Quantifying reciprocal relationships between poverty and health: combining a causal loop diagram with longitudinal structural equation modelling.

BACKGROUND: This study takes on the challenge of quantifying a complex causal loop diagram describing how poverty and health affect each other, and does so using longitudinal data from The Netherlands. Furthermore, this paper elaborates on its methodological approach in order to facilitate replication and methodological advancement. METHODS: After adapting a causal loop diagram that was built by stakeholders, a longitudinal structural equation modelling approach was used. A cross-lagged panel model with nine endogenous variables, of which two latent variables, and three time-invariant exogenous variables was constructed. With this model, directional effects are estimated in a Granger-causal manner, using data from 2015 to 2019. Both the direct effects (with a one-year lag) and total effects over multiple (up to eight) years were calculated. Five sensitivity analyses were conducted. Two of these focus on lower-income and lower-wealth individuals. The other three each added one exogenous variable: work status, level of education, and home ownership. RESULTS: The effects of income and financial wealth on health are present, but are relatively weak for the overall population. Sensitivity analyses show that these effects are stronger for those with lower incomes or wealth. Physical capability does seem to have strong positive effects on both income and financial wealth. There are a number of other results as well, as the estimated models are extensive. Many of the estimated effects only become substantial after several years. CONCLUSIONS: Income and financial wealth appear to have limited effects on the health of the overall population of The Netherlands. However, there are indications that these effects may be stronger for individuals who are closer to the poverty threshold. Since the estimated effects of physical capability on income and financial wealth are more substantial, a broad recommendation would be that including physical capability in efforts that are aimed at improving income and financial wealth could be useful and effective. The methodological approach described in this paper could also be applied to other research settings or topics.

School health promotion and fruit and vegetable consumption in secondary schools: a repeated cross-sectional multilevel study.

BACKGROUND: Worldwide, recommendations for fruit and vegetable consumption are not met, which can cause chronic diseases. Especially adolescence is an important phase for the development of health behaviours. Therefore, in the Netherlands, the Healthy School program was established to aid schools in promoting healthy lifestyles among their students. We examined to what extent the variation between secondary schools regarding students' fruit and vegetable consumption could be explained by differences between schools regarding Healthy School certification, general school characteristics, and the school population. Additionally, we examined whether Healthy School certification was related to the outcomes, and whether the association differed for subgroups. METHODS: We performed a repeated cross-sectional multilevel study. We used data from multiple school years from the national Youth Health Monitor on secondary schools (grades 2 and 4, age ranged from approximately 12 to 18 years) of seven Public Health Services, and added data with regard to Healthy School certification, general school characteristics and school population characteristics. We included two outcomes: the number of days a student consumed fruit and vegetables per week. In total, we analysed data on 168,127 students from 256 secondary schools in the Netherlands. RESULTS: Results indicated that 2.87% of the variation in fruit consumption and 5.57% of the variation in vegetable consumption could be attributed to differences at the school-level. Characteristics related to high parental educational attainment, household income, and educational track of the students explained most of the variance between schools. Additionally, we found a small favourable association between Healthy School certification and the number of days secondary school students consumed fruit and vegetables. CONCLUSIONS: School population characteristics explained more variation between schools than Healthy School certification and general school characteristics, especially indicators of parental socioeconomic status. Nevertheless, Healthy School certification seemed to be slightly related to fruit and vegetable consumption, and might contribute to healthier dietary intake. We found small differences for some subgroups, but future research should focus on the impact in different school contexts, since we were restricted in the characteristics that could be included in this study.

Role of Conserved Tyrosine Lid Residues in the Activation of the M2 Muscarinic Acetylcholine Receptor.

The development of subtype selective small molecule drugs for the muscarinic acetylcholine receptor (mAChR) family has been challenging. The design of more selective ligands can be improved by understanding the structure and function of key amino acid residues that line ligand binding sites. Here we study the role of three conserved key tyrosine residues [Y1043.33, Y4036.51, and Y4267.39 (Ballesteros and Weinstein numbers in superscript)] at the human M2 mAChR, located at the interface between the orthosteric and allosteric binding sites of the receptor. We specifically focused on the role of the three tyrosine hydroxyl groups in the transition between the inactive and active conformations of the receptor by making phenylalanine point mutants. Single-point mutation at either of the three positions was sufficient to reduce the affinity of agonists by ∼100-fold for the M2 mAChR, whereas the affinity of antagonists remained largely unaffected. In contrast, neither of the mutations affected the efficacy of orthosteric agonists. When mutations were combined into double and triple M2 mAChR mutants, the affinity of antagonists was reduced by more than 100-fold compared with the wild-type M2 receptor. In contrast, the affinity of allosteric modulators, either negative or positive, was retained at all single and multiple mutations, but the degree of allosteric effect exerted on the endogenous ligand acetylcholine was affected at all mutants containing Y4267.39F. These findings will provide insights to consider when designing future mAChR ligands. SIGNIFICANCE STATEMENT: Structural studies demonstrated that three tyrosine residues between the orthosteric and allosteric sites of the M2 muscarinic acetylcholine receptor (mAChR) had different hydrogen bonding networks in the inactive and active conformations. The role of hydroxyl groups of the tyrosine residues on orthosteric and allosteric ligand pharmacology was unknown. We found that hydroxyl groups of the tyrosine residues differentially affected the molecular pharmacology of orthosteric and allosteric ligands. These results provide insights to consider when designing future mAChR ligands.

Two sides of the same coin? Absolute income and perceived income inadequacy as social determinants of health.

BACKGROUND: Absolute income is commonly used in studies of health inequalities, however it does not reflect spending patterns, debts, or expectations. These aspects are reflected in measures concerning perceived income inadequacy. While health inequities by absolute income or perceived income inadequacy are well established, few studies have explored the interplay of absolute income and perceived income inadequacy in relation to health. METHODS: Multiple data sources were linked into a nationally representative dataset (n = 445,748) of Dutch adults (18 +). The association between absolute income, perceived income inadequacy and health (self-reported health, chronic disease and psychological distress) was tested using logistic and Poisson regressions, controlling for various potential confounders (demographics, education) and mastery. Interactions were tested to check the association between perceived income inadequacy and health for different absolute income groups. RESULTS: Perceived income inadequacy was reported at every absolute income group (with 42% of individuals in the lowest income group and 5% of individuals in the highest income group). Both absolute income and perceived income inadequacy were independently associated with health. The adjusted relative risk (RR) for lowest absolute income group is 1.11 (1.08-1.1.14) and 1.28 (1.24-1.32) for chronic disease and self-reported health respectively, and the Odds Ratio (OR) for psychological distress is 1.28 (1.16-1.42). For perceived income inadequacy the RR's were 1.41 (1.37-1.46) and 1.49 (1.44-1.54) and the OR for psychological distress is 3.14 (2.81-3.51). Mastery appeared to be an important mediator for the relationship between perceived income inadequacy, poor self-rated health and psychological distress. CONCLUSIONS: Absolute income and perceived income inadequacy reflect conceptually different aspects of income and are independently associated with health outcomes. Perceived income inadequacy may be accounted for in health inequality studies, alongside measures of absolute income. In policy-making, targeting perceived income inadequacy might have potential to reduce health inequalities.

School health promotion and the consumption of water and sugar-sweetened beverages in secondary schools: a cross-sectional multilevel study.

BACKGROUND: Overweight among adolescents remains a serious concern worldwide and can have major health consequences in later life, such as cardiovascular diseases and cancer. Still, 33% of secondary school adolescents in the Netherlands consume sugar-sweetened beverages daily and over 26% do not consume water every day. The Dutch Healthy School program was developed to support schools in stimulating healthier lifestyles by focusing on health education, school environments, identifying students' health problems, and school policy. We examined the variation between secondary schools regarding the daily consumption of water and sugar-sweetened beverages and whether this variation can be explained by differences between schools regarding Healthy School certification, general school characteristics, and the school population. METHODS: We performed a cross-sectional multilevel study. We used data from the national Youth Health Monitor of 2019 on secondary schools (grades 8 and 10, age range about 12 to 18 years) of seven Public Health Services and combined these with information regarding Healthy School certification and general school- and school population characteristics. Our outcomes were daily consumption of water and sugar-sweetened beverages. In total, data from 51,901 adolescents from 191 schools were analysed. We calculated the intraclass correlation to examine the variation between schools regarding our outcomes. Thereafter, we examined whether we could explain this variation by the included characteristics. RESULTS: The school-level explained 4.53% of the variation in the consumption of water and 2.33% of the variation in the consumption of sugar-sweetened beverages. This small variation in water and sugar-sweetened consumption could not be explained by Healthy School certification, yet some general school- and school population characteristics did: the proportion of the school population with at least one parent with high educational attainment, the educational track of the adolescents, urbanicity (only for water consumption) and school type (only for sugar-sweetened beverages consumption). CONCLUSIONS: The low percentages of explained variation indicate that school-level characteristics in general (including Healthy School certification) do not matter substantially for the daily consumption of water and sugar-sweetened beverages. Future research should examine whether school health promotion can contribute to healthier lifestyles, and if so, under which level of implementation and school conditions.

Fidelity, adaptation and integration of whole-school health promotion within Dutch schools: a cross-sectional survey study.

Implementing comprehensive health promotion programs in the school setting can be challenging, as schools can be considered complex adaptive systems. As a first step towards understanding what works in improving implementation for which schools and under which conditions, this study aimed to examine the degree of implementation of health promoting school (HPS) programs, in terms of five dimensions of fidelity (adherence, dose, participant responsiveness, quality of delivery and program differentiation), and the dimensions of adaptation and integration. The HPS Implementation Questionnaire was distributed among ±â€…2400 primary, secondary, secondary vocational and special needs schools in the Netherlands. Employees of 535 schools (22.3%) filled out the questionnaire. Data were analysed by descriptive statistics and ANOVA tests. The average degree of implementation was 2.55 (SD = 0.58, range = 0.68-3.90; scaled 0-4). The lowest scores were achieved for participant responsiveness and adherence, and the highest for integration and adaptation. Schools that identified as HPS reported significantly higher overall degree of implementation, adherence, dose, participant responsiveness, program differentiation and adaptation than schools that didn't. Primary schools achieved a significantly higher degree of implementation, dose, participant responsiveness, quality of delivery and integration than other school types. In conclusion, many schools work on student health and well-being to some extent, but the vast majority have much room for improvement. Higher implementation scores for schools that identified as HPS underline the value of HPS programs. A broader perspective on health and more insight into conditions for effectiveness and implementation in secondary and secondary vocational schools are needed.

Qualitative modelling of social determinants of health using group model building: the case of debt, poverty, and health.

BACKGROUND: Social determinants of health (SDoH) are known to have a large impact on health outcomes, but their effects are difficult to make visible. They are part of complex systems of variables largely indirect effects on multiple levels, constituting so-called wicked problems. This study describes a participatory approach using group model building (GMB) with stakeholders, in order to develop a qualitative causal model of the health effects of SDoH, taking poverty and debt in the Dutch city of Utrecht as a case study. METHODS: With GMB we utilised the perspective of stakeholders who are directly involved in policy and practice regarding poverty, debt, and/or health. This was done using system dynamic modelling, in three interactive sessions lasting three hours each. In these sessions, they constructed a model, resulting in a system of variables with causal relationships and feedback loops. Subsequently, the results of these GMB sessions were compared to scientific literature and reviewed by a panel of researchers with extensive experience in relevant scientific fields. RESULTS: The resulting model contains 71 causal relationships between 39 variables, 29 of which are present in feedback loops. The variables of participation in society, stress, shame, social contacts and use of services/provisions appear to hold prominent roles in the model's mechanisms. Most of the relationships in the model are supported by scientific literature. The researchers reviewing the model in the scientific meeting agreed that the vast majority of relationships would concur with scientific knowledge, but that the model constructed by the stakeholders consists mostly of individual-level factors, while important conditions usually relate to systemic variables. CONCLUSIONS: Building a model with GMB helps grasp the complex situation of a wicked problem, for which it is unlikely that its interrelationships result in a fully intuitive understanding with linear mechanisms. Using this approach, effects of SDoH can be made visible and the body of evidence expanded. Importantly, it elicits stakeholders' perspectives on a complex reality and offers a non-arbitrary way of formulating the model structure. This qualitative model is also well suited to serve as conceptual input for a quantitative model, which can be used to test and estimate the relationships.

Tunneling a crosstown highway: a natural experiment testing the longitudinal effect on physical activity and active transport.

BACKGROUND: In the city of Maastricht in the Netherlands, a highway crossing several deprived neighborhoods was tunneled in 2016. The vacant space on top of this tunnel was redesigned and prioritized for pedestrians and cyclists. The aim of this study was to evaluate the effect of this major infrastructural change, named the Green Carpet, on total and transport-based physical activity (PA) levels. METHODS: Participants (≥18 years) were part of one of three area-based exposure groups. The maximal exposure group lived in neighborhoods directly bordering the Green Carpet. The minimal exposure group consisted of individuals living at the other side of the city, and the no exposure group consisted of individuals living in a nearby city. Actual use of the new infrastructure was incorporated as a second measure of exposure. Data were collected before and 3-15 months after the opening of the Green Carpet. Device-based measurements were conducted to obtain PA levels and collect location data. Changes in PA over time and intervention effects were determined using linear mixed models. RESULTS: PA levels in the Green Carpet area increased for the maximal and minimal exposure groups, but did not lead to an increase in total or transport-based PA. For the no exposure group, transport-based MVPA decreased and transport-based SB increased. The significant interaction (time x exposure) for transport-based SB, indicated differences in trends between the no exposure and maximal exposure group (B=-3.59, 95% CI - 7.15; -0.02) and minimal exposure group (B= -4.02, 95% CI -7.85, -0.19). Trends in the results based on analyses focusing on actual use and non-use of the new infrastructure were similar to those of the area-based analyses. CONCLUSIONS: Results suggest that the Green Carpet led to more PA in this specific area, but did not increase the total volume of PA. The area-based differences might reflect the differences between users and non-users, but we should be careful when interpreting these results, due to possible interference of selective mobility bias. This paper reflects that the relationship between infrastructure and PA is not unambiguous. TRIAL REGISTRATION: This research was retrospectively registered at the Netherlands Trial Register ( NL8108 ).

Do parenting practices moderate the association between the physical neighbourhood environment and changes in children's time spent at various physical activity levels? An exploratory longitudinal study.

BACKGROUND: As many children do not meet the recommended daily physical activity (PA) levels, more research is needed towards environmental determinants of children's PA levels. The aims of this longitudinal study were to investigate whether the physical environment and parenting practices have an impact on changes in children's weekday time spent at various PA levels and whether associations between physical neighbourhood environment and changes in children's PA are moderated by parenting practices. METHODS: We performed a secondary data analysis of longitudinal data collected at three timepoints (baseline, 6, and 18 months) from 10 control schools of the Active Living study, a quasi-experimental study, which took place in South Limburg, the Netherlands. In total, 240 children aged 8-12 years were included in the analyses. PA levels were measured using accelerometry (ActiGraph GT3X+). The physical environment was assessed at baseline through neighbourhood audits of the school environment, and PA parenting practices were measured at baseline via validated parental questionnaires. Multivariate multilevel regression analyses were conducted to determine the main effects of the physical environment and parenting practices on changes in children's time spent in sedentary behaviour (SB), light PA and moderate-to-vigorous PA (MVPA) over 18 months. Additionally, moderation of the association between the physical environment and children's PA levels by parenting practices was examined by adding interacting terms to the regression equations. RESULTS: Walkability of the physical environmental was associated with a decrease in SB at 18 months (B = -5.45, p < .05). In addition, the parenting practice logistic support was associated with an increase in MVPA (at all time points, B = .68, B = .73 and B = 1.02, respectively, all p < .05) and a decrease in SB (at 18 months, B = -1.71, p < .05). Stratified analyses (based on significant interaction terms) showed that the effect of specific physical environmental features (e.g., sports facilities) on children's improvements in PA levels were strengthened by favourable parenting practices. DISCUSSION: Besides the main effects of walkability and logistic support, there were indications that several parenting practices moderate the association between the physical environment and changes in children's time in various PA levels. The current findings are exploratory, and need to be confirmed in further research.

Effects of the KEIGAAF intervention on the BMI z-score and energy balance-related behaviors of primary school-aged children.

The aim of the current study was to evaluate the one- and two-year effectiveness of the KEIGAAF intervention, a school-based mutual adaptation intervention, on the BMI z-score (primary outcome), and energy balance-related behaviors (secondary outcomes) of children aged 7-10 years.A quasi-experimental study was conducted including eight intervention schools and three control schools located in low socioeconomic neighborhoods in the Netherlands. Baseline measurements were conducted in March and April 2017 and repeated after one and 2 years. Data were collected on children's BMI z-score, sedentary behavior (SB), physical activity (PA) behavior, and nutrition behavior through the use of anthropometric measurements, accelerometers, and questionnaires, respectively. All data were supplemented with demographics, and weather conditions data was added to the PA data. Based on the comprehensiveness of implemented physical activities, intervention schools were divided into schools having a comprehensive PA approach and schools having a less comprehensive approach. Intervention effects on continuous outcomes were analyzed using multiple linear mixed models and on binary outcome measures using generalized estimating equations. Intervention and control schools were compared, as well as comprehensive PA schools, less comprehensive PA schools, and control schools. Effect sizes (Cohen's d) were calculated.In total, 523 children participated. Children were on average 8.5 years old and 54% were girls. After 2 years, intervention children's BMI z-score decreased (B = -0.05, 95% CI -0.11;0.01) significantly compared to the control group (B = 0.20, 95% CI 0.09;0.31). Additionally, the intervention prevented an age-related decline in moderate-to-vigorous PA (MVPA) (%MVPA: B = 0.95, 95% CI 0.13;1.76). Negative intervention effects were seen on sugar-sweetened beverages and water consumption at school, due to larger favorable changes in the control group compared to the intervention group. After 2 years, the comprehensive PA schools showed more favorable effects on BMI z-score, SB, and MVPA compared to the other two conditions.This study shows that the KEIGAAF intervention is effective in improving children's MVPA during school days and BMI z-score, especially in vulnerable children. Additionally, we advocate the implementation of a comprehensive approach to promote a healthy weight status, to stimulate children's PA levels, and to prevent children from spending excessive time on sedentary behaviors.Trial registrationNetherlands Trial Register, NTR6716 ( NL6528 ), Registered 27 June 2017 - retrospectively registered.

Assessing the role of criminality in neighbourhood safety feelings and self-reported health: results from a cross-sectional study in a Dutch municipality.

BACKGROUND: Neighbourhood safety has repeatedly been shown to be associated with the health and well-being of the residents. Criminality is often seen as one of the key factors affecting neighbourhood safety. However, the relationship between crime, fear of crime and feelings of safety remains underexplored. METHODS: Data on socio-demographic, health and safety perceptions was extracted from the Maastricht municipality survey (the Netherlands) (n = 9656 adults) and merged with data on official neighbourhood crime rates from the Police Registry. Pearson correlation coefficients and multilevel logistic regression models were computed to assess the association between aspects of objective and perceived criminality, individuals' feelings of safety and health. RESULTS: The correlation between the police recorded crime and residents' perceptions of the neighbourhood crime rates was weak (0.14-0.38), with the exception of violent crime (0.59), which indicates that other factors contribute to the perceptions of safety. In turn, the perception of higher rates of violent crime and more nuisance (on the scale 0-10) but not other types of crime or nuisance was positively associated with feeling unsafe (OR 1.27 [1.22;1.32] and 1.39 [1.33;1.46], respectively). Lower general feelings of safety at both the individual and neighbourhood level were consistently associated with worse self-rated health. Among different indicators of safety, the general feelings of safety had the most pronounced association with health, while subjective or objective measures of crime showed limited to no direct relationship with health. CONCLUSIONS: Public health policies targeting safety as a social determinant of health should consider prioritizing areas of violent crime and nuisance to improve general feelings of safety. Further research is needed to understand which factors aside from criminality are driving residents' feelings of safety.

Co-producing active lifestyles as whole-system-approach: theory, intervention and knowledge-to-action implications.

Population health interventions tend to lack links to the emerging discourse on interactive knowledge production and exchange. This situation may limit both a better understanding of mechanisms that impact health lifestyles and the development of strategies for population level change. This paper introduces an integrated approach based on structure-agency theory in the context of 'social practice'. It investigates the mechanisms of co-production of active lifestyles by population groups, professionals, policymakers and researchers. It combines a whole system approach with an interactive knowledge-to-action strategy for developing and implementing active lifestyle interventions. A system model is outlined to describe and explain how social practices of selected groups co-produce active lifestyles. Four intervention models for promoting the co-production of active lifestyles through an interactive-knowledge-to-action approach are discussed. Examples from case studies of the German research network Capital4Health are used to illustrate, how intervention models might be operationalized in a real-world intervention. Five subprojects develop, implement and evaluate interventions across the life-course. Although subprojects differ with regard to settings and population groups involved, they all focus on the four key components of the system model. The paper contributes new strategies to address the intervention research challenge of sustainable change of inactive lifestyles. The interactive approach presented allows consideration of the specificities of settings and scientific contexts for manifold purposes. Further research remains needed on what a co-produced knowledge-to-action agenda would look like and what impact it might have for whole system change.

Study protocol of the quasi-experimental evaluation of "KEIGAAF": a context-based physical activity and nutrition intervention for primary school children.

BACKGROUND: The environment affects children's energy balance-related behaviors to a considerable extent. A context-based physical activity and nutrition school- and family-based intervention, named KEIGAAF, is being implemented in low socio-economic neighborhoods in Eindhoven, The Netherlands. The aim of this study was to investigate: 1) the effectiveness of the KEIGAAF intervention on BMI z-score, waist circumference, physical activity, sedentary behavior, nutrition behavior, and physical fitness of primary school children, and 2) the process related to the implementation of the intervention. METHODS: A quasi-experimental, controlled study with eight intervention schools and three control schools was conducted. The KEIGAAF intervention consists of a combined top-down and bottom-up school intervention: a steering committee developed the general KEIGAAF principles (top-down), and in accordance with these principles, KEIGAAF working groups subsequently develop and implement the intervention in their local context (bottom-up). Parents are also invited to participate in a family-based parenting program, i.e., Triple P Lifestyle. Children aged 7 to 10 years old (grades 4 to 6 in the Netherlands) are included in the study. Effect evaluation data is collected at baseline, after one year, and after two years by using a child questionnaire, accelerometers, anthropometry, a physical fitness test, and a parent questionnaire. A mixed methods approach is applied for the process evaluation: quantitative (checklists, questionnaires) and qualitative methods (observations, interviews) are used. To analyze intervention effectiveness, multilevel regression analyses will be conducted. Content analyses will be conducted on the qualitative process data. DISCUSSION: Two important environmental settings, the school environment and the family environment, are simultaneously targeted in the KEIGAAF intervention. The combined top-down and bottom-up approach is expected to make the intervention an effective and sustainable version of the Health Promoting Schools framework. An elaborate process evaluation will be conducted alongside an effect evaluation in which multiple data collection sources (both qualitative and quantitative) are used. TRIAL REGISTRATION: Dutch Trial Register NTR6716 (registration date 27/06/2017, retrospectively registered), METC163027, NL58554.068.16, Fonds NutsOhra project number 101.253.

Comparative institutional analysis for public health: governing voluntary collaborative agreements for public health in England and the Netherlands.

Democratic institutions and state-society relations shape governance arrangements and expectations between public and private stakeholders about public health impact. We illustrate this with a comparison between the English Public Health Responsibility Deal (RD) and the Dutch 'All About Health…' (AaH) programme. As manifestations of a Whole-of-Society approach, in which governments, civil society and business take responsibility for the co-production of economic utility and good health, these programmes are two recent collaborative platforms based on voluntary agreements to improve public health. Using a 'most similar cases' design, we conducted a comparative secondary analysis of data from the evaluations of the two programmes. The underlying rationale of both programmes was that voluntary agreements would be better suited than regulation to encourage business and civil society to take more responsibility for improving health. Differences between the two included: expectations of an enforcing versus facilitative role for government; hierarchical versus horizontal coordination; big business versus civil society participants; top-down versus bottom-up formulation of voluntary pledges and progress monitoring for accountability versus for learning and adaptation. Despite the attempt in both programmes to base voluntary commitments on trust, the English 'shadow of hierarchy' and adversarial state-society relationships conditioned non-governmental parties to see the pledges as controlling, quasi-contractual agreements that were only partially lived up to. The Dutch consensual political tradition enabled a civil society-based understanding and gradual acceptance of the pledges as the internalization by partner organizations of public health values within their operations. We conclude that there are institutional limitations to the implementation of generic trust-building and learning-based models of change 'Whole-of-Society' approaches.

Early life growth and the development of preschool wheeze, independent from overweight: the LucKi Birth Cohort Study.

OBJECTIVE: To investigate whether birth weight and postnatal growth rates are independently related to the development of overweight and wheeze up to age 3 years. STUDY DESIGN: Children from the LucKi Birth Cohort Study with complete follow-up for repeated questionnaires (at age 0, 7, and 14 months and 3 years) and informed consent to use height and weight data (measured by trained personnel at age 0, 7, and 14 months and 2 and 3 years) were included (n = 566). Wheeze (parental-reported) and overweight (body mass index [BMI] >85th percentile) were regressed with generalized estimating equations on birth weight and relative growth rates (difference SDS for weight, height, and BMI). RESULTS: Higher birth weight and higher weight and BMI growth rates were associated with increased risk of overweight, but not of wheeze, up to age 3 years. Higher height growth rate was associated with lower risk of wheeze up to 3 years, independent of overweight (aOR, 0.65; 95% CI, 0.53-0.79). In time-lag models, wheeze was associated with subsequently reduced height growth up to age 14 months, but not vice versa. CONCLUSION: Only height growth rate, and not weight and BMI growth rate, is associated with preschool wheeze, independent of overweight. Children who wheeze demonstrate a subsequent reduction in height growth up to age 14 months, but not vice versa. Because height growth rate is not associated with overweight, preschool wheeze and overweight are not associated throughout early life growth.

Neighborhood Environment is Associated with Overweight and Obesity, Particularly in Older Residents: Results from Cross-Sectional Study in Dutch Municipality.

We explored whether overweight and obesity were associated with the physical and social environment at neighborhood level. Data from Maastricht municipality survey (The Netherlands) were used (n = 9771 adults). Multinomial regression models were computed (outcome being normal weight, overweight, or obese). We found inconsistent associations between neighborhood social and physical environment characteristics and overweight and obesity in the total sample. The effects were more consistent and stronger for older residents (>65) and obesity as an outcome. Better scores on traffic nuisance, green space, social cohesion, nuisance, and safety were associated with lower odds of obesity among elderly (OR ranged between 0.71 [95% CI 0.44 to 0.93] to 0.85 [95% CI 0.74 to 0.96] for each point of improvement in neighborhood social and physical environment (scale 0-10)). We showed that there are neighborhood-level factors that are associated with obesity, particularly in elderly residents. These could be targeted in preventive strategies outside health care settings.

LucKi Birth Cohort Study: rationale and design.

BACKGROUND: Infancy and childhood are characterized by rapid growth and development, which largely determine health status and well-being across the lifespan. Identification of modifiable risk factors and prognostic factors in critical periods of life will contribute to the development of effective prevention and intervention strategies. The LucKi Birth Cohort Study was designed and started in 2006 to follow children from birth into adulthood on a wide range of determinants, disorders, and diseases. During preschool and school years, the primary focus is on the etiology and prognosis of atopic diseases (eczema, asthma, and hay fever) and overweight/obesity. METHODS/DESIGN: LucKi is an ongoing, dynamic, prospective birth cohort study, embedded in the Child and Youth Health Care (CYHC) practice of the 'Westelijke Mijnstreek' (a region in the southeast of the Netherlands). Recruitment (1-2 weeks after birth) and follow-up (until 19 years) coincide with routine CYHC contact moments, during which the child's physical and psychosocial development is closely monitored, and anthropometrics are measured repeatedly in a standardised way. Information gathered through CYHC is complemented with repeated parental questionnaires, and information from existing registries of pharmacy, hospital and/or general practice. Since the start already more than 5,000 children were included in LucKi shortly after birth, reaching an average participation rate of ~65 %. DISCUSSION: The LucKi Birth Cohort Study provides a framework in which children are followed from birth into adulthood. Embedding LucKi in CYHC simplifies implementation, leads to low maintenance costs and high participation rates, and facilitates direct implementation of study results into CYHC practice. Furthermore, LucKi provides opportunities to initiate new (experimental) studies and/or to establish biobanking in (part of) the cohort, and contributes relevant information on determinants and health outcomes to policy and decision makers. Cohort details can be found on www.birthcohorts.net .

Living environment matters: relationships between neighborhood characteristics and health of the residents in a Dutch municipality.

Characteristics of an individual alone cannot exhaustively explain all the causes of poor health, and neighborhood of residence have been suggested to be one of the factors that contribute to health. However, knowledge about aspects of the neighborhood that are most important to health is limited. The main objective of this study was to explore associations between certain features of neighborhood environment and self-rated health and depressive symptoms in Maastricht (The Netherlands). A large amount of routinely collected neighborhood data were aggregated by means of factor analysis to 18 characteristics of neighborhood social and physical environment. Associations between these characteristics and self-rated health and presence of depressive symptoms were further explored in multilevel logistic regression models adjusted for individual demographic and socio-economic factors. The study sample consisted of 9,879 residents (mean age 55 years, 48 % male). Residents of unsafe communities were less likely to report good health (OR 0.88 95 % CI 0.80-0.97) and depressive symptoms (OR 0.81 95 % CI 0.69-0.97), and less cohesive environment was related to worse self-rated health (OR 0.81 95 % CI 0.72-0.92). Residents of neighborhoods with more car traffic nuisance and more disturbance from railway noise reported worse mental health (OR 0.79 95 % CI 0.68-0.92 and 0.85 95 % CI 0.73-0.99, respectively). We did not observe any association between health and quality of parking and shopping facilities, facilities for public or private transport, neighborhood aesthetics, green space, industrial nuisance, sewerage, neighbor nuisance or satisfaction with police performance. Our findings can be used to support development of integrated health policies targeting broader determinants of health. Improving safety, social cohesion and decreasing traffic nuisance in disadvantaged neighborhoods might be a promising way to improve the health of residents and reduce health inequalities.

Conditions for sustainability of Academic Collaborative Centres for Public Health in the Netherlands: a mixed methods design.

BACKGROUND: Contemporary research should increasingly be carried out in the context of application. Nowotny called this new form of knowledge production Mode-2. In line with Mode-2 knowledge production, the Dutch government in 2006 initiated the so-called Academic Collaborative Centres (ACC) for Public Health. The aim of these ACCs is to build a regional, sustainable knowledge-sharing network to deliver socially robust knowledge. The present study aims to highlight the enabling and constraining push and pull factors of these ACCs in order to assess whether the ACCs are able to build and strengthen a sustainable integrated organizational network between public health policy, practice, and research. METHODS: Our empirical analysis builds on a mixed methods design. Quantitative data was derived from records of a survey sent to all 11 ACCs about personnel investments, number and nature of projects, and earning power. Qualitative data was derived from 21 in-depth interviews with stakeholders involved. The interviews were tape-recorded, transcribed, and manually coded as favourable or unfavourable pull or push factors. RESULTS: The extra funding appeared to be the most enabling push factor. The networks secured external grants for about 150 short- and long-term Mode-2 knowledge production projects in the past years. Enabling pull factors improved, especially the number of policy-driven short-term research projects. Exchange agents were able to constructively deal with the constraining push factors, like university's publication pressure and budget limitations. However, the constraining pull factors like local government's involvement and their low demand for scientific evidence were difficult to overcome. CONCLUSIONS: A clear improvement of the organizational networks was noticed whereby the ACC's were pushed rather than pulled. Efforts are needed to increase the demand for scientific and socially robust evidence from policymakers and to resolve the regime differences between the research and policy systems, in order to make the bidirectionality of the links sustainable.