Facilitators and barriers of intersectoral co-operation to promote healthier and more environmentally friendly behaviour: a qualitative evaluation through focus groups for the INHERIT project.

BACKGROUND: Tackling challenges related to health, environmental sustainability and equity requires many sectors to work together. This "intersectoral co-operation" can pose a challenge on its own. Research commonly focuses on one field or is conducted within one region or country. The aim of this study was to investigate facilitators and barriers regarding intersectoral co-operative behaviour as experienced in twelve distinct case studies in ten European countries. The COM-B behavioural system was applied to investigate which capabilities, opportunities and motivational elements appear necessary for co-operative behaviour. METHOD: Twelve focus groups were conducted between October 2018 and March 2019, with a total of 76 participants (policymakers, case study coordinators, governmental institutes and/or non-governmental organisations representing citizens or citizens). Focus groups were organised locally and held in the native language using a common protocol and handbook. One central organisation coordinated the focus groups and analysed the results. Translated data were analysed using deductive thematic analysis, applying previous intersectoral co-operation frameworks and the COM-B behavioural system. RESULTS: Amongst the main facilitators experienced were having highly motivated partners who find common goals and see mutual benefits, with good personal relationships and trust (Motivation). In addition, having supportive environments that provide opportunities to co-operate in terms of support and resources facilitated co-operation (Opportunity), along with motivated co-operation partners who have long-term visions, create good external visibility and who have clear agreements and clarity on roles from early on (Capability). Barriers included not having necessary and/or structural resources or enough time, and negative attitudes from specific stakeholders. CONCLUSIONS: This study on facilitators and barriers to intersectoral co-operation in ten European countries confirms findings of earlier studies. This study also demonstrates that the COM-B model can serve as a relatively simple tool to understand co-operative behaviour in terms of the capability, opportunity and motivation required amongst co-operation partners from different sectors. Results can support co-operators' and policymakers' understanding of necessary elements of intersectoral co-operation. It can help them in developing more successful intersectoral co-operation when dealing with challenges of health, environmental sustainability and equity.

Citizen Science for public health.

Community engagement in public health policy is easier said than done. One reason is that public health policy is produced in a complex process resulting in policies that may appear not to link up to citizen perspectives. We therefore address the central question as to whether citizen engagement in knowledge production could enable inclusive health policy making. Building on non-health work fields, we describe different types of citizen engagement in scientific research, or 'Citizen Science'. We describe the challenges that Citizen Science poses for public health, and how these could be addressed. Despite these challenges, we expect that Citizen Science or similar approaches such as participatory action research and 'popular epidemiology' may yield better knowledge, empowered communities, and improved community health. We provide a draft framework to enable evaluation of Citizen Science in practice, consisting of a descriptive typology of different kinds of Citizen Science and a causal framework that shows how Citizen Science in public health might benefit both the knowledge produced as well as the 'Citizen Scientists' as active participants.

A systematic review of financial incentives given in the healthcare setting; do they effectively improve physical activity levels?

BACKGROUND: According to current physical activity guidelines, a substantial percentage of the population in high-income countries is inactive, and inactivity is an important risk factor for chronic conditions and mortality. Financial incentives may encourage people to become more active. The objective of this review was to provide insight in the effectiveness of financial incentives used for promoting physical activity in the healthcare setting. METHODS: A systematic literature search was performed in three databases: Medline, EMBASE and SciSearch. In total, 1395 papers published up until April 2015 were identified. Eleven of them were screened on in- and exclusion criteria based on the full-text publication. RESULTS: Three studies were included in the review. Two studies combined a financial incentive with nutrition classes or motivational interviewing. One of these provided a free membership to a sports facility and the other one provided vouchers for one episode of aerobic activities at a local leisure center or swimming pool. The third study provided a schedule for exercise sessions. None of the studies addressed the preferences of their target population with regard to financial incentives. Despite some short-term effects, neither of the studies showed significant long-term effects of the financial incentive. CONCLUSIONS: Based on the limited number of studies and the diversity in findings, no solid conclusion can be drawn regarding the effectiveness of financial incentives on physical activity in the healthcare setting. Therefore, there is a need for more research on the effectiveness of financial incentives in changing physical activity behavior in this setting. There is possibly something to be gained by studying the preferred type and size of the financial incentive.

Preferences for Vaccination: Does Health Literacy Make a Difference?

PURPOSE: The purpose of this study is to examine to what extent health literacy is associated with parental preferences concerning childhood vaccination. METHODS: A cross-sectional study was conducted among 467 Dutch parents of newborns aged 6 weeks (response rate of 37%). A self-reported questionnaire was used to measure health literacy by means of Chew's Set of Brief Screening Questions, as well as parental preferences for rotavirus vaccination by means of a discrete choice experiment. Five rotavirus-related characteristics were included (i.e., vaccine effectiveness, frequency of severe side effects, location of vaccination, protection duration, and out-of-pocket costs). Panel latent class models were conducted, and health literacy and educational level were added to the class probability model to determine the association between health literacy and study outcomes. RESULTS: Lower educated and lower health literate respondents considered protection duration to be more important and vaccine effectiveness and frequency of severe side effects to be less important compared with higher educated and higher health literate respondents. While all respondents were willing to vaccinate against rotavirus when the vaccine was offered as part of the National Immunization Program, only lower educated and lower health literate parents were willing to vaccinate when the vaccine was offered on the free market. CONCLUSION: Health literacy is associated with parents' preferences for rotavirus vaccination. Whether differences in vaccination decisions are actually due to varying preferences or might be better explained by varying levels of understanding should be further investigated. To contribute to more accurate interpretation of study results, it may be advisable that researchers measure and report health literacy when they study vaccination decision behavior.

Functional, interactive and critical health literacy: Varying relationships with control over care and number of GP visits.

OBJECTIVE: The aim of this study is to examine the extent to which functional, interactive and critical health literacy are associated with patients' perceived control over care and frequency of GP visits. METHODS: Data from the Dutch 'National Panel of People with Chronic Illness or Disability' was used (N=2508). Health literacy was assessed by the Functional, Communicative and Critical Health Literacy measure. Perceived control over care was indicated by perceived ability to organize care, interact with providers and to perform self-care. By multivariate linear and logistic regression analyses, associations between health literacy and perceived control over care and subsequently frequency of GP visits were studied. RESULTS: Mainly interactive health literacy was associated with patients' perceived ability to organize care, interact with healthcare providers and perform self-care, whereas only functional health literacy was associated with number of GP visits. CONCLUSION: The results imply that some patients' may be less able to exert control over their care because of lower health literacy. Functional, interactive and critical health literacy vary in their relevance for patients' ability to exert control. PRACTICE IMPLICATIONS: Initiatives for strengthening patients' role in healthcare may be improved by paying attention to patients' health literacy, specifically functional and interactive health literacy.

Associations among health literacy, diabetes knowledge, and self-management behavior in adults with diabetes: results of a dutch cross-sectional study.

Various studies have examined the association between health literacy and self-management behavior, but few have explored ways through which this occurs. The present study examines to what extent health literacy is associated with diabetes self-management behavior and to what extent diabetes knowledge is a mechanism in this association. The study was based on cross-sectional data retrieved from patient registrations and questionnaires completed in 2010. The sample included 1,714 predominantly type 2 diabetes patients, with a mean age of 67 years. Diabetes self-management was indicated by HbA1c level, glucose self-control and self-reported monitoring of glucose levels, physical activity, and smoking. Multilevel analyses were applied based on multiple imputed data. Lower health literacy was significantly associated with less diabetes knowledge, higher HbA1c level, less self-control of glucose level, and less physical activity. Participants with more diabetes knowledge were less likely to smoke and more likely to control glucose levels. Diabetes knowledge was a mediator in the association between health literacy and glucose self-control and between health literacy and smoking. This study indicates that higher health literacy may contribute to participation in certain self-management activities, in some cases through diabetes knowledge. Diabetes knowledge and health literacy skills may be important targets for interventions promoting diabetes self-management.

The preferences of users of electronic medical records in hospitals: quantifying the relative importance of barriers and facilitators of an innovation.

BACKGROUND: Currently electronic medical records (EMRs) are implemented in hospitals, because of expected benefits for quality and safety of care. However the implementation processes are not unproblematic and are slower than needed. Many of the barriers and facilitators of the adoption of EMRs are identified, but the relative importance of these factors is still undetermined. This paper quantifies the relative importance of known barriers and facilitators of EMR, experienced by the users (i.e., nurses and physicians in hospitals). METHODS: A discrete choice experiment (DCE) was conducted among physicians and nurses. Participants answered ten choice sets containing two scenarios. Each scenario included attributes that were based on previously identified barriers in the literature: data entry hardware, technical support, attitude head of department, performance feedback, flexibility of interface, and decision support. Mixed Multinomial Logit analysis was used to determine the relative importance of the attributes. RESULTS: Data on 148 nurses and 150 physicians showed that high flexibility of the interface was the factor with highest relative importance in their preference to use an EMR. For nurses this attribute was followed by support from the head of department, presence of performance feedback from the EMR and presence of decisions support. While for physicians this ordering was different: presence of decision support was relatively more important than performance feedback and support from the head of department. CONCLUSION: Considering the prominent wish of all the intended users for a flexible interface, currently used EMRs only partially comply with the needs of the users, indicating the need for closer incorporation of user needs during development stages of EMRs. The differences in priorities amongst nurses and physicians show that different users have different needs during the implementation of innovations. Hospital management may use this information to design implementation trajectories to fit the needs of various user groups.

How stable are physical activity habits among adults? The Doetinchem Cohort Study.

INTRODUCTION: Leisure time physical activity in compliance with recommended levels is associated with improved health and lower mortality, but little is known on whether these physical activity habits are stable among adults and what characteristics predict physical activity changes. Our objective was to determine change in the levels of leisure time physical activity among adults during a period of 10 yr. METHODS: Detailed information on time spent on cycling, gardening, doing odd jobs, and sports from three measurement periods (1993-1997, 1998-2002, and 2003-2007) of the population-based Doetinchem Cohort Study was used to define being active: spending at least 3.5 h·wk(-1) on moderate to vigorous physical activities, an approximation of the Dutch recommended level. RESULTS: Almost one-third (31.4%) of the population were active at all three points in time, 3.6% were inactive, and 45.0% of the participants changed their level of physical activity, almost equally distributed over decreasers, increasers, and varying. Not smoking (odds ratio (OR) = 1.47, 95% confidence limits (CL) = 1.14-1.89) and high socioeconomic status (OR = 1.43, 95% CL = 1.07-1.92) were associated with staying active. Inactive men (OR = 0.73, 95% CL = 0.57-0.94) had the highest risk of staying inactive, whereas good perceived health was associated with becoming active (OR = 1.49, 95% CL = 1.09-2.03). CONCLUSIONS: The finding that, in a decade, almost half of the population changed from active to inactive or vice versa affects the interpretation of the long-term health effects of physical activity measured only once, and it stresses the importance of interventions not only in increasing physical activity levels but also in maintaining a physically active lifestyle.

Noncompliance in lifestyle intervention studies: the instrumental variable method provides insight into the bias.

OBJECTIVE: In lifestyle intervention trials, participants of the control group often change their behavior despite the request to maintain their usual lifestyle pattern. These changes in the control group and changes in addition to the intended in the intervention group can lead to undesirable confounding effects. STUDY DESIGN AND SETTING: We address several considerations for study design to prevent noncompliance or minimize its effects. Furthermore, we demonstrate how the instrumental variable method can give insight into the extent of bias introduced by noncompliance in randomized trials, within the context of the Sex Hormones and Physical Exercise study. RESULTS: Noncompliance can be prevented by measures taken in the design phase of a study, for example, limited duration of the study, clear recommendations, power calculation, intensity of the intervention, involvement of the control group, waiting-list control group, and single-consent design nested within an observational study. When nevertheless noncompliance does occur, the instrumental variable method estimates the intervention effect of treatment among the compliers. CONCLUSION: Noncompliance can seriously affect validity of lifestyle trial results. Its occurrence should be prevented by taking measures during the design phase of a study. The instrumental variable method can give insight into confounding by noncompliance in randomized trials.

Behavioral changes after a 1-yr exercise program and predictors of maintenance.

PURPOSE: Public health strategies attempt to stimulate participation in physical activity, aiming at permanent behavior change. We assessed the sustained effect of participating in an exercise program on physical activity behavior 1 yr after completion of the program. Furthermore, we aimed to identify factors that predict sustained exercise participation. METHODS: Previously low-active, postmenopausal women originally participating in an exercise intervention study (the Sex Hormones and Physical Exercise study) were recontacted 1 yr after finishing the study. Their current level of physical activity was assessed by the Modified Baecke Questionnaire. MET-hours per week spent on at least moderate-intensity activities were calculated and used to assess compliance to the international physical activity recommendation. Multivariable linear regression analysis was applied to investigate which factors predict a higher level of physical activity in the intervention group 1 yr after the study. RESULTS: Participation in the Sex Hormones and Physical Exercise study resulted in an increased level of physical activity in both the intervention (median at baseline and at 12 months = 4.9 and 19.8 MET x h x wk(-1), respectively) and the control groups (median at baseline and at 12 months = 4.3 and 5.8 MET x h x wk(-1), respectively). Although the intervention group did not maintain the high physical activity level achieved during the study, 1 yr later they remained more active than the control group (median = 12.1 and 7.9 MET x h x wk(-1), respectively, P = 0.04). Age, baseline activity, and employment were the strongest predictors of the physical activity level in the intervention group 1 yr after finishing the study. CONCLUSION: Sustained changes in physical activity behavior in previously low-active postmenopausal women are feasible after participation in a 1-yr exercise program.

Age, period and cohort effects on body weight and body mass index in adults: The Doetinchem Cohort Study.

OBJECTIVE: To study the development of body weight with ageing, in a general adult population, taking into account possible period and cohort effects. DESIGN: A prospective cohort study with 11 years of follow-up. At baseline and after 6 and 11 years, body weight and height were measured. SETTING: The Doetinchem Cohort Study, consisting of inhabitants of Doetinchem, a town in a rural area of The Netherlands. SUBJECTS: In total, 4070 healthy men and women aged 20-59 years at baseline. RESULTS: Increase in BMI with ageing was less profound based on cross-sectional data than based on longitudinal data. More recent-born cohorts had a higher BMI at a given age than cohorts who were born earlier. Increase in mean BMI with ageing was observed in all age groups and was similar for groups with a different educational level. Highest increase in BMI over 11 years was observed in the youngest group, aged 20-29 years at baseline (2.2 [95 % CL 2.0, 2.3] kg/m2), and lowest increase in the oldest group, aged 50-59 years at baseline (1.1 [1.0, 1.3] kg/m2). CONCLUSIONS: Findings of the present study using longitudinal data suggest that increase in BMI with ageing is underestimated in all age groups by studying cross-sectional data only. Further, weight gain is present in all educational levels and does not stop at middle age.

Adolescent skinfold thickness is a better predictor of high body fatness in adults than is body mass index: the Amsterdam Growth and Health Longitudinal Study.

BACKGROUND: Body mass index (BMI) during adolescence is predictive of BMI at adult age. However, BMI cannot distinguish between lean and fat body mass. Skinfold thickness may be a better predictor of body fatness. OBJECTIVE: The objective of this study was to evaluate the relations between BMI and skinfold thickness during adolescence and body fatness during adulthood. DESIGN: We included 168 men and 182 women from the Amsterdam Growth and Health Longitudinal Study, a prospective study that conducted 8 measurements of BMI and skinfold thickness between 1976 and 2000. BMI and skinfold thickness during adolescence were analyzed in relation to adult body fatness measured at a mean age of 37 y with dual-energy X-ray absorptiometry. RESULTS: None of the boys and 1.7% of the girls were overweight at baseline, whereas the prevalence of high body fatness during adulthood was 29% in men and 32% in women. At the ages of 12-16 y, skinfold thickness was more strongly associated with adult body fatness than was BMI. Age-specific relative risks for a high level of adult body fatness varied between 2.3 and 4.0 in boys and between 2.1 and 4.3 in girls in the highest versus the lowest tertile of the sum of 4 skinfold thicknesses. For the highest tertile of BMI, the relative risk varied between 0.8 and 2.1 in boys and between 1.3 and 1.8 in girls. CONCLUSION: Skinfold thickness during adolescence is a better predictor of high body fatness during adulthood than is BMI during adolescence.

Physical activity and breast cancer: a systematic review.

BACKGROUND: Many epidemiologic studies have found an association between physical activity and breast cancer risk, although this has not been a consistent finding. METHODS: Studies were identified through a systematic review of literature available on PubMed through February 2006. We included all cohort and case-control studies that assessed total or leisure time activities in relation to occurrence or mortality of breast cancer. The fully adjusted risk estimates and 95% confidence intervals for the highest versus lowest level of activity were documented for each study as well as evidence for a dose-response relationship. Methodologic quality was also assessed. Due to statistical and methodologic heterogeneity among studies, we did not carry out statistical pooling. To draw conclusions, we performed a best-evidence synthesis taking study quality into account. RESULTS: Nineteen cohort studies and 29 case-control studies were evaluated. There was strong evidence for an inverse association between physical activity and postmenopausal breast cancer with risk reductions ranging from 20% to 80%. For premenopausal breast cancer, however, the evidence was much weaker. For pre- and postmenopausal breast cancer combined, physical activity was associated with a modest (15-20%) decreased risk. Evidence for a dose-response relationship was observed in approximately half of the higher-quality studies that reported a decreased risk. A trend analysis indicated a 6% (95% confidence interval = 3% to 8%) decrease in breast cancer risk for each additional hour of physical activity per week assuming that the level of activity would be sustained. CONCLUSIONS: There is evidence for an inverse association between physical activity and breast cancer risk. The evidence is stronger for postmenopausal breast cancer than for premenopausal breast cancer.

Physical activity and breast cancer risk: the European Prospective Investigation into Cancer and Nutrition.

There is convincing evidence for a decreased risk of breast cancer with increased physical activity. Uncertainties remain, however, about the role of different types of physical activity on breast cancer risk and the potential effect modification for these associations. We used data from 218,169 premenopausal and postmenopausal women from nine European countries, ages 20 to 80 years at study entry into the European Prospective Investigation into Cancer and Nutrition. Hazard ratios (HR) from multivariate Cox regression models were calculated using metabolic equivalent value-based physical activity variables categorized in quartiles, adjusted for age, study center, education, body mass index, smoking, alcohol use, age at menarche, age at first pregnancy, parity, current oral contraceptive use, and hormone replacement therapy use. The physical activity assessment included recreational, household, and occupational activities. A total physical activity index was estimated based on cross-tabulation of these separate types of activity. During 6.4 years of follow-up, 3,423 incident invasive breast cancers were identified. Overall, increasing total physical activity was associated with a reduction in breast cancer risk among postmenopausal women (P(trend) = 0.06). Specifically, household activity was associated with a significantly reduced risk in postmenopausal (HR, 0.81; 95% confidence interval, 0.70-0.93, highest versus the lowest quartile; P(trend) = 0.001) and premenopausal (HR, 0.71; 95% confidence interval, 0.55-0.90, highest versus lowest quartile; P(trend) = 0.003) women. Occupational activity and recreational activity were not significantly related to breast cancer risk in both premenopausal and postmenopausal women. This study provides additional evidence for a protective effect of physical activity on breast cancer risk.

Effects of retirement on lifestyle in relation to changes in weight and waist circumference in Dutch men: a prospective study.

OBJECTIVE: To study changes in lifestyle in relation to changes in body weight and waist circumference associated with occupational retirement in men. DESIGN: A prospective cohort study with 5 years of follow-up. At baseline and at follow-up, questionnaires were completed and body weight and waist circumference were measured. SETTING: The Doetinchem Cohort Study, consisting of inhabitants of Doetinchem, a town in a rural area of The Netherlands. SUBJECTS: In total 288 healthy men aged 50-65 years at baseline, who either remained employed or retired over follow-up. RESULTS: The effect of retirement on changes in weight and waist circumference was dependent on type of former occupation. Increase in body weight and waist circumference was higher among men who retired from active jobs (0.42 kg year(-1) and 0.77 cm year(-1), respectively) than among men who retired from sedentary jobs (0.08 kg year(-1) and 0.23 cm year(-1), respectively). Weight gain and increase in waist circumference were associated with a decrease in fruit consumption and fibre density of the diet, with an increase in frequency of eating breakfast, and with a decrease in several physical activities, such as household activities, bicycling, walking and doing odd jobs. CONCLUSION: Retirement was associated with an increase in weight and waist circumference among those with former active jobs, but not among those with former sedentary jobs. Retirement may bring opportunities for healthy changes in diet and physical activity, which could be used in health promotion programmes.

Factors of the physical environment associated with walking and bicycling.

PURPOSE: The purpose of this study was to identify factors of the physical environment that may influence time spent on walking and bicycling. METHODS: Demographic factors and time spent on walking and bicycling (during leisure time and for commuting purposes) were assessed with a self-administered questionnaire. GIS databases were used to objectively measure the total square area of green space and recreational space (woods, parks, sport grounds, allotments for vegetable gardens, and grounds for day trips) in a circle around the postal code of a respondent with a radius of 300 and 500 m. Multilevel regression analysis was used to study the association between walking and bicycling on the one hand, and green and recreational space on the other hand. Analyses were adjusted for gender, age, and educational level. RESULTS: In a neighborhood defined as a circle with a 300-m radius, the square area of sport grounds was associated with bicycling in general and the square area of parks was associated with bicycling for commuting purposes. It is, however, very likely that these results reflect the association of living in the outskirts of town and time spent on bicycling. CONCLUSION: The present study showed green and recreational space, specifically sport grounds and parks, to be associated with time spent on bicycling.

Are stress related factors associated with alcohol intake?

Moderate alcohol consumption is related to reduced risks of coronary heart disease and all-cause mortality. Our goal is to advance our understanding of the associations between stress-related factors and alcohol consumption, using cutoff points for alcohol intake that reflect health benefits rather than health risks. Cross-sectional data were used from 4,131 respondents (age 20-65 years) participating in a cohort study in the Netherlands on psychosocial factors and cancer risk. Analyses were performed among drinkers only, for men and women separately. Heavy alcohol intake (>/= 3 glasses per day for men, >/= 2 glasses per day for women) was associated with only a few stress-related factors in multivariate analyses. No significant associations between the total amount of stressors and alcohol intake were found. We conclude that stress-related factors are only marginally associated with a heavy alcohol intake compared with fair drinking, using the safe limits of drinking as cutoff point.

Reproducibility and relative validity of the short questionnaire to assess health-enhancing physical activity.

BACKGROUND/OBJECTIVES: The purpose of this study is to determine reproducibility and relative validity of the Short QUestionnaire to ASsess Health-enhancing physical activity (SQUASH). METHODS: Participants (36 men and 14 women, aged 27-58) were asked to complete the SQUASH twice with an inbetween period of approximately 5 weeks. In addition, participants wore the Computer Science and Applications (CSA) Activity Monitor for a 2-week period following the first questionnaire. RESULTS: The Spearman correlation for overall reproducibility of the SQUASH was 0.58 (95%-CI 0.36-0.74). Correlations for the reproducibility of the separate questions varied between 0.44 and 0.96. Spearman's correlation coefficient between CSA readings and the total activity score was 0.45 (95%-CI 0.17-0.66). CONCLUSIONS: In conclusion, the SQUASH is a fairly reliable and reasonably valid questionnaire and may be used to order subjects according to their level of physical activity in an adult population. Because the SQUASH is a short and simple questionnaire, it may proof to be a very useful tool for the evaluation of health enhancing physical activity in large populations.

Clustering of lifestyle risk factors in a general adult population.

BACKGROUND: The objective of the study was to evaluate the degree of clustering of common lifestyle risk factors in a general adult population and to define subgroups with elevated clustering. METHODS: Data on lifestyle risk factors (smoking, low vegetable and fruit consumption, excessive alcohol intake, and low physical activity), sociodemographics, and health perception were collected by questionnaire from 16,789 men and women aged 20 to 59. RESULTS: About 20% of the subjects had at least three lifestyle risk factors. Prevalence of risk factors was higher among unemployed, low-educated subjects and those who had experienced health deterioration. All lifestyle risk factors showed significant clustering, except for low physical activity and excessive alcohol consumption. The strongest association was observed for alcohol and smoking (prevalence odds ratio (POR): 2.38; 95% confidence interval: 2.18-2.61). Clustering of smoking and alcohol consumption was strongest among the young subjects (POR: 3.78) and, although moderately, clustering of lifestyle risk factors was elevated in subjects who had experienced a deterioration in health. CONCLUSIONS: These findings suggest that common lifestyle risk factors cluster among adult subjects. The tendency for risk factors to aggregate has important implications for health promotion. Information on high-risk groups will help in planning future preventive strategies.