Informative value of referral letters from general practice for child and adolescent mental healthcare.

Although referral letters (RLs) form a nodal point in a patient's care journey, little is known about their informative value in child and adolescent mental healthcare. To determine the informative value of RLs to child and adolescent psychiatry, we conducted a chart review in medical records of minors registered at specialized mental healthcare between January 2015 and December 2017 (The Netherlands). Symptoms indicated in RLs originating from general practice (N = 723) were coded and cross-tabulated with the best estimate clinical classifications made in psychiatry. Results revealed that over half of the minors in the sample were classified in concordance with at least one reason for referral. We found fair to excellent discriminative ability for indications made in RLs concerning the most common psychiatric classifications (95% CI AUC: 60.9-70.6 for anxiety disorders to 90.5-100.0 for eating disorders). Logistic regression analyses suggested no statistically significant effects of gender, age, severity or mental healthcare history, with the exception of age and attention deficit hyperactivity disorders (ADHD), as RLs better predicted ADHD with increasing age (OR = 1.14, 95% CI 1.03-1.27). Contextual problems, such as difficulties studying, problems with parents or being bullied were indicated frequently and associated with classifications in various disorder groups. To conclude, general practitioners' RLs showed informative value, contrary to common beliefs. Replication studies are needed to reliably incorporate RLs into the diagnostic work-up.

Pregnant women at increased risk of adverse perinatal outcomes: A combination of less healthy behaviors and adverse psychosocial and socio-economic circumstances.

Smoking during pregnancy is associated with a multitude of health behaviors and with the psychosocial and socio-economic circumstances of pregnant women. Limited research has so far been conducted on the clustering of these characteristics and on their effect on pregnancy outcomes. This study aimed to identify different groups of pregnant women based on their behavioral, psychosocial and socio-economic characteristics and their pregnancy outcomes. In total, 2455 women who were 12 weeks pregnant completed a questionnaire on smoking behavior, health behaviors and psychosocial and socio-economic characteristics. Neonatal and maternal outcomes were extracted from the Dutch perinatal registration. Subgroups were identified with latent class analysis and adverse pregnancy outcomes were compared between subgroups with logistic regression. Women were classified into four latent classes. Two classes represented the healthy higher-educated pregnant women who did not smoke: one group of multigravida women and one of primigravida women, also characterized by less pregnancy-specific knowledge and more pregnancy-related stress. The remaining women were grouped into two less healthy groups. One group frequently quit smoking, reported less healthy eating, less physical activity and comparable stress levels as the healthy higher-educated groups. The last group contained the most smokers, had the highest scores on psychosocial and pregnancy-related stress and the most adverse socio-economic circumstances. This group had an increased risk of adverse maternal outcomes, in particular developing diabetes during pregnancy. A comprehensive and integrated approach is needed to improve outcomes in pregnancies with a combination of adverse health, psychosocial, and socio-economic conditions.

Parent Training Programs for Ethnic Minorities: a Meta-analysis of Adaptations and Effect.

This meta-analysis focuses on parent training programs for ethnic minority families and reports on (i) the adaptation of program content and (ii) the process that informs these adaptations. Relevant studies are reviewed to determine the adaptations made and the impact of the adaptations on parenting and child outcomes. Studies were eligible for inclusion if they enrolled predominantly ethnic minority parents with children aged 0-12 years, used a randomized controlled trial design with post-intervention assessments, focused on group-based parent training programs and on prevention of parenting problems, and reported parenting behavior outcomes. A total of 18 studies were included in the analysis. The results show that parent training programs targeting ethnic minority parents have a small but significant effect on improving parenting behavior (k = 18, Cohen's d = 0.30), child outcomes (k = 16, Cohen's d = 0.13), and parental perspectives (k = 8, Cohen's d = 0.19). Most of the programs made adaptations related to surface and deep structure sensitivity. Programs with cultural adaptations, especially deep structure sensitivity (k = 7, Cohen's d = 0.54), are more effective in improving parenting behavior. Because only a third of the included studies provided details on the processes that guided the adaptations made, additional studies are needed to provide information on the process of adaptation; this will enable others to learn from the procedures that can be undertaken to culturally adapt interventions.

Critical stakeholder determinants to the implementation of intersectoral community approaches targeting childhood obesity.

Several intersectoral community approaches targeting childhood obesity (IACOs) have been launched in the Netherlands. Translation of these approaches into practice is however arduous and implementation. We therefore studied the implementation of five IACOs in the Netherlands for one-and-a-half years. IACO implementation was evaluated via an adapted version of the MIDI questionnaire, consisting of 18 theory-based constructs. A response rate of 62% was obtained. A hierarchical multivariate linear regression model was used to analyse our data; the final regression model predicted 65% of the variance in adherence. Higher levels of self-efficacy, being an implementer embedded in community B, and having more than 1 year of experience with IACO implementation were associated with higher degrees of adherence. Formal ratification of implementation by management and being prescribed a higher number of activities were related to lower degrees of adherence. We advise that, when designing implementation strategies, emphasis should be placed on the enhancement of professionals' self-efficacy, limitation of the number of activities prescribed and allocation of sufficient time to get acquainted and experienced with IACO implementation. Longitudinal studies are needed to further evaluate interaction between and change within critical determinants while progressing through the innovation process.

The effectiveness of school-based smoking prevention interventions among low- and high-SES European teenagers.

Preventing smoking initiation among adolescents of lower socio-economic groups is crucial for the reduction of socio-economic inequalities in health. The aim of the present study was to examine whether effective smoking prevention interventions in Europe are equally effective among adolescents of low- and high-socio-economic status (SES). As part of the European Union-funded TEENAGE project, three school-based smoking prevention intervention studies in Europe were selected for secondary analyses: (i) a Dutch class competition intervention, (ii) the European Smoking Prevention Framework (ESFA) study and (iii) the A Stop Smoking in Schools Trial (ASSIST) intervention. All three studies differed in effectiveness by SES. The Dutch class competition study only had a significant effect among higher SES adolescents. The results for the ESFA study and ASSIST study were mixed and depended on which SES indicator was used. The conclusion of the study is that stratified analyses provide important insights in differential intervention effects for higher and lower socio-economic groups. Although findings from the different studies were mixed, interventions that use a social network approach in which youngsters are allowed to deliver the intervention themselves may be a successful strategy in targeting adolescents from lower socio-economic groups.

Does a smoking prevention program in elementary schools prepare children for secondary school?

INTRODUCTION: A smoking prevention program was developed to prepare children in elementary school for secondary school. This study assessed the effects on smoking in secondary school. METHODS: In 2002, 121 schools in The Netherlands were randomly assigned to the intervention or control group. The intervention group received 3 lessons in 5th grade of elementary school and a second 3 lessons in 6th grade. The control group received "usual care". Students completed 5 questionnaires: before and after the lessons in 5th and 6th grade and in the first class of secondary school. At baseline, 3173 students completed the questionnaire; 57% completed all questionnaires. RESULTS: The program had limited effect at the end of elementary school. One year later in secondary school significant effects on behavioral determinants and smoking were found. The intervention group had a higher intention not to smoke (ß=0.13, 95% confidence interval=0.01-0.24) and started to smoke less often than the control group (odds ratio=0.59, 95% confidence interval=0.35-0.99): smoking increased from 2.5% to 3.6% in the intervention group and from 3.2% to 6.5% in the control group. Girls showed the largest differences in smoking between intervention and control condition. CONCLUSIONS: A prevention program in elementary school seems to be effective in preventing smoking.

[Slight decrease in the prevalence of smoking around pregnancy]. / Licht dalende prevalentie van roken rondom de zwangerschap.

OBJECTIVE: To establish smoking prevalence of fertile-aged women; before and during pregnancy, and 6 months after delivery. DESIGN: Cross-sectional. METHOD: Yearly surveys by questionnaires handed out during 2001-2003 to mothers visiting a Well Baby Clinic with infants aged 0-6 months. RESULTS: Out ofa total of 14,540 questionnaires, 9133 (63%) were completed and returned. Before pregnancy 25% of all the women concerned smoked, 6% stopped 6 months before getting pregnant; this percentage rose between 2001 (5%) and 2003 (7%). During pregnancy, 14% of the women smoked. This percentage was significantly lower in 2002 and 2003 (13%) compared to 16% in 2001. 11% smoked while pregnant (average 5 cigarettes daily), and 3% stopped some time during pregnancy. Of the mothers who quitted smoking before or during pregnancy, two thirds did so permanently. Nevertheless 15% of all women smoked during the first half year after delivery. This percentage was lowest in 2003 (14%) and highest in 2001 (17%). 28% of all mothers with infants aged 0-6 months had partners who smoked (daily 10 cigarettes average), these women were more likely to start smoking again (RR: 2). CONCLUSION: Minor positive changes were observed within the study period. A smoking partner contributed to smoking relapse after delivery.

Sustainability of the prevention of passive infant smoking within well-baby clinics.

This study assessed the antecedents of continued use of an education program to prevent passive smoking in infants. It consists of a booklet for parents and a manual for health professionals describing a five-step procedure for discussing passive smoking. A questionnaire was sent to 67 managers, 670 nurses, and 335 physicians working in well-baby clinics (response rate: 70%, 53%, 47% respectively). Questions concerned the completeness of use, level of institutionalization, and characteristics of the organization, the user, and the dissemination strategy. Seventy-one percent of nurses and 42% of physicians worked with the program. They foremost provided the first three steps of the five-step procedure. Physicians' completeness of use was related to their perceived responsibility in providing this education, and nurses' use was related to their perceived self-efficacy, responsibility, training attendance, participation in the adoption decision, and level of institutionalization. Diffusion efforts should focus on improving the completeness of use and level of institutionalization.

Determinants of participation in a cardiometabolic health check among underserved groups.

Cardiometabolic diseases affect underserved groups disparately. Participation in health checks is also lower, widening health inequalities in society. Two-stage screening (non-invasive health risk assessment (HRA) and GP consultations for high-risk individuals) seems cost-effective, provided that drop-out rates are low in both steps. We aimed to explore the process of decision-making regarding HRA participation among underserved groups (45-70 y): native Dutch with a lower socioeconomic status (SES), Turkish, Moroccan, and Surinamese participants. We conducted a cross-sectional questionnaire study. The questionnaire comprised the following determinants: a self-formulated first reaction, a structured set of predefined determinants, and the most important barrier(s) and facilitator(s) for HRA completion. We used univariable and (stepwise) multivariate logistic regression analyses to assess which determinants were associated with HRA completion. Of the 892 participants in the questionnaire, 78% (n = 696) also completed the HRA. Moroccans and patients from GP practices with a predominantly non-Western population less often completed the HRA. A lower SES score, wanting to know one's risk, not remembering receiving the invitation (thus requiring a phone call), fear of the test result and/or adjusting lifestyle, perceived control of staying healthy, wanting to participate, and perceiving no barriers were associated with completing the HRA. We conclude that our 'hard-to-reach' population may not be unwilling to participate in the HRA. A more comprehensive approach, involving key figures within a community informing people about and providing help completing the HRA, would possibly be more suitable. Efforts should be particularly targeted at the less acculturated immigrants with an external locus of control.

Prevention of smoking in adolescents with lower education: a school based intervention study.

OBJECTIVE: To assess the effect of an antismoking intervention focusing on adolescents in lower education. Students with lower education smoke more often and perceive more positive norms, and social pressure to smoke, than higher educated students. An intervention based on peer group pressure and social influence may therefore be useful to prevent smoking among these students. DESIGN: Group randomised controlled trial. SETTING: 26 Dutch schools that provided junior secondary education. SUBJECTS: 1444 students in the intervention and 1118 students in the control group, all in the first grade, average age 13 years. INTERVENTION: Three lessons on knowledge, attitudes, and social influence, followed by a class agreement not to start or to stop smoking for five months and a class based competition. MAIN OUTCOME MEASURES: Comparison of smoking status before and immediately after and one year after the intervention, using multilevel analysis. RESULTS: In the intervention group, 9.6% of non-smokers started to smoke, in the control group 14.2%. This leads to an odds ratio of 0.61 (95% CI= 0.41 to 0.90) to uptake smoking in the intervention group compared with the control group. One year after the intervention, the effect was no longer significant. CONCLUSIONS: In the short-term, an intervention based on peer pressure decreases the proportion of adolescents with lower education who start smoking. Influencing social norms and peer pressure would therefore be a promising strategy in terms of preventing smoking among adolescents. The results also suggest that additional interventions in later years are needed to maintain the effect.

Prevalence of passive smoking in infancy in The Netherlands.

The objective of the study was to assess the prevalence of passive smoking in infancy. This was done by self-report questionnaires completed by parents who attended the well-baby clinic in the period February-May 1996. A total of 2720 questionnaires were spread among parents with babies between 1 and 14 months: smoking and non-smoking parents. The questionnaires contained questions on smoking habits, smoking at home, smoking in presence of the baby. A total of 1702 parents filled in and returned the questionnaire (63%); 24% of the mothers and 33% of their partners smoked. In 44% of the families, one or more persons smoked; 22% of the mothers and 26% of the partners smoked at home. In 39% of the families, one or both parents smoked at home; 42% of the babies were exposed to tobacco smoke in the living-room, 8% were exposed in the car, and 4% during feeding. In cases where only the mother smoked, 13% of the infants were exposed to tobacco smoke during feeding. In the families where only the partner smoked, the babies were predominantly exposed to smoke in the car (18%). If both parents smoked, the child was most frequently exposed to tobacco smoke in the living-room (73%). It can be concluded that health workers, nurses, pediatricians and family physicians should be advised to inform parents systematically of the harmful effects of passive smoking in infancy. If parents are unable or unwilling to stop smoking, it is important to advise them to refrain from smoking in the presence of the baby.

Behavioural factors related to metabolic control in patients with phenylketonuria.

BACKGROUND: The objective of this study was to determine the importance of parental factors possibly related to dietary control in early and continuously treated patients with phenylketonuria (PKU). METHODS: A questionnaire was disseminated among parents of 238 patients with PKU born after the nationwide introduction of newborn screening for PKU (1 September 1974) until 31 December 1995. The questionnaire was based on a behavioural model measuring people's attitudes, subjective norms, and self-efficacy. Dietary control was defined on the basis of mean phenylalanine (Phe) concentration of the PKU patients measured between 1 January 1994 and 31 December 1996. RESULTS: Response rate was 71%. Attitudes: children of parents who believed that their child adheres well to the diet, even if his or her Phe concentrations are sometimes too high, had lower Phe concentrations than children of parents who disagree with this statement (adjusted difference -103 micromol/L, p < 0.001). Subjective norm: Phe concentrations were higher when parents answered that their relatives did not approve when their child deviates from the diet (p = 0.004). Self-efficacy: children of parents who reported difficulties in having their child eat the synthetic protein substitute three times a day had higher Phe concentrations than those of parents who did not have such difficulties (adjusted difference 156 micromol/L, p = 0.007). CONCLUSION: More attention should be given to parents having their child eat the synthetic protein substitute at least three times a day and to teaching parents to keep strictly to the diet without being too rigid. These factors were strongly associated to dietary control and may be amenable to change.

Factors that influence passive smoking in infancy: a study among mothers of newborn babies in The Netherlands.

BACKGROUND: The aim of this study was to assess the factors that influence smoking in the presence of the infant by mothers, partners, other family members, and friends. METHODS: An observational study using questionnaires was performed with smoking and nonsmoking parents of babies between 1 and 14 months old attending Dutch well-baby clinics between February and May 1996. The main measures were prevention of passive smoking in children by mothers and the relation with self-reported attitudes, social influence, and self-efficacy. RESULTS: A total of 1702 parents completed the questionnaire (63%). A total of 1551 questionnaires were completed by the mother. Sixty-five percent of the mothers prevented passive smoking by their child. This figure was 55% for smokers and 69% for nonsmokers. Attitude was the factor that most explained preventive behavior among both smokers and nonsmokers. Among the respondents, a lack of prevention of passive smoking was significantly related to (1) a negative attitude and 2) a negative social influence exerted by their partner, (3) lower self-efficacy in reducing passive smoking, and (4) increasing age of the child. (5) Finally, a lack of prevention is associated with the mother's self-efficacy in asking others not to smoke. This association strongly differs between smoking and nonsmoking mothers. CONCLUSION: The results suggest that health education efforts should focus on attitude and self-efficacy, assuming that these precede actual behavior, and in particular on the health consequences of the exposure of young children to tobacco smoke. The information should not be restricted to parents of newborn babies; it should also focus on parents with older children. Particular attention should be paid to smokers with a low educational level. The results also indicate that education should strengthen the ability of nonsmoking parents to deal with smokers and the ability of smoking parents to deal with their own smoking behavior.

Parental education on passive smoking in infancy does work.

BACKGROUND: Passive smoking is harmful to young children. A protocol has been developed to allow health care workers to communicate with parents about preventing passive smoking. The main message was to refrain from smoking in the presence of the child. The aim of the study was to assess the effectiveness of this education programme. METHOD: The prevalence of smoking in the presence of infants aged 0-10 months was compared before and after the implementation of the education programme. National samples of mothers completed questionnaires in 1996 (n = 1,129) and in 1999 (n = 2,534). Questions were asked about smoking in the living room in the presence of infants, and about parental smoking, and background characteristics. RESULTS: The prevalence of passive infant smoking decreased from 41% to 18%. The adjusted odds ratio for passive infant smoking in 1999 compared to 1996 was 0.34 (0.26-0.44) when none of the parents smoked, 0.19 (0.14-0.27) when one of the parents smoked, and 0.30 (0.20-0.44) when both parents smoked. CONCLUSION: The implementation of this health education programme seems to have been very successful in reducing passive smoking in children. Implementation of similar health education programmes in other countries is recommended.