What makes community sports programs successful? A group concept mapping study to identify effective elements.

Adults in socially vulnerable positions can benefit from participation in community sports programs. However, there is a lack of knowledge about the effective elements of these programs. To identify these elements, we consulted three groups of stakeholders: social sports coaches, program coordinators, and social workers. The effective elements were systematically arranged by means of group concept mapping (GCM), a mixed-methods approach for organizing thoughts. The social sports coaches (n = 14) mentioned 152 effective elements, the program coordinators (n = 5) mentioned 81 effective elements and the social workers (n = 8) mentioned 115 effective elements. Overlapping effective elements were mentioned by all three stakeholder groups, such as the role of the social sports coach, a safe sports climate, and structure of sports programs. However, the sport-specific knowledge and skills of coaches were mentioned only by program coordinators. Moreover, only the social workers provided elements that were protective in nature, such as not overburdening the participants. Average importance scores differed for these elements within groups and between groups. In conclusion, various effective elements were deemed necessary for community sports programs to be successful. Moreover, GCM appeared a successful tool to systematically identify effective elements of an intervention from the perspective of relevant stakeholders.

Qualitative evaluation of a Salutogenic Healthy Eating Programme for Dutch people with type 2 diabetes.

The salutogenic model of health (SMH) is a health-promoting theory that focuses on resources, strengths, and coping capacities in everyday life as a way to improve health and wellbeing. The SMH was applied to develop a programme for enabling healthy eating practices among people with type 2 diabetes mellitus (T2DM): the SALUD programme. This study aims to gain insight in how participants with T2DM experienced the content and meaning of the SALUD programme. Three focus groups with participants (six to eight participants/group) that finished the SALUD programme were conducted. The focus groups were video-recorded, transcribed ad verbatim and thematically analysed. The SALUD programme was perceived by the participants as a positive, meaningful learning experience. Key factors why the participants described the programme as positive were that they felt a sense of social-belonging and (emotionally) safe (theme 1). The SALUD programme's positive encouraging approach presented by the coach invited participants to join an active learning process (theme 2). Performing trial-and-error experiments and weekly reflecting on goals is what characterized active learning. The meaningfulness of the learning process (theme 3) was derived from (i) positive self-confrontation; (ii) exploring mind-body connections and perceiving improved health and (iii) noticing positive changes in their social environment (theme 3). To conclude, the study uncovered that the SALUD programme incited a positive, meaningful learning process for healthy eating and the contextual factors important in this. Potential leads to further improve the SALUD programme are discussed in order to maximize the chance of inciting an inclusive, active learning process.

Bariatric surgery stigma from the perspective of patients: A scoping review.

AIMS: To explore the experiences and consequences of bariatric surgery stigma from the perspective of bariatric surgery patients and to identify knowledge gaps in the literature. DESIGN: A scoping review. DATA SOURCES: Studies published between December 2002 and January 2022 were identified from the following databases: PubMed, Web of Science, PsycINFO and MEDLINE. REVIEW METHODS: We screened 3092 records and included 28 studies. Findings were grouped thematically using the health stigma discrimination framework. RESULTS: Patients experienced several types of stigmas, including perceived, experienced, anticipated and internalized stigma, related to undergoing bariatric surgery. Patients were confronted with negative comments and judgement from others when they disclosed their decision to have surgery or when they revealed that they had undergone surgery. These experiences led to conflicts in the decision-making process, such as delaying the choice for surgery, seeking surgery abroad or opting out. Patients who internalized stigma often reported feelings of shame and embarrassment for choosing surgery and felt the need for secrecy or selective disclosure. Stigma experiences were influenced by gender and differed between different subgroups of patients. CONCLUSION: The stigma surrounding bariatric surgery has detrimental consequences for eligible individuals and bariatric surgery patients. However, the evidence from patients' perspective remains limited. More research into patient's experiences is needed to improve patient care and further educate healthcare professionals. In addition, to better understand the nature and implications of bariatric surgery stigma, future research should be founded on stigma theories and distinguish between the different types of stigmas. IMPACT: This scoping review contributes to a better understanding of the implications the stigma surrounding bariatric surgery has for bariatric surgery patients before and after surgery. The knowledge generated by this review can inform improvements in the education and management of people living with obesity and bariatric surgery patients. REPORTING METHOD: The scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews checklist. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution. PROTOCOL REGISTRATION: A protocol was not registered for this scoping review.

Strategies for public health adaptation to climate change in practice: social learning in the processionary Moth Knowledge Platform.

Social learning theory can support understanding of how a group of diverse actors addresses complex challenges related to public health adaptation. This study focuses on one specific issue of public health adaptation: oak processionary moth (OPM) adaptation. With a social learning framework, we examined how public health adaption strategies gradually develop and are adjusted on the basis of new knowledge and experiences. For this qualitative case study, data were collected through 27 meetings of the Processionary Moth Knowledge Platform in the Netherlands and six additional interviews. Results indicate that relations between stakeholders, including experts played a major role in the learning process, facilitating the development and implementation of OPM adaptation and connecting local challenges to national adaptation strategies. Uncertainties regarding knowledge and organization were recurrent topics of discussion, highlighting the iterative and adaptive nature of public health adaptation. The study emphasizes the importance of building relationships among stakeholders and small steps in the learning process that can lead to the creation of new strategies and, if successful, the prevention of negative health impacts.

Effects of a Salutogenic Healthy Eating Program in Type 2 Diabetes (the SALUD Study): Protocol for a Randomized Controlled Trial.

BACKGROUND: Healthy eating can improve the course of type 2 diabetes mellitus (T2DM) considerably. As changing eating behaviors in everyday is challenging, there is a need for a nutritional strategy with an eye for everyday life of people with T2DM. A theory centered around the everyday life context is salutogenesis. Salutogenic principles have been operationalized in a new nutritional program for T2DM on food literacy and well-being: the Salutogenic Intervention for Type 2 Diabetes (SALUD) program. OBJECTIVE: This study aims to describe the protocol of the invention study that will examine the quantitative and qualitative effects of the SALUD program. METHODS: A semiblinded randomized controlled trial will be performed in the Netherlands. A sample size of 56 (including a 30% dropout rate) people with T2DM has been calculated, of whom half (n=28, 50%) will follow the SALUD program (intervention) and half (n=28, 50%) will receive usual care (control). Recruitment strategies consist of advertisement via local health care professionals, posters, social media, and local newspapers. The SALUD program consists of 12 weekly web-based group sessions under the supervision of a certified lifestyle coach. Fidelity of the delivery is guaranteed by selecting a salutogenic coach, use of an intervention manual, training of the coach, weekly evaluation forms, and recording several sessions. The theoretical salutogenic principle of the intervention is mobilizing 2 important psychosocial resources required for organizing healthy eating in everyday life: self-identity and social support. Measurements will be performed at 3 times: at baseline (T0), after 12 weeks (postintervention; T1), and after 24 weeks (follow-up; T2). The primary outcome is food literacy, measured with the self-perceived food literacy scale questionnaire (expected effect size=0.9). Secondary outcomes are self-efficacy, quality of life, sense of coherence, diet quality, body weight, BMI, and waist-hip ratio. All outcomes will be tested with linear mixed models, following an intention-to-treat approach and standard principles of randomized controlled trials. In addition, a qualitative analysis will be performed. RESULTS: The proposed study will provide useful information on the effects of a salutogenic program on healthy eating and well-being in people with T2DM in everyday life. Recruitment started on October 1, 2021. The intervention participants followed the SALUD program between January and August, 2022. The acquisition of the data was completed on August 1, 2022; publications are expected in 2023. CONCLUSIONS: This study will be one of the first salutogenic interventions for T2DM, which will provide valuable information on what salutogenic intervention entail. The SALUD program may serve as a concrete, web-based tool. The combination of quantitative and qualitative measures allows a comprehensive evaluation of effects. These insights can be used for further optimalization of T2DM interventions. TRIAL REGISTRATION: Netherlands Trial Registry, NL8963; https://trialsearch.who.int/Trial2.aspx?TrialID=NL8963. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40490.

Unravelling mechanisms underlying the action principles of a community-based health promotion programme: a realist evaluation.

BACKGROUND: Since 1986, WHO has advised that applying action principles such as citizen participation and intersectoral collaboration leads to better health. However, less is known about the workability of these principles and how they trigger specific outcomes in interaction with the context. A critical realist perspective was applied to get a better understanding of what worked, and why it worked, in the context of a Dutch community-based health promotion programme (CBHPP). The aim of the study was to unravel the mechanisms underlying the action principles and find combinations of contextual factors and mechanisms that trigger outcomes in a CBHPP. METHODS: In this single case study, a critical realist methodology was followed. Qualitative data used in this study originated from multiple sources and methods to ensure validity. They include evaluation sessions with coalition members (n = 6) and individual interviews (n = 6); group sessions with community workers (n = 1), a health broker (n = 1), and citizens (n = 12); and seven semi-annual progress reports and minutes of the coalition meetings. The collected data were then compared with the programme theory through a heuristic process of constructing, exploring, and refining context-mechanism-outcome configurations. RESULTS: The programme initiated a variety of new activities that differed in content, intensity, duration, and number of participants, organised and implemented together with citizens. The most prominent mechanism underlying both action principles were programme-related, namely, patience, personal contact, contribution of budget, and the programme coordinator's leadership. Another important mechanism was creating visibility, which resulted in the involvement of the municipality and a budget to sustain the programme. CONCLUSION: In this case study, personal contact, patience, perseverance, participatory action research activities, and visibility were found to be the most notable mechanisms underlying the citizen participation and intersectoral collaboration action principles. As the principle-based approach added value to the existing context and introduced most of the mechanisms that triggered the outcomes, it is recommended to include citizen participation and intersectoral collaboration not only as action principles but explicitly as targets in a CBHPP.

Intersectoral collaboration in a Dutch community health promotion programme: building a coalition and networks.

In health promotion programmes (HPP), it is crucial to have intersectoral collaboration within coalitions and to build networks between health and other societal sectors. A health broker role is recognized as being helpful in connecting the coalition with the broader network, and participatory action research (PAR) is deemed supportive because it facilitates evaluation, reflection, learning and action. However, there is a lack of insight into how processes that affect collaboration develop over time. Therefore, this study aimed to provide insights into the coalition's processes that facilitate building and maintaining intersectoral collaboration within a HPP coalition and network and how these processes contribute to the coalition's ambitions. As part of PAR, the coalition members used the coordinated action checklist (CAC) and composed network analysis (CNA) in 2018 and 2019. The CAC and CNA results were linked back into the coalition in five group sessions and used for reflection on pro-gress and future planning. Coalition governance, interaction with the context, network building and brokerage, and generating visibility emerged as the most prominent processes. Important insights concerned the health broker's role and positioning, the programme coordinator's leadership and the importance of visibility and trust leading to investment in continuation. The combined research instruments and group sessions supported discussion and reflection, sharing visions and adjusting working strategies, thereby strengthening the coalition's capacity. Thus, PAR was useful for evaluating and simultaneously facilitating the processes that affect collaboration.

In this study, we explored collaboration between professionals working in different sectors within and outside healthcare. We looked at the processes that facilitate the building and maintenance of intersectoral collaboration within a coalition that developed a health promotion programme together with a network of contacts in the community. Participatory action research (PAR) was used, which means that results from research tools like questionnaires and interviews were discussed with workers and inhabitants involved, so that they could adjust their working strategy and ambitions. The most important processes appeared to be the organization of the coalition, how the members of the coalition interacted with the context and built the network, and how they publicized their activities. Important findings concerned the health broker's role, the programme coordinator's leadership and the importance of visibility and trust. The collaboration in this programme delivered the following achievements: increased capacities of group members, health promoting activities, a broader and strengthened network and a shift in community workers' thinking about health, resulting in the involvement of the municipality, which provided budget to invest in the continuation of the programme. We concluded that PAR was useful for evaluating and simultaneously facilitating the processes that affect collaboration.

Development of Sense of Coherence Stability in the AGORA Healthy Ageing Study.

Sense of coherence (SOC) is a psycho-social trait formed in childhood or adolescence, allowing individuals to be more resilient to daily life stressors, stay well, and improve their personal health. Although SOC remains stable after the age of thirty, only a few studies investigated its stability in adulthood. The aim was to investigate the development of SOC over time in 489 participants and its association with age, gender, educational level, or negative life events. The study was performed as part of the Healthy Ageing project of the Academic Collaborative Centre AGORA, a longitudinal study involving four municipalities of Eastern Netherlands. A self-administrated questionnaire was used to monitor the SOC of the elderly in 2008, 2010, and 2013, using the Orientation to Life Questionnaire (SOC-13). The analysis included repeated-measures ANOVA analysis and bivariate analysis using Pearson's chi square test. We found no statistically significant variation in SOC over time (F (2, 282) = 2.99, p = 0.052) and no significant association with age (F (2, 282) = 2.851, p = 0.06), gender (F (2, 282) = 0.845, p = 0.43), or educational level (F (2, 282) = 0.708, p = 0.49). SOC remained stable in the elderly population, even if they experienced negative events over their lifespan.

The positive impact of a care-physical activity initiative for people with a low socioeconomic status on health, quality of life and societal participation: a mixed-methods study.

BACKGROUND: Overweight and obesity rates are increasing worldwide, particularly among people with a low socioeconomic status (SES). Care-physical activity (care-PA) initiatives may improve participants' lifestyles and thereby lower overweight and obesity rates. A two-year care-PA initiative specifically developed for citizens with a low SES, X-Fittt 2.0, was offered free of charge to participants, and included 12 weeks of intensive guidance and sports sessions, and 21 months of aftercare. Here, we study the impact of X-Fittt 2.0 on health, quality of life (QoL) and societal participation using a mixed-methods design. METHODS: Questionnaires and body measurements were taken from 208 participants at the start of X-Fittt 2.0 (t0) and after 12 weeks (t1), one year (t2) and two to three years (t3). We also held 17 group discussions (t1, n = 71) and 68 semi-structured interviews (t2 and t3). Continuous variables were analysed using a linear mixed-model analysis (corrected for gender, age at t0, height, education level and employment status at the different time points), while we used descriptive statistics for the categorical variables. Qualitative data were analysed using a thematic analysis. RESULTS: Body weight was significantly lower at all three post-initiative time points compared with the baseline, with a maximum of 3.8 kg difference at t2. Body Mass Index, waist circumference, blood pressure and self-perceived health only significantly improved during the first 12 weeks. A positive trend regarding paid work was observed, while social visits decreased. The latter might be explained by the COVID-19 pandemic, as lockdowns limited social life. Furthermore, participants reported increased PA (including sports) and a few stopped smoking or drinking alcohol. Participants mentioned feeling healthier, fitter and more energetic. Additionally, participants' self-esteem and stress levels improved, stimulating them to become more socially active. However, the participants also mentioned barriers to being physically active, such as a lack of money or time, or physical or mental health problems. CONCLUSIONS: X-Fittt 2.0 improved the health, QoL and societal participation of the participants. Future initiatives should take into account the aforementioned barriers, and consider a longer intervention period for more sustainable results. More complete data are needed to confirm the findings.

The Health Impact of Social Community Enterprises in Vulnerable Neighborhoods: Protocol for a Mixed Methods Study.

BACKGROUND: This 4-year research project focuses on 6 social community enterprises (SCEs) that operate in 5 neighborhoods in a Dutch city. Residents of these neighborhoods face problems such as poor average levels of physical and mental health, high unemployment rates, and weak social cohesion. SCEs offer residents social, cultural, and work-related activities and are therefore believed to help these persons develop themselves and strengthen the social ties in the community. Because of a lack of empirical evidence; however, it is unclear whether and how SCEs benefit the health and well-being of participants. OBJECTIVE: This paper outlines a protocol for an evaluation study on the impact of SCEs, aiming to determine (1) to what extent SCEs affect health and well-being of participating residents, (2) what underlying processes and mechanisms can explain such impact, and (3) what assets are available to SCEs and how they can successfully mobilize these assets. METHODS: A mixed methods multiple-case study design including repeated measurements will be conducted. Six SCEs form the cases. An integrated model of SCE health intervention will be used as the theoretical basis. First, the impact of SCEs is measured on the individual and community level, using questionnaires and in-depth interviews conducted with participants. Second, the research focuses on the underlying processes and mechanisms and the organizational and sociopolitical factors that influence the success or failure of these enterprises in affecting the health and well-being of residents. At this organizational level, in-depth interviews are completed with SCE initiators and stakeholders, such as municipal district managers. Finally, structurally documented observations are made on the organizational and sociopolitical context of the SCEs. RESULTS: This research project received funding from the Netherlands Organization for Health Research and Development in 2018. Data collection takes place from 2018 until 2022. Data analysis starts after the last round of data collection in 2022 and finalizes in 2024. Expected results will be published in 2023 and 2024. CONCLUSIONS: Despite the societal relevance of SCEs, little empirical research has been performed on their functioning and impact. This research applies a variety of methods and includes the perspectives of multiple stakeholders aiming to generate new empirical evidence. The results will enable us to describe how SCE activities influence intermediate and long-term health outcomes and how the organizational and sociopolitical context of SCEs may shape opportunities or barriers for health promotion. As the number of these initiatives in the Netherlands is increasing rapidly, this research can benefit many SCEs attempting to become more effective and increase their impact. The findings of this research will be shared directly with relevant stakeholders through local and national meetings and annual reports and disseminated among other researchers through scientific publications. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/37966.

Stigma Toward Bariatric Surgery in the Netherlands, France, and the United Kingdom: Protocol for a Cross-cultural Mixed Methods Study.

BACKGROUND: Bariatric surgery is an effective procedure for the treatment of obesity. Despite this, only 0.1% to 2% of eligible individuals undergo surgery worldwide. The stigma surrounding surgery might be a reason for this. Thus far, no research has systematically studied the nature and implications of bariatric surgery stigma. The limited studies on bariatric surgery stigma are often conducted from the perspective of the public or health care professions and either use small and nonrepresentative samples or fail to capture the full essence and implications of the stigma altogether, including attitudes toward patients and perpetrators of the stigma. In addition, studies from patients' perspectives are limited and tend to address bariatric surgery stigma superficially or implicitly. Finally, the extent to which cultural factors shape and facilitate this stigma and the experiences of patients have not yet been researched. OBJECTIVE: This study aimed to explore the perceptions, experiences, and consequences of bariatric surgery stigma from the perspective of the public, health care professionals, and patients before and after bariatric surgery. Furthermore, although the concept of stigma is universal, every society has specific cultural norms and values that define acceptable attributes and behaviors for its members. Therefore, this study also aimed to explore the extent to which cultural factors influence bariatric surgery stigma by comparing the Netherlands, France, and the United Kingdom. METHODS: This paper describes the protocol for a multiphase mixed methods research design. In the first part, we will conduct a scoping review to determine the current knowledge on bariatric surgery stigma and identify knowledge gaps. In the second part, semistructured interviews among patients before and after bariatric surgery will be conducted to explore their experiences and consequences of bariatric surgery stigma. In the third part, surveys will be conducted among both the public and health care professionals to determine the prevalence, nature, and impact of bariatric surgery stigma. Surveys and interviews will be conducted in the Netherlands, France, and the United Kingdom. Finally, data integration will be conducted at the interpretation and reporting levels. RESULTS: The study began in September 2020 and will continue through September 2025. With the results of the review, we will create an overview of the current knowledge regarding bariatric surgery stigma from patients' perspectives. Qualitative data will provide insights into patients' experiences with bariatric surgery stigma. Quantitative data will provide information related to the prevalence and nature of bariatric surgery stigma from the perspective of the public and health care professionals. Both qualitative and quantitative data will be compared for each country. CONCLUSIONS: The findings from this study will lead to new insights that can be used to develop strategies to reduce bariatric surgery stigma and improve access, use, and outcomes of bariatric surgery. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/36753.

Developing an Intervention and Evaluation Model of Outdoor Therapy for Employee Burnout: Unraveling the Interplay Between Context, Processes, and Outcomes.

Background: Burnout is a major societal issue adversely affecting employees' health and performance, which over time results in high sick leave costs for organizations. Traditional rehabilitation therapies show suboptimal effects on reducing burnout and the return-to-work process. Based on the health-promoting effects of nature, taking clients outdoors into nature is increasingly being used as a complementary approach to traditional therapies, and evidence of their effectiveness is growing. Theories explaining how the combination of general psychological support and outdoor-specific elements can trigger the rehabilitation process in outdoor therapy are often lacking, however, impeding its systematic research. Aim: The study aims to develop an intervention and evaluation model for outdoor therapy to understand and empirically evaluate whether and how such an outdoor intervention may work for rehabilitation after burnout. Methodological Approach: We build on the exemplary case of an outdoor intervention for rehabilitation after burnout, developed by outdoor clinical psychologists in Netherlands. We combined the generic context, process, and outcome evaluation model and the burnout recovery model as an overarching deductive frame. We then inductively specified the intervention and evaluation model of outdoor therapy, building on the following qualitative data: semi-structured interviews with outdoor clinical psychologists and former clients; a content analysis of the intervention protocol; and reflective meetings with the intervention developers and health promotion experts. Results: We identified six key outdoor intervention elements: (1) physical activity; (2) reconnecting body and mind; (3) nature metaphors; (4) creating relationships; (5) observing natural interactions; and (6) experiential learning. The results further showed that the implementation of these elements may facilitate the rehabilitation process after burnout in which proximal, intermediate, and distal outcomes emerge. Finally, the results suggested that this implementation process depends on the context of the therapist (e.g., number of clients per day), therapy (e.g., privacy issues), and of the clients (e.g., affinity to nature). Conclusion: The intervention and evaluation model for outdoor therapy shows how key outdoor intervention elements may contribute to the rehabilitation process after burnout. However, our model needs to be further tested among a larger group of clients to empirically evaluate whether and how outdoor therapy can support rehabilitation.

What works for vulnerable families? Interpretations of effective health promotion.

Under the umbrella of the Healthy Futures Nearby programme, 46 small-scale projects were funded to promote changes in health-related behaviours (smoking, alcohol, diet and exercise) and to improve perceived health among vulnerable families in the Netherlands. The evaluation of these health-related multiple project programmes is often based on funder-defined outcomes and strategies. However, within the funded projects, assumptions about improving the health of vulnerable families based on local knowledge and experiences will also shape the project outcomes and strategies. These additional outcomes and strategies are project-specific interpretations of effective health promotion. Knowing these interpretations is crucial for the policy related and scientific relevance of the evaluation. Therefore, we aimed to determine the interpretations of each project and how they translate into relevant inputs for the overall evaluation of the programme. Based on 46 semi-structured group interviews with local project stakeholders, we produced a list of assumptions about what health promotion for vulnerable families should look like and then identified five main clusters: (i) strategies of offering pre-defined, health (behaviour)-related activities to families, (ii) actively involving vulnerable families in the initiative, (iii) assumptions about how health promotion should start with or include non-health-related topics, (iv) assumptions on how one should build on what already exists in the local context of the families and (v) assumptions on the role of the (health) professional in health promotion among vulnerable families. These project interpretations of effective health promotion provide inputs and priorities for the HFN programme's overall evaluation.

Nourishing Hope? Changes in Malnutrition and Changes in Girls' Aspirations-Evidence From the Suaahara II Adolescent Girls Panel in Nepal.

PURPOSE: Malnutrition is a pressing public health challenge in South Asia with adverse consequences for adolescent girls' well-being and, potentially, aspirations as drivers of developmental progress. This study aimed to investigate associations between changes in malnutrition and changes in girls' aspirations in key life domains. METHODS: We analyzed two-period panel data from the Suaahara II Adolescent Girls Panel (10-19 years) in Nepal (2018-2019, n = 613). Height, weight, blood samples, 24-hour dietary recalls, and indicators of girls' educational, occupational, marital, and fertility aspirations were collected. Height-for-age z-scores, body mass index-for-age z-scores, hemoglobin concentration (Hb g/dL), and dietary diversity scores for women were calculated. Through cluster-robust fixed-effects regressions, we examined whether changes in thinness (body mass index-for-age z-scores < -2 standard deviation), anemia (Hb <115 g/L nonpregnant <11 years; Hb <120 g/L nonpregnant >12 years; Hb <110 g/L pregnant), and reaching minimum dietary diversity for women were associated with changes in educational, marital, or fertility aspirations. RESULTS: A change from thinness to no thinness increased girls' aspired ages of having a first child by 2.77 years (standard error [SE] 1.22, p = .025). A change from anemia to no anemia increased girls' aspired years of education by .54 (SE .27, p = .044). This association was stronger for postmenarche girls (b -.62, SE .29, p = .035). No associations were found between changes in minimum dietary diversity for women and any of the aspirations. CONCLUSIONS: Thinness and anemia were negatively associated with adolescent girls' aspirations in domains of fertility and education. Multisectoral integrated policies and programs that improve adolescent nutritional status and diets have the potential to foster adolescent girls' aspirations and thereby increase their future potential.

Unravelling adolescent girls' aspirations in Nepal: Status and associations with individual-, household-, and community-level characteristics.

BACKGROUND: Adolescents' aspirations have potential to influence their present and future well-being. Limited knowledge exists on adolescent girls' aspirations and their determinants, particularly in low-income contexts. METHODS AND FINDINGS: Using cross-sectional data, collected in 2018 in Nepal, within the Suaahara II Adolescent Panel Survey, (n = 840), adolescent girls' aspirations in several domains-education, occupation, marriage, fertility, health, and nutrition-were described. Regression models were estimated to explore associations between individual, household and community characteristics and these aspirations for all adolescents and separately for younger (10-14 years) and older (15-19 years) girls. Age, school attendance, and self-efficacy, as well as household wealth, caste/ethnicity, size, and agro-ecological zone of residence were significantly associated with aspirations, although effect sizes and significance varied by aspiration domain and age group. CONCLUSIONS: Findings underscore the curtailing effect of poverty on aspirations and the dynamic nature of aspirations. Initiatives to foster girls' aspirations must address both individual and contextual factors.

What is needed to facilitate healthy dietary behaviours in pregnant women: A qualitative study of Dutch midwives' perceptions of current versus preferred nutrition communication practices in antenatal care.

OBJECTIVE: The aim of this paper was to explore midwives' perceptions of current and preferred nutrition communication practices in antenatal care, and to identify what is needed to achieve their preferred practices. DESIGN: A qualitative descriptive design was used. Semi-structured interviews were conducted with twenty Dutch midwives working in primary care or secondary care settings across the Netherlands. To create a positive atmosphere, interviews were based on the principles of Appreciative Inquiry. FINDINGS: Opportunities identified in current practices included midwives' sense of responsibility, their skills and experience, availability of resources, and group consultations. Barriers were the precarity and lack of prioritization of the topic, and the current focus on food safety (risks). Ideally, midwives envisioned nutrition communication as a continuous trajectory, in which not only reliable and consistent information is provided, but also more personalized and positive communication, to empower pregnant women. KEY CONCLUSIONS: Midwives favour nutrition communication practices characterized by continuity of care and woman-centeredness. Opportunities to realize such practices in antenatal care are the use of innovative tools to support nutrition communication, more sustainable collaborations with dietitians, and better nutrition education for midwives. IMPLICATIONS FOR PRACTICE: Midwives could act as facilitators and gatekeepers in nutrition communication, requiring limited time and expertise from midwives, and empowering pregnant women.

Opportunities for dietitians to promote a healthy dietary intake in pregnant women with a low socio-economic status within antenatal care practices in the Netherlands: a qualitative study.

BACKGROUND: A healthy dietary intake during pregnancy is important for maternal and child health. However, pregnant women with a low socio-economic status often fail to meet dietary guidelines and requirements for healthy nutrition. Dietitians may play an important role in providing nutritional advice during pregnancy because midwives often experience a lack of nutritional knowledge, time and skills to provide adequate advice. However, there is limited research on the support that dietitians can offer in antenatal care practices for pregnant women. Therefore, this study aims to explore the opportunities for dietitians to support pregnant women with a low socio-economic status in concurrent antenatal care practices in the Netherlands. METHODS: In-depth interviews were conducted with 14 pregnant women with a low socio-economic status and 13 dietitians to identify barriers for healthy eating for pregnant women and the associated opportunities for dietitians to support these women in making healthy dietary changes. RESULTS: Four opportunities for dietitians to support pregnant women in making dietary changes could be discerned: (1) creating awareness of healthy and unhealthy eating patterns, (2) providing reliable and personally relevant information, (3) help identifying barriers and solutions for healthy eating and (4) making healthy eating manageable. Dietitians indicated that supporting pregnant women with a low socio-economic status in consuming a healthy diet requires the investment of sufficient time, effort and money. CONCLUSIONS: Dietitians are trained and well-equipped to provide extensive support to pregnant women to promote a healthy dietary intake, especially when the complex interplay of barriers that pregnant women with a low socio-economic status experience for healthy eating needs to be addressed. In addition, there is a strong need for strengthening the collaboration between dietitians and midwives because midwives are the primary care provider for pregnant women in the Netherlands, but they often lack sufficient opportunities to provide adequate nutrition support. Strengthening this collaboration could promote that nutrition becomes a recurring and standard topic in antenatal care.

Understanding Public Health Adaptation to Climate Change: An Explorative Study on the Development of Adaptation Strategies Relating to the Oak Processionary Moth in The Netherlands.

Understanding of public health adaptation (PHA) to climate change and implementation is limited. This study therefore focuses on one specific PHA issue: adaptation to the oak processionary moth (OPM). The aim is to examine the development of OPM adaptation in order to offer a problem description of the complexities involved in OPM adaptation. In this explorative case study, we investigate adaptation strategies based on semi-structured interviews with 26 actors involved in OPM adaptation in The Netherlands. The results indicate that the context of OPM adaptation is relatively complex, given the involvement of many interdependent actors. OPM adaptation was developed with limited knowledge and strategies were based on ad hoc approaches in which there was ambiguity about tasks and expertise. In addition, different actors have different perceptions and values concerning health, sustainability, risks and responsibilities influencing decision-making processes, while also posing a challenge to collaboration and the development of a coordinated approach. The generation of knowledge and its translation into practical strategies calls for interdisciplinary cooperation in knowledge development. PHA adaptation involves more than technical and organisational solutions alone. It also entails the development of a shared problem perception and solution space in which citizens are also engaged.

Development of a salutogenic intervention for healthy eating among Dutch type 2 diabetes mellitus patients.

Healthy eating can be challenging for type 2 diabetes mellitus (T2DM) patients. The theory of salutogenesis, which focuses on the resources required to organize behavioural changes in everyday life, was used to develop an intervention for healthy eating. The aim was to describe the development, structure and content of this salutogenic intervention. The development consisted of two phases that were based on the operationalization of important key principles of salutogenesis. In Phase 1 (Exploration and synthesis), a systematic review and three qualitative studies were performed to explore important characteristics to enable healthy eating in everyday life. The results were used to develop the draft intervention. In Phase 2 (Validation and adjustment), interviews and workshops were conducted with T2DM patients, healthcare providers and scientists. Based on this, the draft intervention was modified into its final form. The developmental process resulted in a 12-week, group-based intervention that aimed to enable important resources for healthy eating via self-examination, reflection, setting goals and sharing experiences. Attention was also paid to disease information, disease acceptance, food literacy, stress management, self-identity and social support. The group sessions began following an individual intake session, with a booster session held 3 months after the intervention. The researcher's translation of the stakeholders' priorities into an intervention was corrected for and approved by the stakeholders concerned. This comprehensive salutogenic intervention was developed based on practical and scientific evidence. Providing transparency in developmental processes and content is important because it determines the scientific integrity and credibility of an intervention.

Healthy eating can be difficult for people with the disease type 2 diabetes. This article describes how a programme aimed at helping type 2 diabetes patients to eat healthily was developed. The draft version of the programme was based on a theoretical framework that aims to understand what creates health in everyday life, and on conversations with type 2 diabetes patients and healthcare providers. The draft programme was adjusted based on the feedback of type 2 diabetes patients, healthcare providers and scientists. This resulted in a 12-week, group-based programme that enables people to think about who they are and what they want by setting health goals and sharing experiences. Attention was also paid to disease knowledge, disease acceptance, nutritional skills, dealing with stress, self-identity and social support. The group sessions began following an individual intake session, with a booster session held 3 months after the intervention. By involving everybody, we were able to develop a programme that takes into account the preferences, needs and priorities of all stakeholders. It is important to describe the development and the content of programmes encouraging healthy eating to determine their quality and effectivity.

Seizing and realizing the opportunity: A salutogenic perspective on rehabilitation after burnout.

BACKGROUND: Most research on burnout has focused on its antecedents, correlates, and consequences. However, little empirical attention has been paid to what constitutes successful rehabilitation after burnout, especially among young employees. OBJECTIVE: The present study empirically examined resources supporting successful rehabilitation after burnout among young employees (between 18 and 35 years of age) from a salutogenic perspective. METHODS: Interpretative phenomenological analysis was used as a methodological framework to explain the experiences of young employees underlying their rehabilitation after burnout. RESULTS: The analysis showed that the rehabilitation process comprises four phases: 1) facing the crisis; 2) addressing the root causes; 3) seizing and achieving the opportunity; and 4) staying at work. Essential overarching resources facilitating successful recovery after burnout included receiving social support from family, friends, and colleagues, as well as having a feeling of control over the rehabilitation process. Participants learned to be aware of potential pitfalls that could trigger burnout symptoms, while having confidence in their ability to prevent burnout from reoccurring. These continuous learning processes were experienced as a prerequisite to remain at work. CONCLUSIONS: Receiving social support and experiencing a feeling of control over the rehabilitation process appear to be key resources in facilitating a stable, meaningful return to work after burnout.