Bored, afraid, alone: What can we learn from children with paediatric obesity about the impact of the COVID-19 pandemic for future pandemics, care practices and policies?

PURPOSE: The aim of this study was to gain insight into the perspectives of children with paediatric obesity themselves, during the pandemic and afterwards, regarding their wellbeing and health, and to solicit their advice on tailoring obesity care to match their daily realities. DESIGN AND METHODS: We used a 'draw, write and tell' interview technique, conducted walk-alongs, participant observations and a group session with children with paediatric obesity from seldom-heard communities in Amsterdam, the Netherlands. Data was analysed using reflexive thematic analysis. RESULTS: Children reported that during lockdowns they were confined to the house, causing them to feel bored and alone. This triggered them to fall into previous unhealthy patterns, such as an increase in sitting on the couch or lying in bed, gaming or watching TV, feeling hungry a lot and eating more. Some children experienced major events, such as mourning the death of a loved one or taking care of other family members, and thus felt they had to grow up fast. CONCLUSION: Our study adds to our understanding of the mechanisms of the impact of the COVID-19 pandemic from the perspectives of children with paediatric obesity from seldom-heard communities and emphasizes the importance of considering how the pandemic (and related measures) affected the daily - as well as future - lives of children in vulnerable circumstances. PRACTICAL IMPLICATIONS: The recommendations children gave could be explored as pathways for more child-centred, successful and tailored obesity care practices and policies in order to support their (mental) wellbeing and health.

Development of an action programme tackling obesity-related behaviours in adolescents: a participatory system dynamics approach.

System dynamics approaches are increasingly addressing the complexity of public health problems such as childhood overweight and obesity. These approaches often use system mapping methods, such as the construction of causal loop diagrams, to gain an understanding of the system of interest. However, there is limited practical guidance on how such a system understanding can inform the development of an action programme that can facilitate systems changes. The Lifestyle Innovations Based on Youth Knowledge and Experience (LIKE) programme combines system dynamics and participatory action research to improve obesity-related behaviours, including diet, physical activity, sleep and sedentary behaviour, in 10-14-year-old adolescents in Amsterdam, the Netherlands. This paper illustrates how we used a previously obtained understanding of the system of obesity-related behaviours in adolescents to develop an action programme to facilitate systems changes. A team of evaluation researchers guided interdisciplinary action-groups throughout the process of identifying mechanisms, applying the Intervention Level Framework to identify leverage points and arriving at action ideas with aligning theories of change. The LIKE action programme consisted of 8 mechanisms, 9 leverage points and 14 action ideas which targeted the system's structure and function within multiple subsystems. This illustrates the feasibility of developing actions targeting higher system levels within the confines of a research project timeframe when sufficient and dedicated effort in this process is invested. Furthermore, the system dynamics action programme presented in this study contributes towards the development and implementation of public health programmes that aim to facilitate systems changes in practice.

Obesity care for youth during the COVID-19 pandemic: Challenges youth healthcare nurses experienced in providing obesity care in the Netherlands.

The COVID-19 pandemic deeply affected the lives of children and young people; studies report adverse effects on mental, physical, and social well-being. However, the impact of the pandemic on obesity care for children received little attention. The aim of this study was to gain insight into the challenges youth healthcare nurses experienced and to describe implications for future obesity care and policy. We conducted interviews, participant observations, and a group session with youth healthcare nurses during the pandemic in Amsterdam, the Netherlands. Youth healthcare nurses reported a deterioration in the problems of children and young people who were already in the highest classification for pediatric obesity, such as increased weight gain, mental health problems, and socio-economic problems. The nurses experienced immense challenges while trying to provide obesity care, such as a decrease in face-to-face contact with youth and their families, as well as loss of continuity of care. It is important to reconnect with these families, invest in a trusted relationship with youth receiving obesity care, and prioritize available and accessible obesity care for those who need it the most.

Development and content validity of an application to assess 24-hour movement behaviors in 0-4-year-old children involving end-users and key stakeholders: the My Little Moves app.

BACKGROUND: Recently, research focus has shifted to the combination of all 24-h movement behaviors (physical activity, sedentary behavior and sleep) instead of each behavior separately. Yet, no reliable and valid proxy-report tools exist to assess all these behaviors in 0-4-year-old children. By involving end-users (parents) and key stakeholders (researchers, professionals working with young children), this mixed-methods study aimed to 1) develop a mobile application (app)-based proxy-report tool to assess 24-h movement behaviors in 0-4-year-olds, and 2) examine its content validity. METHODS: First, we used concept mapping to identify activities 0-4-year-olds engage in. Parents (n = 58) and professionals working with young children (n = 21) generated a list of activities, sorted related activities, and rated the frequency children perform these activities. Second, using multidimensional scaling and cluster analysis, we created activity categories based on the sorted activities of the participants. Third, we developed the My Little Moves app in collaboration with a software developer. Finally, we examined the content validity of the app with parents (n = 14) and researchers (n = 6) using focus groups and individual interviews. RESULTS: The app has a time-use format in which parents proxy-report the activities of their child, using eight activity categories: personal care, eating/drinking, active transport, passive transport, playing, screen use, sitting/lying calmly, and sleeping. Categories are clarified by providing examples of children's activities. Additionally, 1-4 follow-up questions collect information on intensity (e.g., active or calm), posture, and/or context (e.g., location) of the activity. Parents and researchers considered filling in the app as feasible, taking 10-30 min per day. The activity categories were considered comprehensive, but alternative examples for several activity categories were suggested to increase the comprehensibility and relevance. Some follow-up questions were considered less relevant. These suggestions were adopted in the second version of the My Little Moves app. CONCLUSIONS: Involving end-users and key stakeholders in the development of the My Little Moves app resulted in a tailored tool to assess 24-h movement behaviors in 0-4-year-olds with adequate content validity. Future studies are needed to evaluate other measurement properties of the app.

The Effects of the Jump-In Whole-School Intervention on the Weight Development of Children in Amsterdam, the Netherlands.

BACKGROUND: This study assessed the effects of the "Jump-in" whole-school intervention in Amsterdam, the Netherlands, on children's weight development by comparing children exposed to the intervention and controls from 3 other large Dutch cities. Jump-in is a comprehensive intervention that aims to stimulate healthy nutrition and physical activity in children at primary schools in Amsterdam. In addition, the relationship between the intervention's implementation degree and its effectiveness was studied. METHODS: Demographic and anthropometric data, collected by youth health care professionals via routine health checks at T0 (2014) and T1 (2019), were used to analyze possible intervention effects by comparing the weight development of children exposed to the Jump-in intervention versus unexposed controls. Implementation logs from health promotion professionals were used to determine intervention effects per implementation degree. Multilevel regression analyses were used for all analyses. RESULTS: In total, 4299 children were included mean age ± 5.5 years (T0), 10.6 years (T1), and ≈50% boys/girls at both times. Receiving the fully implemented intervention resulted in a decline in standardized body-mass index (zBMI) compared to the controls (-0.23, confidence interval [CI] -0.33, -0.13). It also led to higher odds to move into a healthier weight category over time (odds ratio [OR] 1.36, CI 1.06, 1.74), yet no statistically significant shift towards a healthy weight was found. CONCLUSIONS: Relative to the controls, children exposed to the intervention showed positive zBMI developments, with stronger effects when the implementation degree was higher. Despite positive results, creating more impact might require the further integration of school-based programs into whole-systems approaches that include other energy-balance behaviors.

A Longitudinal Study in Worrisome Sexual Behavior Following Sexual Abuse in Infancy or Early Childhood: The Amsterdam Sexual Abuse Case.

Worrisome sexual behavior (WSB) is often described as an outcome specific to child sexual abuse (CSA). Therefore, it is highly relevant to study WSB in relation to sexual abuse, especially in very young children, as it is hard to recognize sexual abuse in children who have limited verbal capacities of disclosing. Over time, literature describing WSB following CSA has gradually broadened. However, a gap remains regarding the long-term development of WSB in children who were sexually abused during infancy or very early childhood. To our knowledge, our study is the first to examine developmentally-related sexual behavior versus sexual abuse-specific behavior longitudinally in children who were sexually abused at a very young age. In total, we examined the sexual behavior, as reported by parents of 45 children who experienced early-age sexual abuse for a period of more than five years. Overall, we found that WSB is likely to be a CSA-specific and potentially long-term outcome for children who were sexually abused at a very young age. Despite the decrease in sexual abuse-specific behavior over time, the level of this behavior was still significantly high 8 years after the sexual abuse. This finding supports long-term monitoring and assessment and intervention for WSB over time. Despite these findings, it is important to note that WSB does not serve as proof of sexual abuse in children; likewise, when a child does not present with WSB, it does not indicate the absence of a substantiated history of sexual abuse.

Developing a digital informed consent app: opportunities and challenges of a new format to inform and obtain consent in public health research.

BACKGROUND: Informed consent procedures for large population-based cohort studies should be comprehensive and easy-to-use. This is particularly challenging when participants from different socio-economic groups and multicultural ethnic backgrounds are involved. Recently, more and more studies have tried to use multimedia in informed consent procedures. We describe the development and testing of a digital informed consent app and elaborate on whether this may contribute to a comprehensive and practical procedure to obtain informed consent for public health research. METHODS: In a sample of parents with young children, we used a mixed method approach to study the user experience of an informed consent app and evaluate whether it can be used to adequately inform people and register their consent. Through semi-structured interviews we investigated participants' experiences with and opinions about the app, with a special focus on comprehensibility of the content and the usability of the app. Information retention questions were asked to evaluate to what extent participants could recall key aspects of the provided study information. RESULTS: The 30 participants in this study used the app between 4 and 15 min to give their consent. Overall, they found the app well-designed, informative and easy to use. To learn more about the study for which informed consent is asked, most of the participants chose to watch the animated film, which was generally found to convey information in a clear manner. The identification process was met with mixed reactions, with some feeling it as a secure way to give consent, while for others it contradicted their view of using data anonymously. Information retention questions showed that while all participants remembered various aspects of the study, fewer than half answered all four questions satisfactorily. CONCLUSION: Our study shows that a well-designed informed consent app can be an effective tool to inform eligible participants and to record consents. Still, some issues remain, including trust barriers towards the identification procedure and lack of information retention in some participants. When implementing consent procedures that incorporate digital formats, it may be beneficial to also invest in a complementary face-to-face recruitment approach.

Intent to vaccinate against SARS-CoV-2 and its determinants across six ethnic groups living in Amsterdam, the Netherlands: A cross-sectional analysis of the HELIUS study.

BACKGROUND: Ethnic minority groups experience a disproportionately high burden of infections, hospitalizations and mortality due to COVID-19, and therefore should be especially encouraged to receive SARS-CoV-2 vaccination. This study aimed to investigate the intent to vaccinate against SARS-CoV-2, along with its determinants, in six ethnic groups residing in Amsterdam, the Netherlands. METHODS: We analyzed data of participants enrolled in the population-based multi-ethnic HELIUS cohort, aged 24 to 79 years, who were tested for SARS-CoV-2 antibodies and answered questions on vaccination intent from November 23, 2020 to March 31, 2021. During the study period, SARS-CoV-2 vaccination in the Netherlands became available to individuals working in healthcare or > 75 years old. Vaccination intent was measured by two statements on a 7-point Likert scale and categorized into low, medium, and high. Using ordinal logistic regression, we examined the association between ethnicity and lower vaccination intent. We also assessed determinants of lower vaccination intent per ethnic group. RESULTS: A total of 2,068 participants were included (median age 56 years, interquartile range 46-63). High intent to vaccinate was most common in the Dutch ethnic origin group (369/466, 79.2%), followed by the Ghanaian (111/213, 52.1%), South-Asian Surinamese (186/391, 47.6%), Turkish (153/325, 47.1%), African Surinamese (156/362, 43.1%), and Moroccan ethnic groups (92/311, 29.6%). Lower intent to vaccinate was more common in all groups other than the Dutch group (P < 0.001). Being female, believing that COVID-19 is exaggerated in the media, and being < 45 years of age were common determinants of lower SARS-CoV-2 vaccination intent across most ethnic groups. Other identified determinants were specific to certain ethnic groups. CONCLUSIONS: Lower intent to vaccinate against SARS-CoV-2 in the largest ethnic minority groups of Amsterdam is a major public health concern. The ethnic-specific and general determinants of lower vaccination intent observed in this study could help shape vaccination interventions and campaigns.

Deinstitutionalization from the perspective of community-dwelling adults with a severe mental illness in Amsterdam: a cohort study protocol.

BACKGROUND: People with a severe mental illness (SMI) increasingly receive ambulatory forms of care and support. The trend of deinstitutionalization accelerated in the Netherlands from 2008 and onwards without sufficient understanding of its consequences. The study protocol herein focuses on deinstitutionalization from the perspective of adults with an SMI living within the community in Amsterdam and aims at delivering better insight into, amongst others, their recovery, quality of life, societal participation and needs for care and support. METHODS: A cohort design will be used. A representative sample of community-dwelling adults with an SMI, including those in care (n = 650) and not in care (n = 150), will be followed over time. During a two-year time period, participants will be interviewed twice using a wide-ranging set of validated instruments. Interview data will be matched with administrative data about the care process, as retrieved from their patient files. Primary outcomes are changes over time in recovery, societal participation and quality of life, controlled for the occurrence of adverse life-events during follow-up. Additionally, prevalence estimates of and associations between social functioning, safety and discrimination, substance use and health indicators will be investigated. DISCUSSION: The study protocol aims at delivering a comprehensive insight into the needs of community-dwelling adults with an SMI based on which ambulatory care and support can best be provided to optimally promote their social recovery and well-being.

The ENCOMPASS framework: a practical guide for the evaluation of public health programmes in complex adaptive systems.

BACKGROUND: Systems thinking embraces the complexity of public health problems, including childhood overweight and obesity. It aids in understanding how factors are interrelated, and it can be targeted to produce favourable changes in a system. There is a growing call for systems approaches in public health research, yet limited practical guidance is available on how to evaluate public health programmes within complex adaptive systems. The aim of this paper is to present an evaluation framework that supports researchers in designing systems evaluations in a comprehensive and practical way. METHODS: We searched the literature for existing public health systems evaluation studies. Key characteristics on how to conduct a systems evaluation were extracted and compared across studies. Next, we overlaid the identified characteristics to the context of the Lifestyle Innovations Based on Youth Knowledge and Experience (LIKE) programme evaluation and analyzed which characteristics were essential to carry out the LIKE evaluation. This resulted in the Evaluation of Programmes in Complex Adaptive Systems (ENCOMPASS) framework. RESULTS: The ENCOMPASS framework includes five iterative stages: (1) adopting a system dynamics perspective on the overall evaluation design; (2) defining the system boundaries; (3) understanding the pre-existing system to inform system changes; (4) monitoring dynamic programme output at different system levels; and (5) measuring programme outcome and impact in terms of system changes. CONCLUSIONS: The value of ENCOMPASS lies in the integration of key characteristics from existing systems evaluation studies, as well as in its practical, applied focus. It can be employed in evaluating public health programmes in complex adaptive systems. Furthermore, ENCOMPASS provides guidance for the entire evaluation process, all the way from understanding the system to developing actions to change it and to measuring system changes. By the nature of systems thinking, the ENCOMPASS framework will likely evolve further over time, as the field expands with more completed studies.

A systematic review of proxy-report questionnaires assessing physical activity, sedentary behavior and/or sleep in young children (aged 0-5 years).

BACKGROUND: Accurate proxy-report questionnaires, adapted to the child's developmental stage, are required to monitor 24-h movement behaviors in young children, especially for large samples and low-resource settings. OBJECTIVES: This review aimed to summarize available studies evaluating measurement properties of proxy-report questionnaires assessing physical activity, sedentary behavior and/or sleep in children aged 0-5 years. METHODS: Systematic literature searches were carried out in the PubMed, Embase and SPORTDiscus databases, up to January 2021. For physical activity and sedentary behavior questionnaires this is a review update, whereas for sleep questionnaires we included all relevant studies published up to now. Studies had to evaluate at least one of the measurement properties of a proxy-report questionnaire assessing at least duration and/or frequency of physical activity, sedentary behavior and/or sleep in 0- to 5-year-old children. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guideline was used to evaluate the quality of evidence. RESULTS: Thirty-three studies were included, examining a total of 37 questionnaires. Ten questionnaires were designed for infants, two for toddlers, 11 for preschoolers, and 14 for a broader age range targeting multiple of these age groups. Twenty questionnaires assessed constructs of sleep, four assessed constructs of physical activity, two assessed screen behavior, five assessed constructs of both physical activity and sedentary behavior, and six assessed constructs of all 24-h movement behaviors. Content validity was evaluated for six questionnaires, structural validity for two, internal consistency for three, test-retest reliability for 16, measurement error for one, criterion validity for one, and construct validity for 26 questionnaires. None of the questionnaires were considered sufficiently valid and/or reliable for assessing one or more movement behaviors in 0- to 5-year-old children, and the quality of evidence was mostly low or very low. CONCLUSIONS: Valid and/or reliable questionnaires assessing 24-h movement behaviors in 0- to 5-year-olds are lacking. High-quality studies are therefore required, to develop proxy-report questionnaires and evaluate their measurement properties. PROSPERO REGISTRATION NUMBER: CRD42020169268.

SARS-CoV-2 antibody prevalence and correlates of six ethnic groups living in Amsterdam, the Netherlands: a population-based cross-sectional study, June-October 2020.

OBJECTIVES: It has been suggested that ethnic minorities have been disproportionally affected by the COVID-19. We aimed to determine whether prevalence and correlates of past SARS-CoV-2 exposure varied between six ethnic groups in Amsterdam, the Netherlands. DESIGN, SETTING, PARTICIPANTS: Participants aged 25-79 years enrolled in the Healthy Life in an Urban Setting population-based prospective cohort (n=16 889) were randomly selected within ethnic groups and invited to participate in a cross-sectional COVID-19 seroprevalence substudy. OUTCOME MEASURES: We tested participants for SARS-CoV-2-specific antibodies and collected information on SARS-CoV-2 exposures. We estimated prevalence and correlates of SARS-CoV-2 exposure within ethnic groups using survey-weighted logistic regression adjusting for age, sex and calendar time. RESULTS: Between 24 June and 9 October 2020, we included 2497 participants. Adjusted SARS-CoV-2 seroprevalence was comparable between ethnic Dutch (24/498; 5.1%, 95% CI 2.8% to 7.4%), South-Asian Surinamese (22/451; 4.9%, 95% CI 2.2% to 7.7%), African Surinamese (22/400; 8.3%, 95% CI 3.1% to 13.6%), Turkish (30/408; 7.9%, 95% CI 4.4% to 11.4%) and Moroccan (32/391; 7.2%, 95% CI 4.2% to 10.1%) participants, but higher among Ghanaians (95/327; 26.3%, 95% CI 18.5% to 34.0%). 57.1% of SARS-CoV-2-positive participants did not suspect or were unsure of being infected, which was lowest in African Surinamese (18.2%) and highest in Ghanaians (90.5%). Correlates of SARS-CoV-2 exposure varied across ethnic groups, while the most common correlate was having a household member suspected of infection. In Ghanaians, seropositivity was associated with older age, larger household sizes, living with small children, leaving home to work and attending religious services. CONCLUSIONS: No remarkable differences in SARS-CoV-2 seroprevalence were observed between the largest ethnic groups in Amsterdam after the first wave of infections. The higher infection seroprevalence observed among Ghanaians, which passed mostly unnoticed, warrants wider prevention efforts and opportunities for non-symptom-based testing.

A sexual abuse case series of infants and toddlers by a professional caregiver: A qualitative analysis of parents' experiences during the initial crisis period post-discovery.

BACKGROUND: The discovery that one's child has been sexually abused may be one of the worst events a parent can experience. The importance of parental support for the recovery of child sexual abuse (CSA) victims emphasizes the need to gain insight in difficulties parents face after disclosure. OBJECTIVE: To improve crisis intervention by exploring how parents of very young, mostly male CSA victims involved in a large unique CSA case, look back on their initial reactions after disclosure, the impact of media coverage, and their experiences with service responses during the immediate aftermath of CSA discovery. PARTICIPANTS AND SETTING: We conducted 18 qualitative interviews with 21 parents enrolled in the longitudinal Amsterdam Sexual Abuse Case (ASAC) study. METHODS: We used thematic analysis, combining a deductive and inductive approach. RESULTS: We identified four themes regarding parents' initial experiences after disclosure: shock, uncertainty, roller coaster and survival mode. Four themes emerged regarding the impact of media coverage: vulnerable to exposure, fear that the child would recognize the suspect, no escape possible, and burden versus acknowledgement. Parents' experiences regarding the actions of professionals also generated four themes: stressful and confronting, need for support, need for information, and need for professional competence. CONCLUSIONS: Disclosure of extrafamilial CSA left parents in shock, affecting their sense of control. Media coverage exacerbated stress for many parents, although some also drew support from it. Actions of professionals defined by parents as helpful included: being supportive, compassionate, accessible, and competent, providing information, and promoting autonomy. Implications for professionals are discussed.

Differences in SARS-CoV-2 infections during the first and second wave of SARS-CoV-2 between six ethnic groups in Amsterdam, the Netherlands: A population-based longitudinal serological study.

BACKGROUND: Surveillance data in high-income countries have reported more frequent SARS-CoV-2 diagnoses in ethnic minority groups. We examined the cumulative incidence of SARS-CoV-2 and its determinants in six ethnic groups in Amsterdam, the Netherlands. METHODS: We analysed participants enrolled in the population-based HELIUS cohort, who were tested for SARS-CoV-2-specific antibodies and answered COVID-19-related questions between June 24-October 9, 2020 (after the first wave) and November 23, 2020-March 31, 2021 (during the second wave). We modelled SARS-CoV-2 incidence from January 1, 2020-March 31, 2021 using Markov models adjusted for age and sex. We compared incidence between ethnic groups over time and identified determinants of incident infection within ethnic groups. FINDINGS: 2,497 participants were tested after the first wave; 2,083 (83·4%) were tested during the second wave. Median age at first visit was 54 years (interquartile range=44-61); 56·6% were female. Compared to Dutch-origin participants (15·9%), cumulative SARS-CoV-2 incidence was higher in participants of South-Asian Surinamese (25·0%; adjusted hazard ratio [aHR]=1·66; 95%CI=1·16-2·40), African Surinamese (28·9%, aHR=1·97; 95%CI=1·37-2·83), Turkish (37·0%; aHR=2·67; 95%CI=1·89-3·78), Moroccan (41·9%; aHR=3·13; 95%CI=2·22-4·42), and Ghanaian (64·6%; aHR=6·00; 95%CI=4·33-8·30) origin. Compared to those of Dutch origin, differences in incidence became wider during the second versus first wave for all ethnic minority groups (all p-values for interaction<0·05), except Ghanaians. Having household members with suspected SARS-CoV-2 infection, larger household size, and low health literacy were common determinants of SARS-CoV-2 incidence across groups. INTERPRETATION: SARS-CoV-2 incidence was higher in the largest ethnic minority groups of Amsterdam, particularly during the second wave. Prevention measures, including vaccination, should be encouraged in these groups. FUNDING: ZonMw, Public Health Service of Amsterdam, Dutch Heart Foundation, European Union, European Fund for the Integration of non-EU immigrants.

Developing the logic framework underpinning a whole-systems approach to childhood overweight and obesity prevention: Amsterdam Healthy Weight Approach.

BACKGROUND: Whole-systems approaches (WSAs) are well placed to tackle the complex local environmental influences on overweight and obesity, yet there are few examples of WSAs in practice. Amsterdam Healthy Weight Approach (AHWA) is a long-term, municipality-led program to improve children's physical activity, diet, and sleep through action in the home, neighborhood, school, and city. Adopting a WSA, local political, physical, social, educational, and healthcare drivers of childhood obesity are viewed as a complex adaptive system. Since 2013, AHWA has reached >15,000 children. During this time, the estimated prevalence of 2-18-year-olds with overweight or obesity in Amsterdam has declined from 21% in 2012 to 18.7% in 2017. Declining trends are rarely observed in cities. There is a need to formally articulate AHWA program theory in order to: (i) inform future program evaluation which can interpret this decline within the context of AHWA and (ii) contribute a real-life example of a WSA to the literature. METHODS: This study aimed to formally document the program theory of AHWA to permit future evaluation. A logic framework was developed through extensive document review and discussion, during program implementation. RESULTS: The working principles of the WSA underpinning AHWA were made explicit in an overarching theory of change, articulated in a logic framework. The framework was operationalized using an illustrative example of sugar intake. CONCLUSIONS: The logic framework will inform AHWA development, monitoring, and evaluation and responds to a wider need to outline the working principles of WSAs in public health.

Improving Physical Activity Levels in Prevocational Students by Student Participation: Protocol for a Cluster Randomized Controlled Trial.

BACKGROUND: A consistent finding in the literature is the decline in physical activity during adolescence, resulting in activity levels below the recommended guidelines. Therefore, promotion of physical activity is recommended specifically for prevocational students. OBJECTIVE: This protocol paper describes the background and design of a physical activity promotion intervention study in which prevocational students are invited to participate in the design and implementation of an intervention mix. The intervention is expected to prevent a decline in physical activity in the target group. METHODS: The effectiveness of the intervention was evaluated in a two-group cluster randomized controlled trial with assessments at baseline and 2-year follow-up. A simple randomization was applied, allocating 11 schools to the intervention group and 11 schools to the control group, which followed the regular school curriculum. The research population consisted of 3003 prevocational students, aged 13-15 years. The primary outcome measures were self-reported physical activity levels (screen time, active commuting, and physical activity). As a secondary outcome, direct assessment of physical fitness (leg strength, arm strength, hip flexibility, hand speed, abdominal muscle strength, BMI, and body composition) was included. An intervention-control group comparison was presented for the baseline results. The 2-year interventions began by mapping the assets of the prevocational adolescents of each intervention school using motivational interviewing in the structured interview matrix and the photovoice method. In addition, during focus group sessions, students, school employees, and researchers cocreated and implemented an intervention plan that optimally met the students' assets and opportunities in the school context. The degree of student participation was evaluated through interviews and questionnaires. RESULTS: Data collection of the SALVO (stimulating an active lifestyle in prevocational students) study began in October 2015 and was completed in December 2017. Data analyses will be completed in 2021. Baseline comparisons between the intervention and control groups were not significant for age (P=.12), screen time behavior (P=.53), nonschool active commuting (P=.26), total time spent on sports activities (P=.32), total physical activities (P=.11), hip flexibility (P=.22), maximum handgrip (P=.47), BMI (P=.44), and sum of skinfolds (P=.29). Significant differences between the intervention and control groups were found in ethnicity, gender, active commuting to school (P=.03), standing broad jump (P=.02), bent arm hang (P=.01), 10× 5-m sprint (P=.01), plate tapping (P=.01), sit-ups (P=.01), and 20-m shuttle run (P=.01). CONCLUSIONS: The SALVO study assesses the effects of a participatory intervention on physical activity and fitness levels in prevocational students. The results of this study may lead to a new understanding of the effectiveness of school-based physical activity interventions when students are invited to participate and cocreate an intervention. This process would provide structured health promotion for future public health. TRIAL REGISTRATION: ISRCTN Registry ISRCTN35992636; http://www.isrctn.com/ISRCTN35992636. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/28273.

The Amsterdam Sexual Abuse Case: What Scars did it Leave? Long-Term Course of Psychological Problems for Children Who have been Sexually Abused at a Very Young Age, and their Parents.

Longitudinal research of CSA in infancy and early childhood is scarce. The current study examined the long-term course of psychological outcomes (PTSD, dissociation and internalizing and externalizing behavioral problems) in children who were sexually abused in the early childhood. Additionally, we looked into the outcomes for their parents by assessing PTSD symptoms and negative emotional reactions towards the sexual abuse of their child. We examined the outcomes for five consecutive years in a sample of children (n = 45) who were sexually abused at a very young age (0-3) and their parents (n = 42), included in the Amsterdam Sexual Abuse Case-study. We found that outcomes following CSA in early childhood go beyond PTSD symptoms and can manifest in atypical symptoms such as behavioral problems. Parents experienced persistent PTSD in the years following CSA disclosure. CSA in very young children warrants long-term monitoring, as negative outcomes still present 8 years later.

Beyond maternal education: Socio-economic inequalities in children's diet in the ABCD cohort.

OBJECTIVE: We examined whether the role of maternal education in children's unhealthy snacking diet is moderated by other socio-economic indicators. METHODS: Participants were selected from the Amsterdam Born Children and their Development cohort, a large ongoing community-based birth cohort. Validated Food Frequency Questionnaires (FFQ) (n = 2782) were filled in by mothers of children aged 5.7±0.5yrs. Based on these FFQs, a snacking dietary pattern was derived using Principal Component Analysis. Socio-economic indicators were: maternal and paternal education (low, middle, high; based on the highest education completed) household finance (low, high; based on ability to save money) and neighbourhood SES (composite score including educational level, household income and employment status of residents per postal code). Cross-sectional multivariable linear regression analysis was used to assess the association and possible moderation of maternal education and other socio-economic indicators on the snacking pattern score. Analyses were adjusted for children's age, sex and ethnicity. RESULTS: Low maternal education (B 0.95, 95% CI 0.83;1.06), low paternal education (B 0.36, 95% CI 0.20;0.52), lower household finance (B 0.18, 95% CI 0.11;0.26) and neighbourhood SES (B -0.09, 95% CI -0.11;-0.06) were independently associated with higher snacking pattern scores (p<0.001). The association between maternal education and the snacking pattern score was somewhat moderated by household finance (p = 0.089) but remained strong. Children from middle-high educated mothers (B 0.44, 95% CI 0.35;0.52) had higher snacking pattern scores when household finance was low (B 0.49, 95% CI 0.33;0.65). CONCLUSIONS: All socio-economic indicators were associated with increased risk of unhealthy dietary patterns in young children, with low maternal education conferring the highest risk. Yet, within the group of middle-high educated mothers, lower household finance was an extra risk factor for unhealthy dietary patterns. Intervention strategies should therefore focus on lower educated mothers and middle-high educated mothers with insufficient levels of household finance.

A System Dynamics and Participatory Action Research Approach to Promote Healthy Living and a Healthy Weight among 10-14-Year-Old Adolescents in Amsterdam: The LIKE Programme.

This paper describes the design of the LIKE programme, which aims to tackle the complex problem of childhood overweight and obesity in 10-14-year-old adolescents using a systems dynamics and participatory approach. The LIKE programme focuses on the transition period from 10-years-old to teenager and was implemented in collaboration with the Amsterdam Healthy Weight Programme (AHWP) in Amsterdam-East, the Netherlands. The aim is to develop, implement and evaluate an integrated action programme at the levels of family, school, neighbourhood, health care and city. Following the principles of Participatory Action Research (PAR), we worked with our population and societal stakeholders as co-creators. Applying a system lens, we first obtained a dynamic picture of the pre-existing systems that shape adolescents' behaviour relating to diet, physical activity, sleep and screen use. The subsequent action programme development was dynamic and adaptive, including quick actions focusing on system elements (quick evaluating, adapting and possibly catalysing further action) and more long-term actions focusing on system goals and/or paradigm change. The programme is supported by a developmental systems evaluation and the Intervention Level Framework, supplemented with routinely collected data on weight status and health behaviour change over a period of five years. In the coming years, we will report how this approach has worked to provide a robust understanding of the programme's effectiveness within a complex dynamic system. In the meantime, we hope our study design serves as a source of inspiration for other public health intervention studies in complex systems.

The relationship of prenatal antibiotic exposure and infant antibiotic administration with childhood allergies: a systematic review.

BACKGROUND: Early antibiotic exposure may be contributing to the onset of childhood allergies. The main objective of this study was to conduct a systematic review on the relationship between early life antibiotic exposure and childhood asthma, eczema and hay fever. METHODS: Pubmed and Embase were searched for studies published between 01-01-2008 and 01-08-2018, examining the effects of (1) prenatal antibiotic exposure and (2) infant antibiotic administration (during the first 2 years of life) on childhood asthma, eczema and hay fever from 0 to 18 years of age. These publications were assessed using the Newcastle Ottawa Scale (NOS) and analysed narratively. RESULTS: (1) Prenatal antibiotics: Asthma (12 studies): The majority of studies (9/12) reported significant relationships (range OR 1.13 (1.02-1.24) to OR 3.19 (1.52-6.67)). Three studies reported inconsistent findings. Eczema (3 studies): An overall significant effect was reported in one study and in two other studies only when prenatal antibiotic exposure was prolonged. (2) Infant antibiotics: Asthma (27 studies): 17/27 studies reported overall significant findings (range HR 1.12 (1.08-1.16) to OR 3.21 (1.89-5.45)). Dose-response effects and stronger effects with broad-spectrum antibiotic were often reported. 10/27 studies reported inconsistent findings depending on certain conditions and types of analyses. Of 19 studies addressing reverse causation or confounding by indication at least somewhat, 11 reported overall significant effects. Eczema (15 studies): 6/15 studies reported overall significant effects; 9 studies had either insignificant or inconsistent findings. Hay fever (9 studies): 6/9 reported significant effects, and the other three insignificant or inconsistent findings. General: Multiple and broad-spectrum antibiotics were more strongly associated with allergies. The majority of studies scored a 6 or 7 out of 9 based on the NOS, indicating they generally had a medium risk of bias. Although most studies showed significant findings between early antibiotic exposure and asthma, the actual effects are still unclear as intrapartum antibiotic administration, familial factors and confounding by maternal and child infections were often not addressed. CONCLUSIONS: This review points to a moderate amount of evidence for a relationship between early life antibiotics (especially prenatal) and childhood asthma, some evidence for a relationship with hay fever and less convincing evidence for a relationship with eczema. More studies are still needed addressing intra-partum antibiotics, familial factors, and possible confounding by maternal and childhood infections. Children exposed to multiple, broad-spectrum antibiotics early in life appear to have a greater risk of allergies, especially asthma; these effects should be investigated further.