Urban densification in the Netherlands and its impact on mental health: An expert-based causal loop diagram.

Urban densification is a key strategy to accommodate rapid urban population growth, but emerging evidence suggests serious risks of urban densification for individuals' mental health. To better understand the complex pathways from urban densification to mental health, we integrated interdisciplinary expert knowledge in a causal loop diagram via group model building techniques. Six subsystems were identified: five subsystems describing mechanisms on how changes in the urban system caused by urban densification may impact mental health, and one showing how changes in mental health may alter urban densification. The new insights can help to develop resilient, healthier cities for all.

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.

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.

Flourishing mental health and lifestyle behaviours in adults with Type 1 and Type 2 Diabetes Mellitus: results from the Diabetes MILES - The Netherlands Study.

OBJECTIVE: To examine the associations between mental health and lifestyle in adults with type 1 and type 2 diabetes mellitus (T1DM and T2DM). METHODS: Online survey data from the cross-sectional Diabetes MILES - The Netherlands Study was analysed, including 270 adults with T1DM and 325 with T2DM. Mental health status (flourishing, moderate and languishing) in relation to diet, physical activity, alcohol consumption and smoking was analysed with ANCOVA and logistic regressions (adjusted for confounders). RESULTS: 47% of T1DM-, and 55% of T2DM participants reported flourishing mental health. Due to an insufficient number, participants with languishing mental health were excluded. In T2DM, participants with flourishing mental health had more optimal diet quality (mean ± SEM: 70 ± 1 vs 68 ± 1 diet quality score, p = 0.015), and physical activity levels (mean ± SEM: 3484 ± 269 vs 2404 ± 273 MET minutes/week, p = 0.001) than those with moderate mental health, but did not differ with respect to alcohol consumption and smoking. In T1DM, no significant associations were found. CONCLUSION: Only in T2DM, people with flourishing mental health had more optimal lifestyle behaviours compared to people with moderate mental health. Further research is needed to determine if mental health is more important for specific lifestyle behaviours, and if the mental health effect differs across diabetes types.

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.

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.

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.

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.

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.

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.

Qualitative, longitudinal exploration of coping strategies and factors facilitating infant and young child feeding practices among mothers in rural Rwanda.

BACKGROUND: Mothers in low-income countries face many challenges to appropriately feed their children in the first year such as poverty, food insecurity and high workloads. However, even in the lowest income families there are mothers who succeed to feed their children according to the recommendations. In this paper, we explored the coping strategies that facilitate appropriate breastfeeding and complementary feeding practices among rural Rwandan mothers from birth to one year of a child's life. METHODS: This qualitative longitudinal study recruited a purposive sample of 17 mothers who followed the infant and young child feeding recommendations (IYCF). They were selected from a larger study of 36 mothers. In-depth interviews were conducted with mothers of the total group (36 mothers) within the first week, at 4th, 6th, 9th and 12th months postpartum. Interviews were audio-recorded, transcribed verbatim and analyzed thematically. RESULTS: Coping strategies included improving mothers' own diet for adequate breastmilk production, prioritizing child feeding over livelihood chores, livelihood diversification and mothers' anticipatory behaviors such as preparing child's food in advance. Some of those coping strategies were shifting overtime depending on the development of the children. Personal factors such as breastfeeding self-efficacy, religious beliefs and perceived benefits of breastfeeding were among the facilitating factors. Additionally, social support that mothers received from family members, other mothers in the community, Community Health Workers (CHWs) and health professionals played an important role. CONCLUSION: In challenging contextual conditions, mothers manage to follow the recommended breastfeeding and complementary feeding practices through the interplay of active coping strategies, feeling to be in control and social support. Nutrition promotion interventions that aim to improve IYCF should consider strengthening mothers' capability in gaining greater control of their IYCF practices and the factors facilitating their appropriate IYCF practices.

Life course learning experiences and infant feeding practices in rural Rwanda.

Most studies about infant and young child feeding (IYCF) practices are often perceived as an individual choice depending on mothers' or caregivers' knowledge or attitudes and are focused on mothers' failure rather than successes in adequately feeding their children. However, the role of life course experiences in IYCF is less investigated. Applying a Salutogenic Model of Health, this study on 14 mothers looks at women's life course learning experiences shaping appropriate IYCF practices during the first year of child's life in a rural district of Rwanda. Transcripts from in-depth interviews were analysed using thematic analysis. Results indicate that positive social interaction with parents or grandmothers during childhood such as sharing meals, parental role models for dietary choices and cooking skills gained by participating in household food preparation played a role in shaping appropriate IYCF practices. Negative experiences during childhood also had a positive influence on IYCF practices for some participants by converting life course constraints into learning opportunities. Motherhood increased mothers' sense of responsibility over their children's health and nutrition. Moreover, mothers' participation in community cooking classes and role modelling approach were strong avenues that enabled their learning through positive interactions and encouragement. Nutrition promotion interventions should consider tailoring nutrition advice to the complexity of mothers' life course experiences by creating opportunities for positive learning experiences of appropriate IYCF practices.

Prenatal infant feeding intentions and actual feeding practices during the first six months postpartum in rural Rwanda: a qualitative, longitudinal cohort study.

BACKGROUND: Exclusive breastfeeding (EBF) is advocated by the WHO for the first 6 months. In Rwanda, the percentage of infants who are exclusively breastfed decreases from 94% among infants aged 0-1 month to 81% among those aged 4-5 months. Little is known about what influences mothers' breastfeeding practices. This study aimed to gain insights into expectant mothers' prenatal feeding intentions, the underlying reasons, actual practices after birth, and factors facilitating or impeding EBF for the first 6 months of a child's life in Muhanga District, Rwanda. METHODS: This qualitative longitudinal study, conducted between December 2016 and October 2017 as part of a larger study, recruited a purposive sample of 39 pregnant women attending prenatal consultations during their last trimester in two rural health centers. Women were interviewed during pregnancy, within the first week after birth and at 4 and 6 months postpartum to explore intentions, actual practices, critical transition points, and facilitating or impeding factors. Interviews were recorded, transcribed verbatim, and analyzed thematically. RESULTS: Of the 39 participants, 38 intended to breastfeed within the first hour after birth, and 32 intended to breastfeed exclusively for the first 6 months. In practice, 34 initiated breastfeeding within the first hour, and 12 breastfed exclusively for 6 months. Impeding factors include perceived breastmilk insufficiency, pressure from family members, past experiences, mothers' concerns over their infants' health, mothers' heavy workload, poverty and food insecurity. Factors facilitating early initiation and EBF include mothers' awareness of EBF's advantages, confidence in their breastfeeding ability, and support from health professionals and family members. CONCLUSION: Despite participants' intentions about breastfeeding, there was a gap between intentions and actual practices. An interplay of barriers at individual, group and societal levels impeded women from EBF for the first 6 months. EBF promotion interventions should consider supporting and equipping breastfeeding mothers with skills to deal with perceived breastmilk insufficiency and to recognize the true signs of baby hunger cues. Furthermore, important influential family and community members should be targeted to support mothers to breastfeed. Interventions that consider addressing the issue of poverty-driven food insecurity should not be overlooked either.

Care Farming for People with Dementia; What Can Healthcare Leaders Learn from This Innovative Care Concept?

There is growing recognition that traditional dementia care models fall short for people with dementia and their family caregivers. This has led to a call for new dementia care approaches. In response to this call, innovations in long-term dementia care are taking place both in the community and in residential care. One of these innovations is the care concept called "care farming." Care farms are farms that combine agricultural activities with care and support services for a variety of client groups, including people with dementia. Although the concept is being implemented in an increasing number of countries, the Netherlands and Norway are still front-runners in providing and researching this innovative dementia care approach. Over the last couple of years, several research projects have been carried out in these countries addressing a wide range of issues related to dementia care provision at care farms and using a wide range of research methods. This paper synthesizes the knowledge that has been generated in these research projects. By sharing the knowledge obtained in the Netherlands and Norway, we hope to inspire leaders in healthcare undertaking similar efforts to innovate care for the increasing number of people with dementia. By providing starting-points for future research, we additionally hope to contribute to a research agenda to further advance the field.

Combined Interventions to Reduce Burnout Complaints and Promote Return to Work: A Systematic Review of Effectiveness and Mediators of Change.

Burnout has adverse effects on the health and work-related outcomes of employees. Nevertheless, little is known about effective ways of reducing burnout complaints and facilitating full return to work, which defines rehabilitation. This study consists of a systematic review of the effects of combined interventions (i.e., both person-directed and organization-directed). It also includes the identification and description of mediators of change, thereby explaining how combined interventions do or do not work. Seven electronic databases were searched for English peer-reviewed publications: the Psychology and Behavioral Sciences Collection; PsycARTICLES; Web of Science; Scopus; SocINDEX; PubMed; and PsycINFO, using various combinations of search terms (e.g., burnout AND intervention). Out of 4110 abstracts published before 29 September, 2019, 10 studies (reporting the effects of nine combined interventions) fulfilled the inclusion criteria, which were defined using PICOS criteria (participants, interventions, comparators, outcomes and study design). Although the risk of bias of the included studies is high, all combined interventions were effective in facilitating rehabilitation. Results suggest that involving employees in decision-making and enhance their job control and social support, while eliminating stressors, explain the effectiveness of the intentions. With caution, workplace health promotion practitioners are encouraged to use these findings to tackle burnout among employees.

A Salutogenic Approach to Understanding the Potential of Green Programs for the Rehabilitation of Young Employees With Burnout: Protocol for a Mixed Method Study on Effectiveness and Effective Elements.

BACKGROUND: Burnout is the leading cause of absenteeism in the Netherlands, with associated sick leave costs amounting to around €1.8 billion. Studies have indicated that burnout complaints increased from almost 14.4% in 2014 to 17.3% in 2018, especially among employees between the ages of 18 and 35 years, and further increases are expected. Although there are many published articles on burnout, not much is known about what constitutes effective rehabilitation (ie, the reduction of burnout complaints and the facilitation of returning to work). At the same time, multiple pilot studies have indicated that green programs are effective in both reducing burnout complaints and facilitating return to work. Green programs have been developed by professionals experienced in using the natural environment to facilitate rehabilitation (eg, through green exercise and healing gardens). The literature nevertheless lacks comprehensive and contextual insight into what works and why. OBJECTIVE: The overarching aim of this study is to explore the potential of green programs for young employees with burnout. We present the study protocol from an ongoing research project consisting of 2 phases, each composed of 2 research objectives that sequentially build upon each other. METHODS: The study is based on a sequential design with 4 research objectives, using both qualitative and quantitative research methods. In the first phase, a systematic literature review (research objective 1) and in-depth interviews (research objective 2) will be used to explore mechanisms underlying the rehabilitation of young employees with burnout. In the second phase, a multicase study will be conducted to examine the extent to which green programs are built on mechanisms identified in the first phase (research objective 3). By employing a pretest and posttest design, a specific green program that captures most of those mechanisms will then be evaluated on its effect and process with regard to the rehabilitation of young employees with burnout (research objective 4). The project started in June 2018 and will continue through June 2022. RESULTS: The first phase (research objectives 1 and 2) is intended to generate information on the mechanisms underlying the rehabilitation of young employees with burnout. The second phase (research objectives 3 and 4) is designed to demonstrate the extent to which and how the selected green program facilitates the rehabilitation of young employees with burnout. CONCLUSIONS: Understanding how green programs can facilitate the rehabilitation of young employees with burnout complaints can help to address this societal issue. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/15303.

Evaluating the Healthy Futures Nearby Program: Protocol for Unraveling Mechanisms in Health-Related Behavior Change and Improving Perceived Health Among Socially Vulnerable Families in the Netherlands.

BACKGROUND: The persistence of health inequalities within high-income societies such as the Netherlands indicates the importance of researching effective ways to reduce those inequalities. Multiple strategies for reducing health inequalities have been identified. Specifically targeting health-related behaviors among lower socioeconomic status groups is one of those strategies. All in all, it seems relatively clear what types of approaches in general lead to health-related behavior change. However, it is still unclear how these approaches, in interaction with context, trigger a specific desired change. In the Netherlands, the private funding organization, Fonds NutsOhra, funded 46 small-scale projects under the umbrella of the Healthy Futures Nearby program. The projects aim to reduce vulnerable families' health deprivation by triggering lifestyle changes. OBJECTIVE: This study aimed to outline and justify the protocol for the overall evaluation of the program. The evaluation aimed to find out to what extent and how the small-scale projects and approaches within the program affect (or not) health-related behaviors and improve perceived health. METHODS: The approach to the overall evaluation of the 46 projects builds on a combination of 3 frequently used evaluation models; it is theory-based, realist informed, and uses a mixed methodology design. Methods include analysis of quantitative project data, document analysis, focus groups, and interviews. A study design has been drawn up that values and uses the multifaceted development of the projects and the influence this might have on implementation and project outcomes. Also, it respects the complex nature of the projects and is suited to studying health promotion mechanisms in depth. Finally, it optimizes the usage of all-quantitative and qualitative-project evaluation data available. RESULTS: This study protocol included the design of at least 4 different studies. The results will hence provide information on (1) building and defining theories of change in health promotion practice, (2) mechanisms at work in promotion of healthy behavior among vulnerable families, (3) what works and what does not in professionals' practices in health promotion among those vulnerable groups, and (4) what works and what does not in health promotion projects with a participatory approach. In addition, data will be collected on the overall effectiveness of the 46 initiatives. Data collection started in 2016. Data analysis is currently underway, and the first results are expected to be submitted for publication in 2019. CONCLUSIONS: This overall evaluation provides a unique opportunity. The diversity of projects allows for a study protocol that answers in greater depth questions of how specific health promotion approaches work while also elucidating their effectiveness in a more traditional way. Using a theory-based complexity-sensitive approach that is mainly realist informed, this study also provides an opportunity to see whether combining assumptions from different evaluation perspectives yields relevant information. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/11305.