Evaluation of a Brief Intervention for Promoting Mental Health among Employees in Social Enterprises: A Cluster Randomized Controlled Trial.

Evidence on the effectiveness of workplace mental health promotion for people with disabilities is limited. This study aimed to evaluate the effectiveness of a brief mental health promotion intervention in social enterprises. It had a non-blinded cluster randomized controlled trial design with follow-up one and four months after the intervention. In total 196 employees agreed to participate (86 intervention and 110 control). Empowerment was the main outcome; secondary outcomes were resilience, palliative behavior, determinants of four coping strategies of mental health, quality of life, and life satisfaction. A brief participant satisfaction survey was conducted after the intervention. No significant intervention effect on empowerment was found. However, at one month follow-up, significant favorable effects were found on perceived social support for coping strategies for mental health and on palliative behavior. At four months follow-up, favorable intervention effects were found on quality of life, but unfavorable effects were found on unjustified worrying. In addition, the intervention was well received by the employees. This brief intervention might be a promising first step to improve mental health in people with disabilities working in social enterprises. Nevertheless, additional monitoring by professionals and managers working in the organizations might be needed to maintain these effects.

Feasibility and impact study of a reward-based mobile application to improve adolescents' snacking habits.

OBJECTIVE: Adolescents' snacking habits are driven by both explicit reflective and implicit hedonic processes. Hedonic pathways and differences in sensitivity to food rewards in addition to reflective determinants should be considered. The present study evaluated the feasibility and impact of a mobile phone-delivered intervention, incorporating explicit reflective and implicit rewarding strategies, on adolescents' snack intake. DESIGN: Adolescents (n 988; mean age 14·9 (sd 0·70) years, 59·4 % boys) completed a non-randomized clustered controlled trial. Adolescents (n 416) in the intervention schools (n 3) were provided with the intervention application for four weeks, while adolescents (n 572) in the control schools (n 3) followed the regular curriculum. Outcomes were differences in healthy snacking ratio and key determinants (awareness, intention, attitude, self-efficacy, habits and knowledge). Process evaluation data were collected via questionnaires and through log data of the app. RESULTS: No significant positive intervention effects on the healthy snack ratio (b=-3·52 (se 1·82), P>0·05) or targeted determinants were observed. Only 268 adolescents started using the app, of whom only fifty-five (20·5 %) still logged in after four weeks. Within the group of users, higher exposure to the app was not significantly associated with positive intervention effects. App satisfaction ratings were low in both high and low user groups. Moderation analyses revealed small positive intervention effects on the healthy snack ratio in high compared with low reward-sensitive boys (b=1·38 (se 0·59), P<0·05). CONCLUSIONS: The intervention was not able to improve adolescents' snack choices, due to low reach and exposure. Future interventions should consider multicomponent interventions, teacher engagement, exhaustive participatory app content development and tailoring.

Problem drinking among Flemish students: beverage type, early drinking onset and negative personal & social consequences.

BACKGROUND: Although alcohol is socially accepted in most Western societies, studies are clear about its associated negative consequences, especially among university and college students. Studies on the relationship between alcohol-related consequences and both beverage type and drinking onset, however, are scarce, especially in a European context. The aim of this research was, therefore, twofold: (1) What is the relationship between beverage type and the negative consequences experienced by students? and (2) Are these consequences determined by early drinking onset? We will examine these questions within the context of a wide range of alcohol-related consequences. METHODS: The analyses are based on data collected by the inter-university project 'Head in the clouds?', measuring alcohol use among students in Flanders (Belgium). In total, a large dataset consisting of information from 19,253 anonymously participating students was available. Negative consequences were measured using a shortened version of the Core Alcohol and Drug Survey (CADS_D). Data were analysed using negative binomial regression. RESULTS: Results vary depending on the type of alcohol-related consequences: Personal negative consequences occur frequently among daily beer drinkers. However, a high rate of social negative consequences was recorded for both daily beer drinkers and daily spirits drinkers. Finally, early drinking onset was significantly associated with both personal and social negative consequences, and this association was especially strong between beer and spirits drinking onset and social negative consequences. CONCLUSIONS: Numerous negative consequences, both personal and social, are related to frequent beer and spirits drinking. Our findings indicate a close association between drinking beer and personal negative consequences as well as between drinking beer and/or spirits and social negative consequences. Similarly, early drinking onset has a major influence on the rates of both personal and social negative consequences. The earlier students started drinking, the more negative consequences they experienced during college or university. Several (policy) interventions are discussed. This study is the first to incorporate detailed information on both beverage type and drinking onset, and its associated negative consequences, as measured by the CADS_D, in a large student population.

A school-based intervention improved dietary intake outcomes and reduced waist circumference in adolescents: a cluster randomized controlled trial.

BACKGROUND: In Ecuador, adolescents' food intake does not comply with guidelines for a healthy diet. Together with abdominal obesity adolescent's inadequate diets are risk factors for non-communicable diseases. We report the effectiveness of a school-based intervention on the dietary intake and waist circumference among Ecuadorian adolescents. METHODS: A pair-matched cluster randomized controlled trial including 1430 adolescents (12-14 years old) was conducted. The program aimed at improving the nutritional value of dietary intake, physical activity (primary outcomes), body mass index, waist circumference and blood pressure (secondary outcomes). This paper reports: (i) the effect on fruit and vegetable intake, added sugar intake, unhealthy snacking (consumption of unhealthy food items that are not in line with the dietary guidelines eaten during snack time; i.e. table sugar, sweets, salty snacks, fast food, soft drinks and packaged food), breakfast intake and waist circumference; and, (ii) dose and reach of the intervention. Dietary outcomes were estimated by means of two 24-h recall at baseline, after the first 17-months (stage one) and after the last 11-months (stage two) of implementation. Dose and reach were evaluated using field notes and attendance forms. Educational toolkits and healthy eating workshops with parents and food kiosks staff in the schools were implemented in two different stages. The overall effect was assessed using linear mixed models and regression spline mixed effect models were applied to evaluate the effect after each stage. RESULTS: Data from 1046 adolescents in 20 schools were analyzed. Participants from the intervention group consumed lower quantities of unhealthy snacks (-23.32 g; 95% CI: -45.25,-1.37) and less added sugar (-5.66 g; 95% CI: -9.63,-1.65) at the end of the trial. Daily fruit and vegetable intake decreased in both the intervention and control groups compared to baseline, albeit this decrease was 23.88 g (95% CI: 7.36, 40.40) lower in the intervention group. Waist circumference (-0.84 cm; 95% CI: -1.68, 0.28) was lower in the intervention group at the end of the program; the effect was mainly observed at stage one. Dose and reach were also higher at stage one. CONCLUSIONS: The trial had positive effects on risk factors for non-communicable diseases, i.e. decreased consumption of unhealthy snacks. The program strategies must be implemented at the national level through collaboration between the academia and policy makers to assure impact at larger scale. TRIAL REGISTRATION: ClinicalTrial.gov-NCT01004367 .

Developing a systems-based framework of the factors influencing dietary and physical activity behaviours in ethnic minority populations living in Europe - a DEDIPAC study.

BACKGROUND: Some ethnic minority populations have a higher risk of non-communicable diseases than the majority European population. Diet and physical activity behaviours contribute to this risk, shaped by a system of inter-related factors. This study mapped a systems-based framework of the factors influencing dietary and physical activity behaviours in ethnic minority populations living in Europe, to inform research prioritisation and intervention development. METHODS: A concept mapping approach guided by systems thinking was used: i. Preparation (protocol and terminology); ii. Generating a list of factors influencing dietary and physical activity behaviours in ethnic minority populations living in Europe from evidence (systematic mapping reviews) and 'eminence' (89 participants from 24 academic disciplines via brainstorming, an international symposium and expert review) and; iii. Seeking consensus on structuring, rating and clustering factors, based on how they relate to each other; and iv. Interpreting/utilising the framework for research and interventions. Similar steps were undertaken for frameworks developed for the majority European population. RESULTS: Seven distinct clusters emerged for dietary behaviour (containing 85 factors) and 8 for physical activity behaviours (containing 183 factors). Four clusters were similar across behaviours: Social and cultural environment; Social and material resources; Psychosocial; and Migration context. Similar clusters of factors emerged in the frameworks for diet and physical activity behaviours of the majority European population, except for 'migration context'. The importance of factors across all clusters was acknowledged, but their relative importance differed for ethnic minority populations compared with the majority population. CONCLUSIONS: This systems-based framework integrates evidence from both expert opinion and published literature, to map the factors influencing dietary and physical activity behaviours in ethnic minority groups. Our findings illustrate that innovative research and complex interventions need to be developed that are sensitive to the needs of ethnic minority populations. A systems approach that encompasses the complexity of the inter-related factors that drive behaviours may inform a more holistic public health paradigm to more effectively reach ethnic minorities living in Europe, as well as the majority host population.

Who does not cut down? Comparing characteristics and drinking motives of drinkers and abstainers during the exam periods.

OBJECTIVE: Drinking alcohol during the exams can affect academic performance and future career options, but is rarely investigated. Drinking motives, sociodemographics and personality characteristics are investigated in nonabstainers and weekly drinkers during the exams. PARTICIPANTS: 7,181 Belgian university students who anonymously responded to an email invitation to an online survey. METHODS: Logistic regressions and mixed design analysis of variance on cross-sectional data. RESULTS: One-third of the students continued drinking during the exams, with 40% drinking weekly. Nonabstainers were mainly men, elder, internally motivated when drinking, and housed with parents or independently. Weekly drinkers were similar, except mainly housed in student apartments or independently. Personality characteristics were nonsignificant. All drinking motives were less pronounced during the exams, with smaller differences for internal motives. CONCLUSIONS: Mainly linked to internal drinking motives, drinking during the exams in higher education is underestimated. The characteristics and motives of students doing so can be used in future interventions.

Use of Fitness and Nutrition Apps: Associations With Body Mass Index, Snacking, and Drinking Habits in Adolescents.

BACKGROUND: Efforts to improve snacking and drinking habits are needed to promote a healthy body mass index (BMI) in adolescents. Although commercial fitness and nutrition mobile phone apps are widely used, little is known regarding their potential to improve health behaviors, especially in adolescents. In addition, evidence on the mechanisms through which such fitness and nutrition apps influence behavior is lacking. OBJECTIVES: This study assessed whether the use of commercial fitness or nutrition apps was associated with a lower BMI and healthier snacking and drinking habits in adolescents. Additionally, it explored if perceived behavioral control to eat healthy; attitudes to eat healthy for the good taste of healthy foods, for overall health or for appearance; social norm on healthy eating and social support to eat healthy mediated the associations between the frequency of use of fitness or nutrition apps and BMI, the healthy snack, and beverage ratio. METHODS: Cross-sectional self-reported data on snack and beverage consumption, healthy eating determinants, and fitness and nutrition app use of adolescents (N=889; mean age 14.7 years, SD 0.8; 54.8% [481/878] boys; 18.1% [145/803] overweight) were collected in a representative sample of 20 schools in Flanders, Belgium. Height and weight were measured by the researchers. The healthy snack ratio and the healthy beverage ratio were calculated as follows: gram healthy snacks or beverages/(gram healthy snacks or beverages+gram unhealthy snacks or beverages)×100. Multilevel regression and structural equation modeling were used to analyze the proposed associations and to explore multiple mediation. RESULTS: A total of 27.6% (245/889) of the adolescents used fitness, nutrition apps or both. Frequency of using nutrition apps was positively associated with a higher healthy beverage ratio (b=2.96 [1.11], P=.008) and a higher body mass index z-scores (zBMI; b=0.13 [0.05], P=.008. A significant interaction was found between the frequency of using nutrition and for the zBMI (b=-0.03 [0.02], P=.04) and the healthy snack ratio (b=-0.84 [0.37], P=.03). Attitude to eat healthy for appearance mediated both the fitness app use frequency-zBMI (a × b=0.02 [0.01], P=.02) and the nutrition app use frequency-zBMI (a × b=0.04 [0.01], P=.001) associations. No mediation was observed for the associations between the frequency of use of fitness or nutrition apps and the healthy snack or beverage ratio. CONCLUSIONS: Commercial fitness and nutrition apps show some association with healthier eating behaviors and BMI in adolescents. However, effective behavior change techniques should be included to affect key determinants of healthy eating.

Adding a reward increases the reinforcing value of fruit.

Adolescents' snack choices could be altered by increasing the reinforcing value (RV) of healthy snacks compared with unhealthy snacks. This study assessed whether the RV of fruit increased by linking it to a reward and if this increased RV was comparable with the RV of unhealthy snacks alone. Moderation effects of sex, hunger, BMI z-scores and sensitivity to reward were also explored. The RV of snacks was assessed in a sample of 165 adolescents (15·1 (sd 1·5) years, 39·4 % boys and 17·4 % overweight) using a computerised food reinforcement task. Adolescents obtained points for snacks through mouse clicks (responses) following progressive ratio schedules of increasing response requirements. Participants were (computer) randomised to three experimental groups (1:1:1): fruit (n 53), fruit+reward (n 60) or unhealthy snacks (n 69). The RV was evaluated as total number of responses and breakpoint (schedule of terminating food reinforcement task). Multilevel regression analyses (total number of responses) and Cox's proportional hazard regression models (breakpoint) were used. The total number of responses made were not different between fruit+reward and fruit (b -473; 95 % CI -1152, 205, P=0·17) or unhealthy snacks (b410; 95 % CI -222, 1043, P=0·20). The breakpoint was slightly higher for fruit than fruit+reward (HR 1·34; 95 % CI 1·00, 1·79, P=0·050), whereas no difference between unhealthy snacks and fruit+reward (HR 0·86; 95 % CI 0·62, 1·18, P=0·34) was observed. No indication of moderation was found. Offering rewards slightly increases the RV of fruit and may be a promising strategy to increase healthy food choices. Future studies should however, explore if other rewards, could reach larger effect sizes.

The role of community social capital in the relationship between socioeconomic status and adolescent life satisfaction: mediating or moderating? Evidence from Czech data.

BACKGROUND: The concept of social capital has been extensively used to explain the relationship between socioeconomic status (SES) and adolescent health and well-being. Much less is known about the specific mechanism through which social capital impacts the relationship. This paper investigates whether an individual's perception of community social capital moderates or mediates the association between SES and life satisfaction. METHODS: This study employs cross-sectional data from the 2009-2010 Czech Health Behaviour in School-Aged Children survey: a WHO Collaborative Cross-National Study (HBSC). A sample of 4425 adolescents from the 5th, 7th and 9th grade (94.5% school response rate, 87% student response) was used to perform multilevel analysis. RESULTS: We found that pupils' life satisfaction was positively related to both family affluence and perceived wealth. Moreover, we found the cognitive component of social capital to be positively associated with life satisfaction. Additionally, a significant interaction was found, such that the social gradient in life satisfaction was flattened when pupils reported high levels of perceived community social capital. CONCLUSIONS: The present findings suggest that community social capital acts as an unequal health resource for adolescents, but could potentially represent opportunities for public health policy to close the gap in socioeconomic disparities.

Individual and Environmental Factors Influencing Adolescents' Dietary Behavior in Low- and Middle-Income Settings.

OBJECTIVE: Given the public health importance of improving dietary behavior in chronic disease prevention in low- and middle-income countries it is crucial to understand the factors influencing dietary behavior in these settings. This study tested the validity of a conceptual framework linking individual and environmental factors to dietary behavior among Ecuadorian adolescents aged 10-16 years. METHODS: A cross-sectional survey was conducted in 784 school-going Ecuadorian adolescents in urban and rural Southern Ecuador. Participants provided data on socio-economic status, anthropometry, dietary behavior and its determining factors. The relationships between individual (perceived benefits and barriers, self-efficacy, habit strength, and a better understanding of healthy food) and environmental factors (physical environment: accessibility to healthy food; social environment: parental permissiveness and school support), and their association with key components of dietary behavior (fruit and vegetables, sugary drinks, breakfast, and unhealthy snack intake) were assessed using structural equation modeling. RESULTS: The conceptual model performed well for each component of eating behavior, indicating acceptable goodness-of-fit for both the measurement and structural models. Models for vegetable intake and unhealthy snacking showed significant and direct effects of individual factors (perceived benefits). For breakfast and sugary drink consumption, there was a direct and positive association with socio-environmental factors (school support and parental permissiveness). Access to healthy food was associated indirectly with all eating behaviors (except for sugary drink intake) and this effect operated through socio-environmental (parental permissiveness and school support) and individual factors (perceived benefits). CONCLUSION: Our study demonstrated that key components of adolescents' dietary behaviors are influenced by a complex interplay of individual and environmental factors. The findings indicate that the influence of these factors varied by type of dietary behavior.

Systematic mapping review of the factors influencing dietary behaviour in ethnic minority groups living in Europe: a DEDIPAC study.

BACKGROUND: Europe has a growing population of ethnic minority groups whose dietary behaviours are potentially of public health concern. To promote healthier diets, the factors driving dietary behaviours need to be understood. This review mapped the broad range of factors influencing dietary behaviour among ethnic minority groups living in Europe, in order to identify research gaps in the literature to guide future research. METHODS: A systematic mapping review was conducted (protocol registered with PROSPERO 2014: CRD42014013549). Nine databases were searched for quantitative and qualitative primary research published between 1999 and 2014. Ethnic minority groups were defined as immigrants/populations of immigrant background from low and middle income countries, population groups from former Eastern Bloc countries and minority indigenous populations. In synthesizing the findings, all factors were sorted and structured into emerging clusters according to how they were seen to relate to each other. RESULTS: Thirty-seven of 2965 studies met the inclusion criteria (n = 18 quantitative; n = 19 qualitative). Most studies were conducted in Northern Europe and were limited to specific European countries, and focused on a selected number of ethnic minority groups, predominantly among populations of South Asian origin. The 63 factors influencing dietary behaviour that emerged were sorted into seven clusters: social and cultural environment (16 factors), food beliefs and perceptions (11 factors), psychosocial (9 factors), social and material resources (5 factors), accessibility of food (10 factors), migration context (7 factors), and the body (5 factors). CONCLUSION: This review identified a broad range of factors and clusters influencing dietary behaviour among ethnic minority groups. Gaps in the literature identified a need for researchers to explore the underlying mechanisms that shape dietary behaviours, which can be gleaned from more holistic, systems-based studies exploring relationships between factors and clusters. The dominance of studies exploring 'differences' between ethnic minority groups and the majority population in terms of the socio-cultural environment and food beliefs suggests a need for research exploring 'similarities'. The evidence from this review will feed into developing a framework for the study of factors influencing dietary behaviours in ethnic minority groups in Europe.

Health Policy Development in Flemish Small-Sized Municipalities: A Real-World Intervention.

BACKGROUND: A health promotion institute developed an intervention to support small-sized municipalities (<15,000 citizens; n = 167) in their development of a local health policy. OBJECTIVES: To (1) find out which municipalities showed interest to participate and (2) assess the intervention effects after 1 year. METHOD: The intervention consisted of (1) completing an online tool that generated feedback on the quality level of the health policy (9 scores) and (2) receiving advice (four contacts) from the local-regional support service for health promotion. In total 121 small-sized municipalities agreed to participate (intervention municipalities), and the nonparticipating municipalities (n = 46) were used as a comparison group. Chi-square tests were conducted to compare baseline quality scores between intervention and comparison municipalities and to assess the change (baseline to follow-up) within the intervention group. RESULTS: At baseline, intervention municipalities had significant higher health policy quality scores compared to the comparison municipalities. Municipalities interested in the intervention mostly had already high policy scores. A significant positive shift in the quality levels was found after 1 year in the intervention municipalities. CONCLUSION: The intervention succeeded in improving the quality levels of the local health policy, though municipalities scoring low and possibly benefiting most from the intervention need to be extra-motivated to participate.

Context matters: Student-perceived binge drinking norms at faculty-level relate to binge drinking behavior in higher education.

BACKGROUND: Binge drinking in higher education is an important problem. To target binge drinking in students it is necessary to study the social context of students. Faculties (i.e., colleges or schools in Northern American education) are social contexts in which students behave, but little is known about how the faculty structure relates to monthly binge drinking. This study investigates the relationship with student-perceived binge drinking norms at faculty-level in addition to known personal determinants. METHODS: Data were collected in 7181 students within 22 faculty-level units, using an anonymous online survey. Multilevel analyses were used to investigate the relationship of both individual-level determinants (e.g., perceived norms, social drinking motives) and student-perceived binge drinking norms at faculty-level on monthly binge drinking. RESULTS: Two-third (62.2%) of the sample were female and the mean age was 21.06 (SD=2.85) years. In males, significant faculty-level variance in monthly binge drinking was found. At faculty-level, only same-sex student-perceived binge drinking norms showed a positive relationship (OR=2.581; 95%CI=[1.023,6.509]). At individual level, both opposite- and same-sex perceived binge drinking norms, and social drinking motives positively related to monthly binge drinking. In females, no significant faculty-level variance was found. Only individual-level determinants positively related to monthly binge drinking. No cross-level interactions were found. CONCLUSION: Besides individual determinants, especially in men, faculties are relevant environmental structures and networks to take into account when targeting binge drinking in higher education.

Sensitivity to reward and adolescents' unhealthy snacking and drinking behavior: the role of hedonic eating styles and availability.

BACKGROUND: Although previous research found a positive association between sensitivity to reward (SR) and adolescents' unhealthy snacking and drinking behavior, mechanisms explaining these associations remain to be explored. The present study will therefore examine whether the associations between SR and unhealthy snack and/or sugar-sweetened beverage (SSB) intake are mediated by external and/or emotional eating and if this mediation is moderated by availability at home or at school. METHODS: Cross-sectional data on snacking, availability of snacks at home and at school, SR (BAS drive scale) and external and emotional eating (Dutch eating behavior questionnaire) of Flemish adolescents (n = 1104, mean age = 14.7 ± 0.8 years; 51 % boys; 18.0% overweight) in 20 schools spread across Flanders were collected. Moderated mediation analyses were conducted using generalized structural equation modeling in three steps: (1) direct association between SR and unhealthy snack or SSB intake, (2) mediation of either external or emotional eating and (3) interaction of home or school availability and emotional or external eating. RESULTS: Partial mediation of external eating (a*b = 0.69, p < 0.05) and of emotional eating (a*b = 0.92, p < 0.01) in the relation between SR and intake of unhealthy snacks was found (step 2). The relation between SR and SSB intake was not mediated by external or emotional eating (step 2). No moderation effects of home or school availability were found (step 3). CONCLUSION: Our findings indicate that the association between SR and the consumption of unhealthy snacks is partially explained by external and emotional eating in a population-based sample of adolescents irrespective of the home or school availability of these foods.

Health promotion interventions in social economy companies in Flanders (Belgium).

BACKGROUND: Disadvantaged groups are often not reached by mainstream health promotion interventions. Implementing health promotion (HP) interventions in social economy companies, can be an opportunity to reach those people. The implementation of these interventions in social economy companies was studied. Factors that could be related to the implementation of HP and being supportive towards implementation in the future, were investigated. METHODS: An online, quantitative survey was sent to all 148 sheltered and social workshops in Flanders. In the questionnaire, the status of HP interventions and characteristics of the workshop were explored. Personal factors (such as attitudes towards HP, behavioural control, social norms and moral responsibility) were asked to the person responsible for implementation of HP interventions. Univariate and multivariate logistic regressions were performed. RESULTS: Respondents of 88 workshops completed the questionnaire. Almost 60% of the workshops implemented environmental or policy interventions. Having a positive attitude towards HP, being more morally responsible, and having the subjective norm that employees are positive towards health promotion at work, were related to being more supportive towards the implementation of HP in the univariate analyses. Only attitude stayed significantly related to being more supportive towards the implementation of HP in the multivariate analyses. CONCLUSIONS: Sheltered and social workshops are open to HP interventions, but more can be done to optimize the implementation. To persuade persons responsible for the implementation of HP to invest more in HP, changing attitudes concerning the benefits of health promotion for the employee and the company, is an important strategy.

The Modified Reasons for Smoking Scale: factorial structure, validity and reliability in pregnant smokers.

RATIONALE, AIMS AND OBJECTIVES: Smoking during pregnancy can cause several maternal and neonatal health risks, yet a considerable number of pregnant women continue to smoke. The objectives of this study were to test the factorial structure, validity and reliability of the Dutch version of the Modified Reasons for Smoking Scale (MRSS) in a sample of smoking pregnant women and to understand reasons for continued smoking during pregnancy. METHODS: A longitudinal design was performed. Data of 97 pregnant smokers were collected during prenatal consultation. Structural equation modelling was performed to assess the construct validity of the MRSS: an exploratory factor analysis was conducted, followed by a confirmatory factor analysis.Test-retest reliability (<16 weeks and 32-34 weeks pregnancy) and internal consistency were assessed using the intraclass correlation coefficient and the Cronbach's alpha, respectively. To verify concurrent validity, Mann-Whitney U-tests were performed examining associations between the MRSS subscales and nicotine dependence, daily consumption, depressive symptoms and intention to quit. RESULTS: We found a factorial structure for the MRSS of 11 items within five subscales in order of importance: tension reduction, addiction, pleasure, habit and social function. Results for internal consistency and test-retest reliability were good to acceptable. There were significant associations of nicotine dependence with tension reduction and addiction and of daily consumption with addiction and habit. CONCLUSIONS: Validity and reliability of the MRSS were shown in a sample of pregnant smokers. Tension reduction was the most important reason for continued smoking, followed by pleasure and addiction. Although the score for nicotine dependence was low, addiction was an important reason for continued smoking during pregnancy; therefore, nicotine replacement therapy could be considered. Half of the respondents experienced depressive symptoms. Hence, it is important to identify those women who need more specialized care, which can include not only smoking cessation counselling but also treatment for depression.

Sensitivity to reward is associated with snack and sugar-sweetened beverage consumption in adolescents.

PURPOSE: High intake of palatable foods, such as energy-dense snacks and sugar-sweetened beverages (SSBs), is common among adolescents. An individual's sensitivity to reward (SR) may influence these intakes. The main objective of this study was to investigate the association between SR and both snack and SSB intake among adolescents. METHODS: A representative cross-sectional survey was conducted among 1104 14- to 16-year-olds (mean age = 14.7 ± 0.8 years; 50.9 % boys; 18.0 % overweight) in Flanders. Daily intakes were measured by a food frequency questionnaire. SR was assessed using the behavioral activation system (BAS) scales. Multilevel regression analyses (two level: adolescent school) were conducted using STATA version 13. RESULTS: BAS drive was positively associated with daily intakes of SSBs (13.79 %, p < 0.01), unhealthy snacks (5.42 %, p < 0.001), and energy and nutrients derived from SSBs (p < 0.001) and snacks (p < 0.01). BAS reward responsiveness (RR) was only positively associated with intake of unhealthy snacks (3.85 %, p < 0.05), healthy snacks (6.41 %, p < 0.05), and fat (4.05 %, p < 0.01) and Na (3.89 %, p < 0.05) from snacks. Interaction effects of gender and BAS RR (p < 0.05) were found. Significant positive associations between BAS RR and daily intakes of energy from snacks (6.48 %, p < 0.01) and fat from snacks (7.22 %, p < 0.001) were found only for girls. CONCLUSION: SR was associated with snack and SSB consumption in adolescents, especially in girls. These findings suggest that SR should be taken into account when designing interventions to improve the snack and SSB intake of adolescents.

Water intake and beverage consumption of pre-schoolers from six European countries and associations with socio-economic status: the ToyBox-study.

OBJECTIVE: To study the quantity and quality of water intake from beverages among pre-schoolers and investigate associations with gender and socio-economic status (SES). DESIGN: Kindergarten-based cross-sectional survey within the large-scale European ToyBox-study. A standardized protocol was used and parents/caregivers filled in sociodemographic data and a semi-quantitative FFQ. SETTING: Kindergartens in six European countries (Belgium, Bulgaria, Germany, Greece, Poland and Spain). SUBJECTS: European pre-schoolers (aged 3·5-5·5 years) and their parents/caregivers (n 7051). RESULTS: Mean water intake was 1051 ml/d; plain water, 547 ml/d; plain milk, 241 ml/d; other fruit juice, 104 ml/d; pure fruit juice, 59 ml/d; soft drinks, 55 ml/d; tea, 45 ml/d; sugared and chocolate milk, 37 ml/d; smoothies, 15 ml/d; and light soft drinks, 6 ml/d. Boys had a higher water intake than girls due to a higher consumption of plain water, but more importantly to the consumption of beverages of less quality. Lower-SES pre-schoolers scored better on quantity than high-SES pre-schoolers, but as a consequence of consumption of sugared beverages. Nevertheless, the associations differed by country. CONCLUSIONS: The water intake from beverages did not meet the European Food Safety Authority standard of 1280 ml/d; especially in Western European countries water intake from beverages was low. The most important water sources were plain water, milk and fruit juices. Interventions aiming at a proper and sufficient water intake should focus on both quantity and quality. Messages about water and water sources should be clear for everyone and interventions should be sufficiently tailored.

A comparative study of screening instruments and biomarkers for the detection of cannabis use.

BACKGROUND: The aim of this study was to compare the usefulness of 3 different screening instruments (questionnaires) for the detection of cannabis use (CU) with biological markers in blood and hair. METHODS: Ninety-four students were recruited in October 2013. Participants filled out the Severity of Dependence Scale (SDS), the CAGE-AID ("Cut down Annoyed Guilty Eye-opener"-Adapted to Include Drugs), and ProbCannabis-DT questionnaires concerning their possible CU. Blood and hair samples were taken and analyzed by gas chromatography-mass spectrometry. Logistic regression (Nagelkerke R(2)) and receiver operating characteristic (ROC) curve analyses were performed. THCCOOH (Δ(9)-tetrahydrocannabinoic acid) plasma of ≥5 ng/mL and THC (Δ(9)-tetrahydrocannabinol) hair concentrations of ≥0.1 and ≥0.02 ng/mg were used as the gold standard for CU. The questionnaire results were compared with different concentration ranges for THCCOOH in plasma (<5, 5-75, and >75 ng/mL, indicating the intensity of use) and THC in hair (≥0.02 ng/mg, ≥0.1 ng/mg). RESULTS: The Nagelkerke R(2) for comparing the SDS, CAGE-AID, and ProbCannabis-DT with THCCOOH in plasma was 0.350, 0.489, and 0.335, respectively. The area under the ROC curve (95% confidence interval) was 0.772 (0.662-0.882), 0.797 (0.710-0.884), and 0.769 (0.669-0.870), respectively. Corresponding sensitivity/specificity were 70%/84%, 100%/59%, and 87%/67%, respectively. These values were similar to those compared to a 0.02 ng/mg THC cutoff in hair. CONCLUSIONS: Moderate agreement was found between all questionnaires and biomarkers of CU. The CAGE-AID and probCannabis-DT questionnaires were very sensitive, but less specific. SDS was less sensitive, but more specific.

Associations between parental rules, style of communication and children's screen time.

BACKGROUND: Research suggests an inverse association between parental rules and screen time in pre-adolescents, and that parents' style of communication with their children is related to the children's time spent watching TV. The aims of this study were to examine associations of parental rules and parental style of communication with children's screen time and perceived excessive screen time in five European countries. METHODS: UP4FUN was a multi-centre, cluster randomised controlled trial with pre- and post-test measurements in each of five countries; Belgium, Germany, Greece, Hungary and Norway. Questionnaires were completed by the children at school and the parent questionnaire was brought home. Three structural equation models were tested based on measures of screen time and parental style of communication from the pre-test questionnaires. DISCUSSION: Of the 152 schools invited, 62 (41 %) schools agreed to participate. In total 3325 children (average age 11.2 years and 51 % girls) and 3038 parents (81 % mothers) completed the pre-test questionnaire. The average TV/DVD times across the countries were between 1.5 and 1.8 h/day, while less time was used for computer/games console (0.9-1.4 h/day). The children's perceived parental style of communication was quite consistent for TV/DVD and computer/games console. The presence of rules was significantly associated with less time watching TV/DVD and use of computer/games console time. Moreover, the use of an autonomy-supportive style was negatively related to both time watching TV/DVD and use of computer/games console time. The use of a controlling style was related positively to perceived excessive time used on TV/DVD and excessive time used on computer/games console. With a few exceptions, results were similar across the five countries. CONCLUSIONS: This study suggests that an autonomy-supportive style of communicating rules for TV/DVD or computer/ games console use is negatively related to children's time watching TV/DVD and use of computer/games console time. In contrast, a controlling style is associated with more screen time and with more perceived excessive screen time in particular. Longitudinal research is needed to further examine effects of parental style of communication on children's screen time as well as possible reciprocal effects. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number Register, registration number: ISRCTN34562078 . Date applied29/07/2011, Date assigned11/10/2011.