dutch community health intervention study (n = 768) and an American worksite health promotion trial (n = 15,440). MAIN OUTCOME MEASURES: Objectively assessed dietary fat intake, measured by food frequency questionnaires, and subjective ratings of fat intake (self-rated fat intake). RESULTS: Findings show that the Dutch respondents had higher objectively assessed fat intake and lower subjective ratings of fat intake (P < 0.001). American respondents perceived their diets as higher in fat, more often stated their intentions to reduce fat intake, and were slightly more likely to make realistic estimates of their dietary fat. Dutch subjects were significantly more likely to underestimate their fat intakes. In both samples, women were most likely to underestimate their fat consumption and the most educated persons were most likely to be realistic. CONCLUSIONS: A substantial proportion of adults, both in the United States and the Netherlands, lack accurate awareness about how much fat they consume, though errors tend to be in opposite directions in the two countries. This study is an important first step toward broadening our international understanding of human dietary behavior for disease prevention.

The application and impact of computer-generated personalized nutrition education: a review of the literature.

Computer-tailored nutrition education may be more effective than general nutrition education because messages are tailored to individual behavior, needs and beliefs of subjects. Therefore, the messages are likely to be of more personal relevance and may have stronger motivational effects. Computer-generated nutrition education has been studied for different dietary behaviors, in different target populations, and in different settings. In recent years, eight studies have been published that assessed the impact of comprehensive computer-generated nutrition interventions that were based on behavior change theory. In this article, the process of providing people with computer-tailored nutrition education is described and the studies on the impact of computer-tailored nutrition education are reviewed. The results point to the conclusion that computer-tailored nutrition education is more likely to be read, remembered, and experienced as personally relevant compared to standard materials. Furthermore, computer-tailored nutrition education also appears to have a greater impact in motivating people to change their diet, their fat intake in particular, although at present no definite conclusions can be drawn.

The impact of computer-tailored feedback and iterative feedback on fat, fruit, and vegetable intake.

A randomized trial was conducted to study the impact of individualized computer-generated nutrition information and additional effects of iterative feedback on changes in intake of fat, fruits, and vegetables. Respondents in the experimental group received computer-generated feedback letters tailored to their dietary intake, intentions, attitudes, self-efficacy expectations, and self-rated behavior. After the first feedback letter, half of the experimental group received additional iterative feedback tailored to changes in behavior and intentions. The control group received a single general nutrition information letter in a format similar to the tailored letters. Computer-tailored feedback had a significantly greater impact on fat reduction and fruit and vegetable intake than did general information. Iterative computer-tailored feedback had an additional impact on fat intake. The results confirm that computer-generated individualized feedback can be effective in inducing recommended dietary changes and that iterative feedback can increase the longer term impact of computer-tailored nutrition education on fat reduction.

Nutrition education interventions in a community setting: 2 Dutch examples.

This article presents the results of two studies among participants of two Dutch nutrition education interventions, i.e. a self-help program and a living room group session. Both interventions aim to reduce fat intake in the general population and were developed as part of the Dutch community health project 'Healthy Bergeyk'. The objectives of the studies were to assess number of participants, participant characteristics, use of the self-help program, participant satisfaction and self-reported effects. Telephone interviews and written questionnaires were completed by inhabitants after participating in the interventions. The results are encouraging and the interventions seem to be useful as part of community projects.

The validation of a test to measure knowledge about the fat content of food products.

The objective of the study was to develop and validate a 21-item nutrition knowledge test to measure people's knowledge of the fat content of food-products. After pretesting and provisional development, the test was administered twice to study test-retest reliability. Furthermore, various sub-populations with expected differences in nutrition knowledge completed the test in order to study the construct validity of the questionnaire. The subpopulations consisted of lay-people (N = 81), students of human nutrition and dietetics (N = 108), and professional experts (N = 79) on human nutrition. The internal consistency and uni-dimensionality of the test were determined by calculating the KR-20 statistic and the log-likelihood ratio statistic for the Rasch model. Pearson's correlation and gross misclassification between T1 and T2 were calculated to assess the test-retest reliability. Analysis of variance was used to test for differences in mean knowledge scores between subpopulations. Test-retest reliability was found to be sufficient (R = .85). The internal consistency was moderate (KR20 = .68). According to the Rasch model, two items had to be removed from the test before the log-likelihood ratio statistic of the Rasch model indicated that knowledge about the fat content of food products as assessed by the questionnaire is a uni-dimensional construct. The differences in mean knowledge scores between the subpopulations were significant (p < .01) and in the expected direction (experts > students > lay people). It can be concluded that the test is a reliable and valid instrument to measure knowledge about total fat content in food products and that the Rasch model is a comprehensive method to indicate the reliability of nutritional knowledge tests.

Fat Watch: a nationwide campaign in The Netherlands to reduce fat intake--effect evaluation.

In the Netherlands, the nationwide Fat Watch campaign aiming at a reduction in fat consumption was organized from 1991 onwards. This study describes the effects of the first three consecutive campaign years on attention to fat, diet and health, attitudes, self-efficacy expectations and intentions related to dietary fat reduction, and self-rated fat intake. Data were collected each year according to the Solomon design, by telephone interviews among about 1200 consumers responsible for household purchases. Campaign awareness was high in each campaign year, but a decrease in campaign awareness was found after the first campaign in 1991. The 1991 campaign was primarily aimed at getting the attention of the Dutch public for the fat-reduction message and indeed resulted in increased attention. The second campaign year resulted in small but statistically significant positive changes in attitudes, which was the specific target of the 1992 campaign. Intention to buy low-fat food products was also significantly increased. The 1993 campaign failed to realize the targeted increases in self-efficacy among the study population, but a significant campaign effect on intentions was found. The evaluation of all three campaigns indicated that the Dutch underestimate their personal fat intake and this has been identified as an important barrier to a further reduction in fat consumption. Making subjects aware of their personal fat consumption will be given priority in future campaigns.

Results of a community-based campaign to reduce fat intake.

In 1992, a community-based 'Fat Watch' campaign was held in the city of Alkmaar in the Netherlands. The campaign was implemented within the framework of the nationwide mass-mediated 'Fat Watch' campaign (1991-1994), which aimed at a 10% reduction in fat intake among the general Dutch population. The intervention was carried out as a pilot project to study the effectiveness of strategies and activities, and to apply them subsequently in more cities. The campaign aimed primarily at the active involvement of intermediaries. Effects of the campaign were studied by telephone questionnaires among about 500 respondents, before and after the campaign in both the experimental and a control community. The questionnaire was based on the 'attitude, social influence, self-efficacy' (ASE) model. The results showed that 56% of the respondents were aware of a campaign in their community and that the campaign was positively evaluated by those familiar with it. After the campaign, self-rated fat consumption was significantly higher. No differences between the experimental and control community were found regarding attitude, social influence or self-efficacy expectations towards a reduction in fat consumption or intention to buy low-fat food products. However, as opposed to the control community, there was a significant decrease in actual fat consumption between pre- and post-test in Alkmaar. Furthermore, after the campaign, significantly more respondents in the experimental community intended to eat lower-fat food products and reported a behavioral change in the last six months. It was concluded that the campaign was quite successful as far as campaign awareness was concerned, but that it did not result in substantial change of behavior. The limited decrease in fat consumption observed should be interpreted with care.