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.

Reframing physically active learning as movement-centred pedagogy: a European priority action framework.

BACKGROUND: Physically active learning (PAL) has emerged as a promising way of eliciting health and education-based outcomes for pupils. Concurrently, research suggests large variability in how PAL is perceived, operationalized, and prioritized in practice across Europe. Therefore, this study aimed to co-develop a framework for action to support the adoption and implementation of PAL. METHODS: Adopting a design thinking approach, 40 international stakeholders representing 13 countries engaged in an idea generation workshop during a two-day PAL international conference. Participants included professionals from research (n = 20), practice (n = 4) and policy (n = 1) or a combination (n = 15). Their experience with PAL ranged from none to 19 years (with an average of 3.9 years). Participants were allocated into one of six heterogeneous and multidisciplinary groups and led through interactive tasks to identify: the landscape for PAL across Europe, barriers to the adoption and implementation of PAL, and key objectives for research, policy and practice to improve the adoption and implementation of PAL. All discussions were audio recorded and prioritized objectives were transcribed verbatim and analysed using inductive qualitative content analysis. RESULTS: Five interlinked and mutually reinforcing themes were identified: (1) Integration of the health and education paradigms (2) Coherent national policy and decision making (3) Building confident and competent teachers (4) Adopting a whole school approach for PAL (5) Strengthening the evidence base for PAL. CONCLUSIONS: The priority action framework identifies five key areas for action to facilitate PAL adoption and implementation across Europe. Central to the success of border uptake of PAL is the integration of the health and education paradigms. To achieve this aim, reframing PAL as movement-centered pedagogy would provide a more holistic and inclusive perspective.

Evaluation proposal of a national community-based obesity prevention programme: a novel approach considering the complexity perspective.

Community-based obesity prevention programmes are considered an important strategy to curb the obesity epidemic. The JOGG (Youth At a Healthy Weight) approach is a large-scale community-based programme for childhood obesity prevention in the Netherlands that has been implemented over the past ten years. Practice-based development of the programme, both at the national and local level, increasingly poses challenges for its evaluation. One considerable challenge is the increasing acknowledgement of the complexity in the JOGG-approach, characterized by (a) objectives that vary locally, (b) adaptions to the programme over time in response to a community's shifting needs, challenges and opportunities, and (c) emergent outcomes and non-linear causality.We propose an evaluation framework that highlights elements of the complex local practice, including the local programme theory, implementation, adaption, the influence of context and feedback loops and intended as well as emergent and unintended outcomes. By studying each of these elements in practice, we hope to learn about principles that guide effective obesity prevention across contexts. The results of the proposed evaluation will inform both practice and research.Considering complexity in evaluation is a relatively new challenge in public health and therefore an emergent research area. The proposed framework for complex evaluations allows to retrospectively evaluate a programme that was implemented and developed in practice, and enables us to learn from practice-based experiences. Following the ISBNPA Dare2Share initiative, we kindly invite other researchers in the field to share their ideas and experiences regarding integration of complexity in evaluation.

Behaviours that prompt primary school teachers to adopt and implement physically active learning: a meta synthesis of qualitative evidence.

BACKGROUND: Physically active learning (PAL) - integration of movement within delivery of academic content - is a core component of many whole-of-school physical activity approaches. Yet, PAL intervention methods and strategies vary and frequently are not sustained beyond formal programmes. To improve PAL training, a more comprehensive understanding of the behavioural and psychological processes that influence teachers' adoption and implementation of PAL is required. To address this, we conducted a meta-synthesis to synthesise key stakeholders' knowledge of facilitators and barriers to teachers' implementing PAL in schools to improve teacher-focussed PAL interventions in primary (elementary) schools. METHODOLOGY: We conducted a meta-synthesis using a five-stage thematic synthesis approach to; develop a research purpose and aim, identify relevant articles, appraise studies for quality, develop descriptive themes and interpret and synthesise the literature. In the final stage, 14 domains from the Theoretical Domain Framework (TDF) were then aligned to the final analytical themes and subthemes. RESULTS: We identified seven themes and 31 sub-themes from 25 eligible papers. Four themes summarised teacher-level factors: PAL benefits, teachers' beliefs about own capabilities, PAL teacher training, PAL delivery. One theme encompassed teacher and school-level factors: resources. Two themes reflected school and external factors that influence teachers' PAL behaviour: whole-school approach, external factors. Ten (of 14) TDF domains aligned with main themes and sub-themes: Knowledge, Skills, Social/Professional Role and Identity, Beliefs about Capabilities, Beliefs about Consequences, Reinforcement, Goals, Environmental Context and Resources, Social influences and Emotion. CONCLUSIONS: Our synthesis illustrates the inherent complexity required to change and sustain teachers' PAL behaviours. Initially, teachers must receive the training, resources and support to develop the capability to implement and adapt PAL. The PAL training programme should progress as teachers' build their experience and capability; content should be 'refreshed' and become more challenging over time. Subsequently, it is imperative to engage all levels of the school community for PAL to be fully integrated into a broader school system. Adequate resources, strong leadership and governance, an engaged activated community and political will are necessary to achieve this, and may not currently exist in most schools.

Using a multi-stakeholder experience-based design process to co-develop the Creating Active Schools Framework.

BACKGROUND: UK and global policies recommend whole-school approaches to improve childrens' inadequate physical activity (PA) levels. Yet, recent meta-analyses establish current interventions as ineffective due to suboptimal implementation rates and poor sustainability. To create effective interventions, which recognise schools as complex adaptive sub-systems, multi-stakeholder input is necessary. Further, to ensure 'systems' change, a framework is required that identifies all components of a whole-school PA approach. The study's aim was to co-develop a whole-school PA framework using the double diamond design approach (DDDA). METHODOLOGY: Fifty stakeholders engaged in a six-phase DDDA workshop undertaking tasks within same stakeholder (n = 9; UK researchers, public health specialists, active schools coordinators, headteachers, teachers, active partner schools specialists, national organisations, Sport England local delivery pilot representatives and international researchers) and mixed (n = 6) stakeholder groupings. Six draft frameworks were created before stakeholders voted for one 'initial' framework. Next, stakeholders reviewed the 'initial' framework, proposing modifications. Following the workshop, stakeholders voted on eight modifications using an online questionnaire. RESULTS: Following voting, the Creating Active Schools Framework (CAS) was designed. At the centre, ethos and practice drive school policy and vision, creating the physical and social environments in which five key stakeholder groups operate to deliver PA through seven opportunities both within and beyond school. At the top of the model, initial and in-service teacher training foster teachers' capability, opportunity and motivation (COM-B) to deliver whole-school PA. National policy and organisations drive top-down initiatives that support or hinder whole-school PA. To the authors' knowledge, this is the first time practitioners, policymakers and researchers have co-designed a whole-school PA framework from initial conception. The novelty of CAS resides in identifying the multitude of interconnecting components of a whole-school adaptive sub-system; exposing the complexity required to create systems change. The framework can be used to shape future policy, research and practice to embed sustainable PA interventions within schools. To enact such change, CAS presents a potential paradigm shift, providing a map and method to guide future co-production by multiple experts of PA initiatives 'with' schools, while abandoning outdated traditional approaches of implementing interventions 'on' schools.

Effects of physical activity interventions on cognitive and academic performance in children and adolescents: a novel combination of a systematic review and recommendations from an expert panel.

OBJECTIVE: To summarise the current evidence on the effects of physical activity (PA) interventions on cognitive and academic performance in children, and formulate research priorities and recommendations. DESIGN: Systematic review (following PRISMA guidelines) with a methodological quality assessment and an international expert panel. We based the evaluation of the consistency of the scientific evidence on the findings reported in studies rated as of high methodological quality. DATA SOURCES: PubMed, PsycINFO, Cochrane Central, Web of Science, ERIC, and SPORTDiscus. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: PA-intervention studies in children with at least one cognitive or academic performance assessment. RESULTS: Eleven (19%) of 58 included intervention studies received a high-quality rating for methodological quality: four assessed effects of PA interventions on cognitive performance, six assessed effects on academic performance, and one on both. All high-quality studies contrasted the effects of additional/adapted PA activities with regular curriculum activities. For cognitive performance 10 of 21 (48%) constructs analysed showed statistically significant beneficial intervention effects of PA, while for academic performance, 15 of 25 (60%) analyses found a significant beneficial effect of PA. Across all five studies assessing PA effects on mathematics, beneficial effects were reported in six out of seven (86%) outcomes. Experts put forward 46 research questions. The most pressing research priority cluster concerned the causality of the relationship between PA and cognitive/academic performance. The remaining clusters pertained to PA characteristics, moderators and mechanisms governing the 'PA-performance' relationship and miscellaneous topics. CONCLUSION: There is currently inconclusive evidence for the beneficial effects of PA interventions on cognitive and overall academic performance in children. We conclude that there is strong evidence for beneficial effects of PA on maths performance.The expert panel confirmed that more 'high-quality' research is warranted. By prioritising the most important research questions and formulating recommendations we aim to guide researchers in generating high-quality evidence. Our recommendations focus on adequate control groups and sample size, the use of valid and reliable measurement instruments for physical activity and cognitive performance, measurement of compliance and data analysis. PROSPERO REGISTRATION NUMBER: CRD42017082505.

Factors associated with (non-)participation of cancer survivors with job loss in a supportive return to work program.

PURPOSE: To evaluate and implement supportive programs, it is important to understand which cancer survivors (CSs) are participating in these programs and which motives exist for declining participation. Recently, a supportive return-to-work (RTW) program was offered to CSs with job loss. The purpose of this study was to identify factors and motives associated with (non-)participation of CSs with job loss in the RTW program. METHODS: In this cross-sectional study (N = 286), information on socio-demographic, health-related, psychosocial, and work-related characteristics of CSs in the program was collected. Similar data were collected from those who declined participation. Multivariable logistic regression analyses were conducted (p < 0.05) to identify factors associated with (non-)participation. Motives for declining participation were identified using descriptive analysis. RESULTS: Being married (odds ratio (OR) 0.23; 95 % confidence interval (CI) 0.08-0.69) or living together (OR 0.25; 95 % CI 0.07-0.96) decreased the likelihood of participation in the RTW program. Having a temporary employment contract prior to unemployment (OR 2.60; 95 % CI 1.20-5.63), a clear intention to RTW (OR 2.65; 95 % CI 1.20-5.82), and higher scores on a readiness to RTW instrument, i.e., contemplation scale (OR 2.00; 95 % CI 1.65-2.40) and prepared for action-self-evaluative scale (OR 1.27; 95 % CI 1.04-1.54), increased the likelihood of participation. Physical (50 %) and mental problems (36 %) were leading motives for declining participation. CONCLUSIONS: The results from this study help to distinguish CSs that may not need RTW support, from those who are most in need of RTW support. Practitioners and researchers should tailor RTW support to CSs' socio-demographic, health-related, and work-related characteristics.

Barriers and facilitators to the nationwide dissemination of the Dutch school-based obesity prevention programme DOiT.

BACKGROUND: This article describes the barriers and facilitating factors to the adoption, implementation and continuation of the Dutch Obesity Intervention in Teenagers (DOiT) programme in the Netherlands. METHODS: We evaluated the adoption, implementation and continuation of the programme at 20 voluntary prevocational schools, which adopted the programme. Interviews were conducted with DOiT coordinators and/or teachers (n = 44) at the end of the first and second school year of the 2-year implementation period. Interviews were recorded and transcribed verbatim. Data were coded by two researchers independently. Identified barriers and facilitating factors were categorized into four groups: (i) organizational factors, (ii) individual factors, (iii) characteristics of the programme and (iv) characteristics of the implementation strategy. RESULTS: Teachers and DOiT coordinators identified various implementation barriers (e.g. lack of planning, other urgent unforeseen priorities, no plan to cope with teacher turnover and high teacher workload) as well as facilitating factors (e.g. involvement of DOiT coordinator and support from the DOiT office, sufficient communication and collaboration between teachers, strong teacher motivation and flexibility of the programme). CONCLUSION: Overall, DOiT implementers were satisfied with the compatibility, layout, content and potential for tailoring the programme. Barriers for successful implementation were mainly at the school and teacher level. Findings of this study can be used for further improvement of the DOiT programme and for the development and improvement of other health promotion programmes in the school setting.

Implemented or not implemented? Process evaluation of the school-based obesity prevention program DOiT and associations with program effectiveness.

This study investigates if and to what extent the Dutch Obesity Intervention in Teenagers (DOiT) program was implemented as intended and how this affected program effectiveness. We collected data at 20 prevocational education schools in the Netherlands. We assessed seven process indicators: recruitment, reach, dosage, fidelity, satisfaction, effectiveness and continuation. Data collection involved teacher questionnaires (n= 110), adolescent questionnaires and adiposity measures (n= 938). Using multi-level confirmatory factor analyses, we applied an innovative method to obtain explorative implementation index scores. The percentage of accomplished activities ranged from 9% (for 'closure meeting') up to 93% (for 'obtaining support within the school for adoption'). The percentage of lessons delivered decreased from 74 to 18% towards the end of the program. Fidelity to the teacher manual ranged from 85 to 26%. In general, teachers were satisfied with the DOiT lessons and teaching materials. Despite teachers' satisfaction with the DOiT lessons and teaching materials, degree of program implementation was lower than expected, especially towards the end of the program. Further, some evidence was found for an association between a higher implementation index score and program effectiveness, but more research is needed to test the validity of the implementation index.

Parental modeling, education and children's sports and TV time: the ENERGY-project.

OBJECTIVE: We assessed whether differences in children's sports participation and television time according to parental education were mediated by parental modeling. Moreover, we explored the differences between parental and child reports on parental sports participation and television time as potential mediators. METHODS: 5729 children and 5183 parents participating in the EuropeaN Energy balance Research to prevent excessive weight Gain among Youth (ENERGY-project) during 2010 in seven European countries provided information on sports participation and television time using validated self-report questionnaires. Multilevel country-specific mediation models analyzed the potential mediation effect of parental self-reports and child-reports on parental sports participation and television time. RESULTS: Significant mediation effect was found for parental self-reported television time in four countries (Greece, Hungary, The Netherlands and Slovenia), with the highest proportion for Slovenia (40%) and the lowest for Greece (21%). Child-reported parental television time showed mediation effect in Greece only. Parental self-reported sports participation showed significant mediation effect only in Greece. With child-reported parental sports participation, significant mediation was observed in Greece and Norway. CONCLUSIONS: Parental behaviors appear to be important in explaining parental educational differences in children's sports participation and television time. However, child reports on parental behavior appear to be more relevant than parents' self-reports as correlates of children's own sports participation and television time.

Large proportions of overweight and obese children, as well as their parents, underestimate children's weight status across Europe. The ENERGY (EuropeaN Energy balance Research to prevent excessive weight Gain among Youth) project.

OBJECTIVE: To investigate the magnitude and country-specific differences in underestimation of children's weight status by children and their parents in Europe and to further explore its associations with family characteristics and sociodemographic factors. DESIGN: Children's weight and height were objectively measured. Parental anthropometric and sociodemographic data were self-reported. Children and their parents were asked to comment on children's weight status based on five-point Likert-type scales, ranging from 'I am much too thin' to 'I am much too fat' (children) and 'My child's weight is way too little' to 'My child's weight is way too much' (parents). These data were combined with children's actual weight status, in order to assess underestimation of children's weight status by children themselves and by their parents, respectively. Chi-square tests and multilevel logistic regression analyses were conducted to examine the aims of the current study. SETTING: Eight European countries participating in the ENERGY (EuropeaN Energy balance Research to prevent excessive weight Gain among Youth) project. SUBJECTS: A school-based survey among 6113 children aged 10-12 years and their parents. RESULTS: In the total sample, 42·9 % of overweight/obese children and 27·6 % of parents of overweight/obese children underestimated their and their children's weight status, respectively. A higher likelihood for this underestimation of weight status by children and their parents was observed in Eastern and Southern compared with Central/Northern countries. Overweight or obese parents (OR=1·81; 95 % CI 1·39, 2·35 and OR=1·78, 95 % CI 1·22, 2·60), parents of boys (OR=1·32; 95 % CI 1·05, 1·67) and children from overweight/obese (OR=1·60; 95 % CI 1·29, 1·98 and OR=1·76; 95 % CI 1·29, 2·41) or unemployed parents (OR=1·53; 95 % CI 1·22, 1·92) were more likely to underestimate children's weight status. CONCLUSIONS: Children of overweight or obese parents, those from Eastern and Southern Europe, boys, younger children and children with unemployed parents were more likely to underestimate their actual weight status. Overweight or obese parents and parents of boys were more likely to underestimate the actual weight status of their children. In obesity prevention such underestimation may be a barrier for behavioural change.

A process evaluation of implementing a vocational enablement protocol for employees with hearing difficulties in clinical practice.

OBJECTIVE: A multidisciplinary vocational rehabilitation programme, the Vocational Enablement Protocol (VEP) was developed to address the specific needs of employees with hearing difficulties. In the current study we evaluated the process of implementing the VEP in audiologic care among employees with hearing impairment. DESIGN: In conjunction with a randomized controlled trial, we collected and analysed data on seven process parameters: recruitment, reach, fidelity, dose delivered, dose received and implemented, satisfaction, and perceived benefit. STUDY SAMPLE: Sixty-six employees with hearing impairment participated in the VEP. The multidisciplinary team providing the VEP comprised six professionals. RESULTS: The professionals performed the VEP according to the protocol. Of the recommendations delivered by the professionals, 31% were perceived as implemented by the employees. Compliance rate was highest for hearing-aid uptake (51%). Both employees and professionals were highly satisfied with the VEP. Participants rated good perceived benefit from it. CONCLUSIONS: Our results indicate that the VEP could be a useful treatment for employees with hearing difficulties from a process evaluation perspective. Implementation research in the audiological setting should be encouraged in order to further provide insight into parameters facilitating or hindering successful implementation of an intervention and to improve its quality and efficacy.

The Dutch Obesity Intervention in Teenagers (DOiT) cluster controlled implementation trial: intervention effects and mediators and moderators of adiposity and energy balance-related behaviours.

BACKGROUND: The Dutch Obesity Intervention in Teenagers (DOiT) programme is an evidence-based obesity prevention programme tailored to adolescents attending the first two years of prevocational education in the Netherlands. The initial programme showed promising results during an effectiveness trial. The programme was adapted and prepared for nationwide dissemination. To gain more insight into the process of translating evidence-based approaches into 'real world' (i.e., 'natural') conditions, our research aims were to evaluate the impact of the DOiT-implementation programme on adolescents' adiposity and energy balance-related behaviours during natural dissemination and to explore the mediating and moderating factors underlying the DOiT intervention effects. METHODS: We conducted a cluster-controlled implementation trial with 20 voluntary intervention schools (n=1002 adolescents) and 9 comparable control schools (n = 484 adolescents). We measured adolescents' body height and weight, skinfold thicknesses, and waist circumference. We assessed adolescents' dietary and physical activity behaviours by means of self-report. Data were collected at baseline and at 20-months follow-up. We used multivariable multilevel linear or logistic regression analyses to evaluate the intervention effects and to test the hypothesised behavioural mediating factors. We checked for potential effect modification by gender, ethnicity and education level. RESULTS: We found no significant intervention effects on any of the adiposity measures or behavioural outcomes. Furthermore, we found no mediating effects by any of the hypothesised behavioural mediators. Stratified analyses for gender showed that the intervention was effective in reducing sugar-containing beverage consumption in girls (B = -188.2 ml/day; 95% CI = -344.0; -32.3). In boys, we found a significant positive intervention effect on breakfast frequency (B = 0.29 days/week; 95% CI = 0.01; 0.58). Stratified analyses for education level showed an adverse intervention effect (B = 0.09; 95% CI = 0.02; 0.16) on BMI z-scores for adolescents attending the vocational education track. CONCLUSIONS: Although not successful in changing adolescents' adiposity, the DOiT-implementation programme had some beneficial effects on specific obesity-related behaviours in subgroups. This study underlines the difficulty of translating intervention effectiveness in controlled settings to real world contexts. Adaptations to the implementation strategy are needed in order to promote implementation as intended by the teachers. TRIAL REGISTRATION: Current Controlled Trials ISRCTN92755979.

Biological, socio-demographic, work and lifestyle determinants of sitting in young adult women: a prospective cohort study.

BACKGROUND: Sitting is associated with health risks. Factors that influence sitting are however not well understood. The aim was to examine the biological, socio-demographic, work-related and lifestyle determinants of sitting time (including during transport, work and leisure) in young adult Australian women. METHODS: Self-reported data from 11,676 participants (aged 22-27 years in 2000) in the Australian Longitudinal Study on Women's Health were collected over 9 years in 2000, 2003, 2006 and 2009. Generalised Estimating Equations were used to examine univariable and multivariable associations of body mass index (BMI), country of birth, area of residence, education, marital status, number of children, occupational status, working hours, physical activity, smoking, alcohol intake and stress with week- and weekend-day sitting time. RESULTS: Compared with women in the respective referent categories, (1) women with higher BMI, those born in Asia, those with less than University level education, doing white collar work, working 41-48 hours a week, current smokers, non, rare or risky/high risk drinkers and those being somewhat stressed had significantly higher sitting time; and (2) women living in rural and remote areas, partnered women, those with children, those without a paid job and blue collar workers, those working less than 34 hours a week, and active women had significantly lower sitting time. CONCLUSIONS: Among young adult Australian women, those with higher BMI, those born in Asia, those with higher level occupations and long working hours, were most at risk of higher sitting time. These results can be used to identify at-risk groups and inform intervention development.

Test-retest reliability and construct validity of the DOiT (Dutch Obesity Intervention in Teenagers) questionnaire: measuring energy balance-related behaviours in Dutch adolescents.

OBJECTIVE: Adequate assessment of energy balance-related behaviours in adolescents is essential to develop and evaluate effective obesity prevention programmes. The present study examined the test-retest reliability and construct validity of a questionnaire assessing energy balance-related behaviours in adolescents during the evaluation of the DOiT (Dutch Obesity Intervention in Teenagers) intervention. DESIGN: To assess test-retest reliability, adolescents filled in the questionnaire twice (n 111). To assess construct validity, the results from the first test were compared with data collected in a personal cognitive interview (n 20, independent from the reliability study). For both reliability and validity, intraclass correlation coefficients for continuous data or Cohen's kappa coefficients for categorical data were calculated as well as percentage agreement. SETTING: Data were collected during school time from February to May 2010. SUBJECTS: Study participants were Dutch adolescents aged 12-14 years attending pre-vocational secondary schools. RESULTS: In more than three-quarters of the ninety-five questionnaire items the test-retest reliability appeared to be good to excellent. Moderate reliability was found for all other twenty-one items. Fifty-one items (of ninety-five items) showed good to excellent construct validity. Construct validity appeared moderate in twenty-three items and poor in twenty-one items. Most items with poor construct validity concerned consumption of sugar-containing beverages and high-energy snacks/sweets. CONCLUSIONS: Our study showed good test-retest reliability and largely moderate to good construct validity for the majority of items of the DOiT questionnaire. Items with poor construct validity (most of them found for items concerning energy intake-related behaviours) should be revised and tested again to improve the questionnaire for future use.

Comparison of energy balance-related behaviours and measures of body composition between Turkish adolescents in Turkey and Turkish immigrant adolescents in the Netherlands.

OBJECTIVE: To explore the influences of migration to a Western country on obesity and related risk factors by comparing measures of body composition and energy balance-related behaviours between Turkish adolescents in Turkey (TR-TR) and adolescents from Turkish immigrant ethnicity in the Netherlands (TR-NL). DESIGN: Cross-sectional survey or baseline intervention data from six Dutch school-based studies and one Turkish study. SETTING: Primary and secondary schools. SUBJECTS: A total of 915 (49 % girls; mean age 13·1 (sd 0·8) years) TR-TR adolescents and 433 (51 % girls; mean age 11·7 (sd 1·3) years) TR-NL adolescents were included. Outcome measures were self-reported sugar-containing beverage consumption, fruit and vegetable intake, screen time, physical activity, measured body height and weight, BMI, waist and hip circumferences, and skinfold thicknesses. RESULTS: Our data showed that more TR-NL adolescents were overweight (31 % v. 26 %) and obese (9 % v. 6 %) and had significantly higher mean BMI (21·1 v. 20·0 kg/m2), waist circumference (72·2 v. 71·3 cm) and suprailiac skinfold thickness (19·8 v. 13·1 mm) than TR-TR adolescents. TR-NL adolescents reported significantly higher sugar-containing beverage consumption (1173 v. 115 ml/d), less fruit and vegetable intake (295 v. 647 g/d), less screen time (253 v. 467 min/d) and higher physical activity levels (61 v. 27 min/d) than TR-TR adolescents. CONCLUSIONS: Immigrant adolescents in the Netherlands were more often overweight and had a less favourable dietary pattern than their peers in Turkey, while their physical activity and screen time patterns were more favourable. These results suggest that adolescents from Turkish immigrant ethnicity in the Netherlands have adopted lifestyles towards the host culture.

Number and appraisal of daily hassles and life events in young adulthood: the association with physical activity and screen time: a longitudinal cohort study.

BACKGROUND: Young adults face radical life changes regarding residence, marriage, family and work that may negatively impact their health behaviours. Therefore, we investigated the associations of the number of daily hassles and life events and their subjective appraisal with physical activity and screen time in young adulthood. METHODS: Data came from participants of the Amsterdam Growth and Health Longitudinal Study (AGAHLS). Self-reported physical activity (min/wk) was used from wave 6 (1991; mean age 27), wave 7 (1993; mean age 29), wave 8 (1996/1997; mean age 32) and 9 (2000; mean age 36). Self-reported screen time (h/wk) was assessed in waves 8 and 9. The number and the appraisal of daily hassles and major life events were assessed with the Everyday Problem Checklist and Life Events List, respectively (including five life event domains, i.e.: health, work, home/family, personal/social relations, and finances). The final sample included 474 participants for the physical activity analyses and 475 participants for the screen time analyses. To test the longitudinal associations of daily hassles and life events with physical activity and screen time, univariable and multivariable Generalised Estimating Equations were performed. Effect modification by gender was tested. RESULTS: Physical activity levels were higher in those who had experienced more daily hassles. People who reported higher subjective appraisal in the work and finances life event domains also had higher levels of physical activity, although only the subjective appraisal in the finances domain remained significant in the multivariable model. No significant associations between number and subjective appraisal of daily hassles and life events and screen time were observed. CONCLUSIONS: The occurrence of specific life events may be more influential for people's physical activity behaviour than their respective sum or emotional tone. Still, the assessment of daily hassles may be a relevant addition in this research field. Finally, we suggest that daily hassles and life events are less important for explaining screen time behaviour than for physical activity.

Agreement between parent and child report on parental practices regarding dietary, physical activity and sedentary behaviours: the ENERGY cross-sectional survey.

BACKGROUND: Parents and their parenting practices play an important role in shaping their children's environment and energy-balance related behaviours (EBRBs). Measurement of parenting practices can be parent- or child-informed, however not much is known about agreement between parent and child perspectives. This study aimed to assess agreement between parent and child reports on parental practices regarding EBRBs across different countries in Europe and to identify correlates of agreement. METHODS: Within the ENERGY-project, a cross-sectional survey was conducted among 10-12 year old children and their parents in eight European countries. Both children and parents filled in a questionnaire on 14 parental practices regarding five different EBRBs (i.e. soft drink, fruit juice and breakfast consumption, sports activity and watching TV) and socio-demographic characteristics. Children's anthropometric measurements were taken at school. We calculated percentages of agreement between children and their parents and weighted kappa statistics (for ordinal variables) per practice and country and assessed factors associated with agreement using multilevel linear regression. RESULTS: Reports of 6425 children and their parents were available for analysis. Overall mean agreement between parent and child reports was 43% and varied little among countries. The lowest agreement was found for questions assessing joint parent-child activities, such as sports (27%; Kappa (κ) = 0.14) or watching TV (30%; κ = 0.17), and for parental allowance of the child to have soft drinks (32%; κ = 0.24) or fruit juices (32%; κ = 0.19), or to watch TV (27%; κ = 0.17). Having breakfast products available at home or having a TV in the child's bedroom were the only practices with moderate to good agreement (>60%; κ = 0.06 and 0.77, respectively). In general, agreement was lower for boys, younger children, younger parents, parents with less than 14 years of education, single parents, parents with a higher self-reported body mass index and parents who perceived their child to be underweight. CONCLUSIONS: Parents and children perceive parental practices regarding dietary, physical activity and sedentary behaviours differently in all parts of Europe, with considerable variation across specific practices and countries. Therefore, future studies should assess both, parents and children's view on parental practices.

Differences in beliefs and home environments regarding energy balance behaviors according to parental education and ethnicity among schoolchildren in Europe: the ENERGY cross sectional study.

BACKGROUND: To explore differences in personal and home environmental factors that are regarded as determinants of energy balance-related behaviors (EBRBs) according to parental education and ethnic background among 10-12 year old schoolchildren across Europe. METHODS: A school-based survey among 10-12 year olds was conducted in eight countries across Europe. A range of personal and home environment variables relevant for soft drink consumption, daily breakfast, sport participation and TV time was assessed by means of child report. Personal factors included attitude, health beliefs, and preference/liking. Home environment factors included parental subjective norm, modeling, support, practices and home availability. Children were classified based on parental education (i.e., low vs. high) and ethnic background (i.e., native vs. non-native). Data from 6018 children originating from 83 schools were included in the analyses. RESULTS: Multilevel logistic regression analyses showed that the majority of the factors tested -and especially home environment variables- were more favorable among children from higher educated parents and from native ethnicity. None of the personal and home environment factors was found to be more favorable among children from lower educated parents or non-native ethnicity. CONCLUSIONS: The present study indicates that schoolchildren from lower educated and non-native parents across Europe have EBRB-related beliefs and are exposed to home environments that are less favorable for engagement in healthy EBRBs.

Clustering of energy balance-related behaviors and parental education in European children: the ENERGY-project.

BACKGROUND: Recent research and literature reviews show that, among schoolchildren, some specific energy balance-related behaviors (EBRBs) are relevant for overweight and obesity prevention. It is also well known that the prevalence of overweight and obesity is considerably higher among schoolchildren from lower socio-economic backgrounds. This study examines whether sugared drinks intake, physical activity, screen time and usual sleep duration cluster in reliable and meaningful ways among European children, and whether the identified clusters could be characterized by parental education. METHODS: The cross-sectional study comprised a total of 5284 children (46% male), from seven European countries participating in the ENERGY-project ("EuropeaN Energy balance Research to prevent excessive weight Gain among Youth"). Information on sugared drinks intake, physical activity, screen time and usual sleep duration was obtained using validated self-report questionnaires. Based on these behaviors, gender-specific cluster analysis was performed. Associations with parental education were identified using chi-square tests and odds ratios. RESULTS: Five meaningful and stable clusters were found for both genders. The cluster with high physical activity level showed the highest proportion of participants with highly educated parents, while clusters with high sugared drinks consumption, high screen time and low sleep duration were more prevalent in the group with lower educated parents. Odds ratio showed that children with lower educated parents were less likely to be allocated in the active cluster and more likely to be allocated in the low activity/sedentary pattern cluster. CONCLUSIONS: Children with lower educated parents seemed to be more likely to present unhealthier EBRBs clustering, mainly characterized by their self-reported time spent on physical activity and screen viewing. Therefore, special focus should be given to lower educated parents and their children in order to develop effective primary prevention strategies.