Participatory research in health promotion: a critical review and illustration of rationales.

In health promotion research, enthusiasm for patient and public involvement (PPI) is growing. However, a lack of conceptual clarity leads to ambiguities in participatory processes and purposes, and hampers efforts to achieve and evaluate PPI in research. This study provides an overview of its underlying reasons-or rationales-so as to better understand, guide and interpret PPI in research practice. We conducted a critical review to identify typologies of rationales for PPI. We re-categorized the different types of rationales from these typologies based on their content. We illustrated the resulting categories of rationales with examples from a case study on PPI in research on Lyme disease. Five categories of rationales for PPI were identified. The democratic rationale reflects the normative right of citizens to have a voice in research. The consumerist rationale refers to the economic right of stakeholders with interests to have a say. Rooted in social justice, the transformative rationale seeks to empower marginalized groups. The substantive rationale starts from epistemic considerations and aims to improve the quality of knowledge that research generates. The instrumental rationale is of pragmatic origin and refers to improved efficiency and effectiveness of the research. Our overview of categories of rationales can be used as a frame of reference for PPI in health promotion research. Exploring, stating explicitly and reflecting on the underlying reasons for PPI may help to define realistic purposes, select matching approaches and design appropriate evaluation studies. This might also contribute to the conceptualization of PPI.

Enthusiasm for patient and public involvement in health promotion research is growing. However, it often remains unclear why this involvement is being organized. This lack of clarity makes it difficult to implement such participatory research and to evaluate its added value. We searched for reasons that were given for starting patient and public involvement in research. We found five different reasons. The first is the right of all citizens to have a say in research that affects them. The second is the right of individuals to demand the best research. The third is the desire to involve and empower marginalized groups. The fourth aims to improve the quality of the knowledge generated by the research. The fifth is to achieve more effective and efficient research. Together, these reasons may help researchers get more clarity about why patients or the public should be involved in their studies. This may in turn help to define realistic purposes, design a good participatory process, and conduct appropriate evaluations. All in all, using these five reasons as a frame of reference might lead to a better understanding of what good participatory research in health promotion should look like.

Gaining 'clarity through specificity' in invited patient participation: A case study of a multifaceted participatory practice in the Netherlands.

Patient participation is a highly valued principle. Yet, it remains difficult both to achieve it and to assess its added value, as participation is often started without much clarification of what it means or aims to do. In theory, patients may be invited to participate for reasons of democracy, empowerment, knowledge integration and instrumentalism. By making these rationales explicit in a participatory practice in the Netherlands, we aimed to contribute to the long-needed 'clarity through specificity' in participation. Apart from the rationales, our analytic framework included dimensions of the participatory process, reflected by questions like 'Who participates?', 'In what?' and 'With how much control?' We used this framework to conduct and analyse semi-structured interviews (n = 51) with patient participants (20), professionals (14) and researchers (17). We found that the participatory practice included all rationales and that the actual manifestation of an intended rationale very much depended on the design of the dimensions of the participatory process. We conclude that invited participation may gain in clarity by making explicit the rationales for participation. If put at the centre of attention, and made the leading factor in the design of the dimensions of the participatory process, explicit rationales may support the realisation of participation in practice and prevent it from resulting in mere window-dressing.

Contextual factors that shape uptake of COVID-19 preventive measures by persons of Ghanaian and Eritrean origin in the Netherlands: A focus group study.

OBJECTIVES: To explore the contextual factors that shape uptake of COVID-19 preventive measures, in specific migrant and ethnic minority populations, with a focus on migration-related, sociocultural and socioeconomic conditions. DESIGN: A qualitative design, consisting of three online focus group discussions. SETTING: This study was conducted amongst smaller, albeit substantial, migrant and minority ethnic populations in the Netherlands. PARTICIPANTS: A total of 25 participants (12 male; 13 female) of Ghanaian and Eritrean origin, purposively sampled to ensure diversity within groups, with regards to sex, age, educational level, occupation, household size and length of stay in the Netherlands. Focus group discussions were held online, therefore, experience in the use of video conferencing software was a prerequisite. RESULTS: Participants' awareness and knowledge of COVID-19 and COVID-19 preventive measures was shaped by migration-related factors, such as limited Dutch proficiency, by access to understandable information and interference of misinformation. Participants' engagement by COVID-19 preventive measures was subject to COVID-19 threat appraisal and the ease with which complex behavioural messages could be translated to individual situations. Lastly, a strong social norm to keep with cultural and religious practices, and limited opportunity for preventive behaviour in the work and home context hinder the uptake of preventive behaviour following a decision to act according to measures. CONCLUSIONS: Migration-related, sociocultural, and socioeconomic factors shape uptake of COVID-19 preventive measures amongst persons of Ghanaian and Eritrean origin in The Netherlands. To ensure equitable uptake our results suggest the importance of timely spread of multilingual information tailored to literacy needs; as well as, education and modelling delivered through online platforms and by leading figures in respective communities; and, regulations to ensure continued access to financial and material resources to minimise negative spill-over effects and exacerbation of inequality.

Understanding transnational healthcare use in immigrant communities from a cultural systems perspective: a qualitative study of Dutch residents with a Turkish background.

OBJECTIVES: Transnational utilisation of healthcare by people with an immigrant background carries risks, including medicalisation and adverse iatrogenic outcomes. We investigated the drivers behind such transnational healthcare use from a cultural perspective on health systems. DESIGN: Qualitative interview study (2018). SETTING: Two primary care practices in Amsterdam, the Netherlands. PARTICIPANTS: Thirteen Dutch patients of Turkish background, who had obtained healthcare in Turkey, and who in general visited the primary care practice more than once a month. RESULTS: In the respondents' stories, we observed how: (1) cross-border healthcare use was encouraged by cultural mismatches between expected and provided services and by differing explanatory models of illness upheld by patients and Dutch providers; (2) both transnationalism in patients and entitlements to insurance reimbursement facilitated the use of Turkish health services to bypass perceived barriers in the Dutch system; (3) cultural mismatches were reinforced during general practitioner consultations after the patients' return to the Netherlands, thereby inducing further service use abroad. CONCLUSIONS: Although cultural system influences are difficult to bridge, measures to reduce the unwelcome consequences of transnational healthcare use may include (1) strengthening the provision of culturally sensitive care in the country of residence and (2) restricting the reimbursement of care in the country of origin while maintaining the option to obtain care abroad.

Associations of sustained smoking and smoking cessation with work-related outcomes: a longitudinal analysis.

PURPOSE: The aim of this study was to assess the association between sustained smoking and quitting with work-related outcomes among older workers. METHODS: We categorized a sample of older employees into non-smokers, sustained smokers and quitters. Multivariable regression models were used to test longitudinal associations of sustained smoking and smoking cessation with sickness absence, productivity loss and work ability. RESULTS: We included 3612 non-smokers, 673 sustained smokers and 246 quitters. Comparing sustained smokers to non-smokers, we found higher (but not statistically significant) sickness absence for sustained smokers [1.01, 95% confidence interval (CI) - 0.16-2.17]. We did not find differences in productivity loss (OR 0.82, 95% CI 0.60-1.13) and work ability (0.05, 95% CI -0.05-0.15). For employees with a relatively high physical health at baseline, comparing quitters to sustained smokers, we found higher (but not statistically significant) productivity loss for quitters (OR 2.23, 95% CI 0.94-5.31), and no difference in sickness absence (0.10, 95% CI - 2.67-2.87), and work ability (- 0.10, 95% CI -  0.36-0.16). For employees with a relatively low physical health at baseline, comparing quitters to sustained smokers, we found a statistically significant lower work ability (- 0.31, 95% CI - 0.57-0.05), and no difference in sickness absence (2.53, 95% CI - 1.29-6.34) and productivity loss (OR 1.26, 95% CI 0.66-2.39). CONCLUSIONS: We found no evidence that sustained smokers have less favorable work-related outcomes than non-smokers or that quitters have more favorable work-related outcomes than sustained smokers. The benefits of smoking cessation for employers might take a longer time to develop.

Smoking and sickness absence: a systematic review and meta-analysis.

Objectives Evidence on the effect of smoking on sickness absence could guide workplace smoking cessation interventions and encourage employers to promote smoking cessation among their employees. This systematic review and meta-analysis aimed to summarize evidence on the association between smoking and sickness absence and determine whether there are differences in this association for study design, methodology, and sample characteristics. Methods We searched for studies that reported on smoking status and sickness absence, used empirical data, were published in a peer-reviewed journal in the last 25 years, and written in English. We conducted pooled analyses in which uni- and multivariate generalized linear regression models were applied. Results After screening 2551 unique records, 46 articles from 43 studies were included, of which 33 studies (with 1 240 723 participants) could be included in the pooled analyses. Smoking was associated with an 31% increase in risk of sickness absence compared to non-smoking (95% confidence interval (CI) 1.24-39). We did not find statistically significant different effect sizes for study location, gender, age, occupational class, study design, assessment of sickness absence, short- versus long-term sickness absence, and adjustment for relevant confounders. Furthermore, smoking was associated with 2.89 more sickness absence days per year compared to non-smoking (95% CI 2.08-3.70). Conclusions We found robust evidence showing that smoking increases both the risk and number of sickness absence days in working populations, regardless of study location, gender, age, and occupational class. Encouraging smoking cessation at the workplace could therefore be beneficial for employers and employees.

Sensitivity of point-of-care testing C reactive protein and procalcitonin to diagnose urinary tract infections in Dutch nursing homes: PROGRESS study protocol.

INTRODUCTION: Suspected urinary tract infection (UTI) ranks among the most common reasons for antibiotic use in nursing homes. However, diagnosing UTI in this setting is challenging because UTI often presents with non-specific symptomatology. Moreover asymptomatic bacteriuria is common in elderly, which complicates attribution of causality to detection of bacteria in urine. These diagnostic challenges contribute to overuse of antibiotics and emergence of antimicrobial resistance in nursing homes. Given the diagnostic challenges, there is a need for point-of-care (POC) diagnostic tests to support clinical rules for diagnosing UTI. Procalcitonin (PCT) and C reactive protein (CRP) are inflammatory blood markers that have been proven useful to support diagnosis and monitoring of (bacterial) respiratory tract infections and sepsis. While limited studies suggest their usefulness in supporting UTI diagnosis, their utility has not been studied in elderly populations for this purpose. METHODS AND ANALYSIS: In a 24-month matched prospective study, 'PROGRESS' will assess and compare the sensitivity of rapid POC measurements of blood CRP and PCT levels to support clinical rules for diagnosing UTI in nursing home residents. The primary outcome measure is sensitivity of the POC tests to identify patients with true UTI based on the predefined definition, as derived from receiver operating curves. ETHICS AND DISSEMINATION: This study will be conducted in accordance with Good Clinical Practice guidelines and the principles of the Declaration of Helsinki. The study protocol is approved by the Medical Ethical Committee of Amsterdam UMC location VUmc with reference number 2017.350 and National Central Committee on Research involving Human Subjects with reference number NL62067.029.17. TRIAL REGISTRATION NUMBER: NTR6467.

"Like you are fooling yourself": how the "Stoptober" temporary abstinence campaign supports Dutch smokers attempting to quit.

BACKGROUND: The Stoptober temporary abstinence campaign challenges smokers to engage in a collective quit attempt for 28 days. The campaign is based on social contagion theory, SMART (i.e., Specific, Measurable, Attainable, Realistic and Time-sensitive) goal setting and PRIME (i.e., Plans, Responses, Impulses, Motives and Evaluations) theory. Although Stoptober was found to yield impressive 28-day quit rates, relapse rates remained substantial. Therefore, we examined how Stoptober supported smokers in their attempt to quit and how the campaign's effectiveness could be strengthened. METHODS: In 2016, we conducted semi-structured interviews with 23 Stoptober participants in the Netherlands. Data were analyzed thematically. RESULTS: Respondents explained how social contagion-based components had familiarized them with Stoptober, motivated them to participate, and created a pro-smoking cessation social norm. Setting SMART goals was reported as "fooling yourself", since it distracted respondents from their goal of quitting for good and helped them perceive that temporary abstinence was achievable. Respondents also illustrated the usefulness of PRIME theory. They typically used an individual selection of available supports that varied over time. To achieve long-term abstinence, respondents expressed the need for additional social network support and interactive, personalized and professional support during and after the campaign. CONCLUSIONS: Stoptober supports smokers in their attempts to quit and generally according to the campaign's theoretical principles. Added to available evidence, this finding supports the continuation and wider implementation of Stoptober, while connecting the campaign to social networks and regular smoking-cessation services to help improve long-term abstinence rates.

Understanding the multitude of barriers that prevent smokers in lower socioeconomic groups from accessing smoking cessation support: A literature review.

One explanation for the increasing smoking-related health inequalities is the limited access of lower socioeconomic status (SES) smokers to smoking cessation support. In order to understand this limited access - and to eventually improve accessibility - we provide a structured overview of the barriers that lower SES smokers face in the successive phases of access to cessation support. Our literature review included 43 papers on barriers of access to cessation support for lower SES smokers, published before June 2016. We used the access to health care framework to categorize the extracted barriers into (a) either the abilities of smokers or dimensions of cessation support and (b) one of the successive phases of access to support. We found that lower SES smokers encounter many barriers. They are present in all phases of access to cessation support, and different barriers may be important in each of these phases. We also found that each phase transition is hampered by barriers related to both the abilities of smokers and the dimensions of cessation support, and that these barriers tend to interact, both with each other and with the disadvantaged living conditions of lower SES smokers. In conclusion, reducing smoking-related health inequalities by improving lower SES smokers' access to smoking cessation support requires a comprehensive approach. Our structured overview of barriers may serve as a starting point for tailoring such an approach to the multitude of barriers that prevent lower SES smokers from accessing cessation support, while simultaneously taking into account their disadvantaged living conditions.

Effectiveness of a Large, Nation-Wide Smoking Abstinence Campaign in the Netherlands: A Longitudinal Study.

From 2014, the 28-day smoking abstinence campaign 'Stoptober' is held in the Netherlands. Each year, more than 50,000 people participate in what has become a nation-wide collective cessation attempt. This study aims to determine the short-term effects of 'Stoptober' on participants' smoking behavior and behavioral determinants. Stoptober participants completed online surveys before the start of the campaign (n = 6856) and three months later (n = 1127). Descriptive statistics and t-tests were performed to determine changes in smoking and behavioral determinants. Logistic regression analyses were used to identify differences between subgroups. After three months, 71.8% of respondents had quit smoking and consumption was reduced among sustained smokers. Cessation rates were similar for subgroups by age, sex and educational level. Cessation was positively associated with confidence and self-efficacy at baseline and negatively associated with past year quit attempts and addiction level at baseline. For quitters, we found favorable changes in attitude towards cessation related stress, social norms, social pressure to smoke, self-efficacy to quit, smoking habit strength and smoker identity. For sustained smokers, we found favorable changes in attitude towards cessation related stress, self-efficacy and smoking habit strength. These results suggest that an abstinence campaign with a wide reach in a national population may be effective in decreasing smoking prevalence and cigarette consumption among a broad range of participants.

Implementing multiple intervention strategies in Dutch public health-related policy networks.

Improving public health requires multiple intervention strategies. Implementing such an intervention mix is supposed to require a multisectoral policy network. As evidence to support this assumption is scarce, we examined under which conditions public health-related policy networks were able to implement an intervention mix. Data were collected (2009-14) from 29 Dutch public health policy networks. Surveys were used to identify the number of policy sectors, participation of actors, level of trust, networking by the project leader, and intervention strategies implemented. Conditions sufficient for an intervention mix (≥3 of 4 non-educational strategies present) were determined in a fuzzy-set qualitative comparative analysis. A multisectoral policy network (≥7 of 14 sectors present) was neither a necessary nor a sufficient condition. In multisectoral networks, additionally required was either the active participation of network actors (≥50% actively involved) or active networking by the project leader (≥monthly contacts with network actors). In policy networks that included few sectors, a high level of trust (positive perceptions of each other's intentions) was needed-in the absence though of any of the other conditions. If the network actors were also actively involved, an extra requirement was active networking by the project leader. We conclude that the multisectoral composition of policy networks can contribute to the implementation of a variety of intervention strategies, but not without additional efforts. However, policy networks that include only few sectors are also able to implement an intervention mix. Here, trust seems to be the most important condition.

Opportunities for Tailored Support to Implement Smoke-Free Homes: A Qualitative Study among Lower Socioeconomic Status Parents.

With the aim of preventing children from being exposed to secondhand smoke, we examined to which level lower socio-economic status (SES) households had implemented home smoking rules and the factors that hampered parents in their process of change toward a complete smoke-free home (SFH). We conducted a qualitative study including semi-structured in-depth interviews with 14 parents of young children living in a lower SES neighborhood of a provincial town in the Netherlands. Interview transcripts were subjected to a qualitative content analysis. Three distinct levels of SFH implementation emerged: complete SFH, flexible SFH, and partial SFH. Differences between parents at these three levels essentially concerned: (1) the role of child-related moral considerations in their motivation for an SFH; (2) whether they felt they had the agency to set and enforce home smoking rules; (3) the difficulties they experienced in changing their smoking habit from smoking indoors to smoking outdoors. Parents also had different opinions about the role their children could play in facilitating the parental process of change. We conclude that the current level of SFH implementation may serve as a starting point for developing tailored interventions. Such interventions should probably address other factors than the commonly used awareness-knowledge-commitment approach.

Eating together as a social network intervention for people with mild intellectual disabilities: a theory-based evaluation.

PURPOSE: People with mild intellectual disabilities (MID) generally live independently among the wider community. This can result in social exclusion and feelings of loneliness. Therefore, social work organizations aim to socially include people with MID through organizing activities in neighbourhoods that should lead to enlarged networks and increased societal participation. The "Communal Table" is such a, group-orientated, intervention that organizes monthly dinners in Amsterdam, the Netherlands. Because little is known about the effectiveness of interventions aiming to bring about social inclusion for people with MID we explored which types of participants were reached and whether and how the intervention brought about the intended outcomes. METHODS: We performed a theory-based evaluation, using participatory observations and qualitative interviews (n = 19). The Communal Table attracted a diverse and loyal group of participants. RESULTS: We distinguished four types of participants-lonely participants, activist participants, satisfied participants and calculating participants-whose pre-existing networks played a significant role in their individual needs for support and the outcomes of the intervention. Outcomes reported included experiences of conviviality and warmth, temporary relief of underlying problems and an overall positive opinion about the intervention, but network enlargement or increased societal participation were not reported. CONCLUSIONS: Our findings suggest that social network interventions for people with MID should be tailored to participants' pre-existing networks and related individual needs to be successful.

A school-based interdisciplinary approach to promote health and academic achievement among children in a deprived neighborhood: study protocol for a mixed-methods evaluation.

BACKGROUND: The large number of children that grow up in poverty is concerning, especially given the negative developmental outcomes that can persist into adulthood. Poverty has been found as a risk factor to negatively affect academic achievement and health outcomes in children. Interdisciplinary interventions can be an effective way to promote health and academic achievement. The present study aims to evaluate a school-based interdisciplinary approach on child health, poverty, and academic achievement using a mixed-method design. Generally taken, outcomes of this study increase the knowledge about effective ways to give disadvantaged children equal chances early in their lives. METHODS: An observational study with a mixed-methods design including both quantitative and qualitative data collection methods will be used to evaluate the interdisciplinary approach. The overall research project exists of three study parts including a longitudinal study, a cross-sectional study, and a process evaluation. Using a multi-source approach we will assess child health as the primary outcome. Child poverty and child academic achievement will be assessed as secondary outcomes. The process evaluation will observe the program's effects on the school environment and the program's implementation in order to obtain more knowledge on how to disseminate the interdisciplinary approach to other schools and neighborhoods. DISCUSSION: The implementation of a school-based interdisciplinary approach via primary schools combining the cross-sectoral domains health, poverty, and academic achievement is innovative and a step forward to reach an ethnic minority population. However, the large variety of the interventions and activities within the approach can limit the validity of the study. Including a process evaluation will therefore help to improve the interpretation of our findings. In order to contribute to policy and practice focusing on decreasing the unequal chances of children growing up in deprived neighborhoods, it is important to study whether the intervention leads to positive developmental outcomes in children. TRIAL REGISTRATION: ( NTR 6571 ) (retrospectively registered on August 4, 2017).

Stronger declines in youth alcohol consumption thanks to stronger integrated alcohol policies? A qualitative comparison of ten Dutch municipalities.

BACKGROUND: Little detailed evidence is available on how integrated policies could impact population health and under what conditions such policies could be realized. The aim of this study was to assess how youth alcohol consumption trends in the province of Noord-Brabant, The Netherlands, were related to the development and implementation of integrated policies. METHODS: In a retrospective multiple case study, alcohol policies of six municipalities with stronger declines in youth alcohol consumption between 2007 and 2011 (cases) were compared to four municipalities with weaker declines (controls). Information on the policy process in the same period was obtained through semi-structured in-depth interviews with policy advisors. Information on implemented interventions was extracted from policy documents and checked by the interviewees. Interviews were analyzed for thematic content. RESULTS: Only municipalities with stronger declines in alcohol consumption involved sectors other than public health and had started to implement interventions that use regulatory or enforcement strategies. Their involvement was facilitated by framing youth alcohol consumption as a safety rather than a health problem, whereby local media played a substantial role. Implementation of integrated policies was further facilitated by dedicated leadership and sufficient resources. CONCLUSIONS: Reductions in youth alcohol consumption in Noord-Brabant were stronger when municipalities started to develop integrated policies. Results suggest that integrated policies framing a health problem as a broader societal problem could positively influence population health.

Sustainability of the good behaviour game in Dutch primary schools.

Summary: Sustainability of health promotion programs is essential to maintain their positive effects. However, few studies have examined the extent of program sustainability and the factors influencing it. We examined these issues through the Good Behaviour Game (GBG), a classroom-based program in primary schools with beneficial behavioural and health-related effects that was implemented in 2008. GBG coordinators of 17 participating schools were invited in the study 2 years after the initial program implementation. Sustainability was measured using a 20-item checklist comprised of four dimensions of routinization including: memory, adaptation, values and rules. A semi-structured interview was then completed with 16 of the GBG coordinators to discuss the checklist scores and to probe in more depth the current level of sustainability. Based on the checklist scores, sustainability of the GBG was considered 'high' in five schools, 'medium' in another five and 'weak' in six. Factors influencing sustainability identified by GBG coordinators were organizational strength, strong leadership, program championship and the perceived modifiability and effectiveness of the GBG. Also, different factors were related to different dimensions of routinization. The combination of a sustainability checklist and an interview about influential factors may help to further clarify the sustainability construct and reveal which implementation sites, routinization dimensions and influential factors should be explored to further facilitate the sustaining of programs with proven effectiveness.

Impact of Cross-Sectoral Alcohol Policy on Youth Alcohol Consumption.

OBJECTIVE: Cross-sectoral alcohol policy is recommended to reduce youth alcohol consumption, but little evidence is available on its effectiveness. Therefore, we examined whether regions and municipalities in the Dutch province of Noord-Brabant with stronger cross-sectoral alcohol policy showed larger reductions in alcohol consumption among adolescents aged 12-15. METHOD: Strong regional cross-sectoral alcohol policy was defined as participation in a regional alcohol prevention program. Strong municipal cross-sectoral alcohol policy was operationalized by measures on (a) sector variety: involvement of different policy sectors, and (b) strategy variety: formulation of different policy strategies. Relevant data from policy documents were searched for on the Internet. Data on trends in alcohol consumption were extracted from the 2007 and 2011 cross-sectional Youth Health Monitor that includes a random subset of adolescents aged 12-15 (n = 15,380 in 2007 and n = 15,437 in 2011). We used multilevel regression models. RESULTS: Two of the three regions in which municipalities participated in a regional alcohol prevention program showed a larger reduction in weekly drinking than the region in which municipalities did not participate (-12.2% and -13.4% vs. -8.3%). Municipalities with strong compared to weak sector variety showed a larger increase in adolescents' age at consuming their first alcoholic drink (0.63 vs. 0.42 years). Municipalities with strong strategy variety showed a decrease (-3.8%) in heavy weekly drinking, whereas those with weak variety showed an increase (5.1%). Cross-sectoral alcohol policy did not affect trends in other alcohol outcomes. CONCLUSIONS: Our results suggest that strong cross-sectoral alcohol policy may contribute to reducing some aspects of youth alcohol consumption. Monitoring policy implementation is needed to assess the full impact.

Understanding the impact of area-based interventions on area safety in deprived areas: realist evaluation of a neighbour nuisance intervention in Arnhem, the Netherlands.

BACKGROUND: Area-based health inequalities may partly be explained by higher levels of area disorder in deprived areas. Area disorder may cause safety concerns and hence impair health. This study assessed how, for whom and in what conditions the intervention Meeting for Care and Nuisance (MCN) had an impact on neighbour nuisance and area safety in four deprived districts in Arnhem, the Netherlands. METHODS: Realist evaluation methodology was applied to uncover how, for whom, and under what conditions MCN was expected to and actually produced change. Expected change was based on action plans and scientific theories. Actual change was based on progress reports, media articles, interviews with district managers, and quantitative surveys. RESULTS: Three levels of impact were distinguished. At the organisational level, partly as expected, MCN's coordinated partnership strategy enabled role alignment, communication, and leadership. This resulted in a more efficient approach of nuisance households. At the level of nuisance households, as expected, MCN's joint assistance and enforcement strategy removed many of the underlying reasons for nuisance. This resulted in less neighbour nuisance. At the district level, perceptions of social control and area safety improved only in one district. Key conditions for change included a wider safety approach, dense population, and central location of the district within the city. CONCLUSIONS: This realist evaluation provided insight into the mechanisms by which a complex area-based intervention was able to reduce neighbour nuisance in deprived areas. Depending on wider conditions, such a reduction in neighbour nuisance may or may not lead to improved perceptions of area safety at the district level.

Use of a knowledge broker to establish healthy public policies in a city district: a developmental evaluation.

BACKGROUND: Public health is to a large extent determined by non-health-sector policies. One approach to address this apparent paradox is to establish healthy public policies. This requires policy makers in non-health sectors to become more aware of the health impacts of their policies, and more willing to adopt evidence-informed policy measures to improve health. We employed a knowledge broker to set the agenda for health and to specify health-promoting policy alternatives. This study aimed at gaining in-depth understanding of how this knowledge broker approach works. METHODS: In the context of a long-term partnership between the two universities in Amsterdam and the municipal public health service, we employed a knowledge broker who worked part-time at a university and part-time for an Amsterdam city district. When setting an agenda and specifying evidence-informed policy alternatives, we considered three individual policy portfolios as well as the policy organization of the city district. We evaluated and developed the knowledge broker approach through action research using participant observation. RESULTS: Our knowledge brokering strategy led to the adoption of several policy alternatives in individual policy portfolios, and was especially successful in agenda-setting for health. More specifically, health became an issue on the formal policy agenda as evidenced by its uptake in the city district's mid-term review and the appointment of a policy analyst for health. Our study corroborated the importance of process factors such as building trust, clearly distinguishing the knowledge broker role, and adequate management support. We also saw the benefits of multilevel agenda-setting and specifying policy alternatives at appropriate policy levels. Sector-specific responsibilities hampered the adoption of cross-sectoral policy alternatives, while thematically designed policy documents offered opportunities for including them. Further interpretation revealed three additional themes in knowledge brokering: boundary spanning, a ripple effect, and participant observation. CONCLUSIONS: The employment of a knowledge broker who works simultaneously on both agenda-setting for health as well as the specification of health-promoting policy alternatives seems to be a promising first step in establishing local healthy public policies. Future studies are needed to explore the usefulness of our approach in further policy development and policy implementation.