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Introduction:Outdoor smoke-free policies (SFPs) at sports clubs may contribute to the prevention of smoking among adolescents. Adolescents’ support for such policy is important to its success. The aim of this study is to explore adolescents’ perceptions with regard to an outdoor SFP at sports clubs in the Netherlands.Methods:Focus group discussions (n=27) were held with 180 participants (aged 13–18 years) at 16 sports clubs. Thematic analysis was used to analyze the data.Results:Participants generally supported an outdoor SFP at sports clubs. Five reasons for this support were reported: 1) children should not be exposed to smoking, 2) smoking and sports (clubs) do not fit together, 3) secondhand smoke is undesirable, 4) an outdoor SFP may enhance a sports club’s image, and 5) an outdoor SFP contributes to the prevention of smoking. Some participants voiced considerations against an outdoor SFP, arguing amongst others, that smokers need to be taken into account, and that problems may occur with compliance and enforcement. Support for an outdoor SFP was stronger among participants at clubs with an outdoor SFP than among those without such policy.Conclusions:This study shows that adolescents generally support an outdoor smoke-free policy at sports clubs. After implementation, the outdoor SFP was generally experienced as a normal practice. These results could encourage sports clubs without an outdoor SFP to become smoke-free as well.

BackgroundParenting support guidelines for public health nurses have shifted from a problem-focused to a solution-focused approach. Given the fundamental differences between these two approaches, implementation of solution-focused parenting support is assumed to be difficult. Since the way public health nurses provide parenting support is largely guided by their beliefs, knowledge about their beliefs concerning solution-focused parenting support is important for its actual implementation. This study aims to explore the behavioral, normative, and control beliefs of public health nurses about solution-focused parenting support for future design of implementation interventions and related research activities.MethodsA theory of planned behavior questionnaire was systematically developed and tested using focus groups. Thematic analysis and nominal group technique were used to analyze the data and to reach consensus. Next, this questionnaire was conducted among 449 public health nurses in the Netherlands. Factor analysis and descriptive statistical analysis were performed.ResultsFactor analysis resulted in three distinguishing subscales: behavioral beliefs (α = 0.79), normative beliefs (α = 0.80), and control beliefs (α = 0.64). Beliefs of public health nurses about solution-focused parenting support were moderately positive to positive (means varying from 4.24 to 5.54, on a 1–7 scale), and differences were statistically significant for various background variables. Control beliefs were less positive than behavioral and normative beliefs. Public health nurses trained in solution-focused parenting support reported more positive control beliefs (M = 4.34, SD = 0.83) as compared to untrained public health nurses (M = 4.00, SD = 0.82).ConclusionThis study is the first to provide insight into public health nurses’ beliefs about solution-focused parenting support. The overall moderately positive to positive beliefs of PHNs about solution-focused parenting support suggests that PHNs tend to accept solution-focused parenting support as a viable approach. Compared to behavioral and normative beliefs, PHNs score the lowest on control beliefs.

ObjectiveAlthough several falls risk assessment tools are available, it is unclear which have been validated and which would be most suitable for primary care practices. This systematic review aims to identify the most suitable falls risk assessment tool for the primary care setting (ie, requires limited time, no expensive equipment and no additional space) and that has good predictive performance in the assessment of falls risk among older people living independently.DesignA systematic review based on prospective studies.MethodsAn extensive search was conducted in the following databases: PubMed, Embase, CINAHL, Cochrane and PsycINFO. Tools were excluded if they required expensive and/or advanced software that is not usually available in primary care units and if they had not been validated in at least three different studies. Of 2492 articles published between January 2000 and July 2020, 27 were included.ResultsSix falls risk assessment tools were identified: Timed Up and Go (TUG) test, Gait Speed test, Berg Balance Scale, Performance Oriented Mobility Assessment, Functional Reach test and falls history. Most articles reported area under the curve (AUC) values ranging from 0.5 to 0.7 for these tools. Sensitivity and specificity varied substantially across studies (eg, TUG, sensitivity:10%–83.3%, specificity:28.4%–96.6%).ConclusionsGiven that none of the falls risk assessment tools had sufficient predictive performance (AUC Trial registraion numberThe Netherlands Trial Register, NL7917; Pre-results.

Background Combined lifestyle interventions (CLIs) are designed to help people who are overweight or obese maintain a healthy new lifestyle. The CooL intervention is a CLI in the Netherlands, in which lifestyle coaches counsel adults and children (and/or their parents) who are obese or at high risk of obesity to achieve a sustained healthier lifestyle. The intervention consists of coaching on lifestyle in group and individual sessions, addressing the topics of physical activity, dietary behaviours, sleep, stress management and behavioural change. The aim of this study was to evaluate the implementation process of the Coaching on Lifestyle (CooL) intervention and its facilitating and impeding factors. Methods Mixed methods were used in this action-oriented study. Both quantitative (number of referrals, attendance lists of participants and questionnaires) and qualitative (group and individual interviews, observations, minutes and open questions) data were collected among participants, lifestyle coaches, project group members and other stakeholders. The Consolidated Framework for Implementation Research was used to analyse the data. Results CooL was evaluated by stakeholders and participants as an accessible and useful programme, because of its design and content and the lifestyle coaches’ approach. However, stakeholders indicated that the lifestyle coaches need to become more familiar in the health care network and public sectors in the Netherlands. Lifestyle coaching is a novel profession and the added value of the lifestyle coach is not always acknowledged by all health care providers. Lifestyle coaches play a crucial role in ensuring the impact of CooL by actively networking, using clear communication materials and creating stakeholders’ support and understanding. Conclusion The implementation process needs to be strengthened in terms of creating support for and providing clear information about lifestyle coaching. The CooL intervention was implemented in multiple regions, thanks to the efforts of many stakeholders. Lifestyle coaches should engage in networking activities and entrepreneurship to boost the implementation process. It takes considerable time for a lifestyle coach to become fully incorporated in primary care. Trial registration NTR6208; date registered: 13–01-2017; retrospectively registered; Netherlands Trial Register.

Background Overweight and obesity are problems that are increasing globally in both children as well as adults, and may be prevented by adopting a healthier lifestyle. Lifestyle coaches counsel overweight and obese children (and their parents) as well as adults in initiating and maintaining healthier lifestyle behaviours. It is currently unclear whether this novel professional in the Dutch health care system functions as a linchpin in networks that evolve around lifestyle-related health problems. The aim of the present study is to investigate the formation and development of networks of lifestyle coaches and their positions within these networks. Methods In this longitudinal study, key professionals and professionals within relevant organisations in the Coaching on Lifestyle (CooL) care networks were asked to fill in three online questionnaires. Respondents were asked to indicate whether they collaborated with each of the specified professionals in the context of CooL. The overall network structures and the central role of the lifestyle coaches were examined by using network analysis. Results The results showed that the networks in three out of four regions were relatively centralised, but that none of the networks were dense, and that the professionals seemed to collaborate less with others over time. Half of the lifestyle coaches had a high number of collaborations and a central position within their networks, which also increased over time. In half of the regions, the lifestyle coaches had increased their role as consultants, while their role as gatekeeper and liaison decreased over time. In most regions, the sector of lifestyle coaches had a central position in their networks in just one measurement. Other central sectors were the local sports organisation, public health services, youth health care and the municipal government. Conclusions Overall, we cannot conclude that more central and denser networks were formed during the study period. In addition, the lifestyle coaches were not often positioned as a central sector within these networks. Entrepreneurial, network and brokering competences are required for lifestyle coaches to build up denser networks. Trial registration NTR6208; date registered: 13–01-2017; retrospectively registered; Netherlands Trial Register.

Background: Outdoor smoke-free policies (SFPs) at sports clubs represent an important new area of tobacco control, as many people, including youth, spend a large portion of their free time participating in sports. Nevertheless, the majority of sports clubs worldwide still have not adopted an outdoor SFP. The aim of this study is to explore the perceptions of key stakeholders at different Dutch sports clubs concerning the adoption of an outdoor SFP. Methods: Semi-structured interviews were held with 41 key stakeholders at seven Dutch sports clubs (in field hockey, football, tennis, or korfball) without an outdoor SFP. A thematic approach was used to analyze the data. Results: The majority of respondents reported considerations that were favorable towards adoption of an outdoor SFP, including expected support from club members, changing social norms with regard to smoking, and few members who smoke. Most of all, respondents valued the protection of children from the harmful effects of smoking. However, they also foresaw a number of problems in case of adoption, including impaired social functioning of the sports club, problems with compliance and enforcement, conflict with smokers’ interest, and low priority in club management. Conclusions: Although stakeholders at sports clubs recognize the intrinsic value of an outdoor SFP, they foresee practical problems that are inherent to sports clubs. Adoption could be enhanced by articulating the importance of protecting children from the harmful effects of smoking, referring to ‘success stories’ at sports clubs that are already smoke-free, and actively involving smokers in the adoption process.

BackgroundOutdoor smoke-free policies (SFPs) at sports clubs have significant potential to reduce adolescent smoking. However, the realization of this potential may be strongly dependent on how these policies are implemented in practice. The aim of this study is to explore the perceptions of key stakeholders at different sports clubs in the Netherlands concerning how outdoor SFPs are implemented in practice and which determinants influence implementation.MethodsSemi-structured interviews were held with 46 key stakeholders at eight Dutch sports clubs (i.e., field hockey, soccer, tennis, korfball) with an outdoor SFP. A thematic approach was used for the analysis of the transcripts.ResultsOverall, respondents perceived the implementation of an outdoor SFP at sports clubs as feasible. The SFP is often enforced, people who smoke react positively when they are approached, the SFP has led to less (visible) smoking at the venue, and a nonsmoking norm is reinforced. However, we identified three ‘critical situations’ in which implementation is less than optimal: 1) when children are not present at the sports club, 2) when alcohol is involved, and 3) when people who smoke relocate to the entrance of the sports club. Several determinants influenced implementation in those critical situations: 1) determinants related to individual smokers and club members (i.e., support, communication towards people who smoke), 2) determinants related to the SFP itself (i.e., clarity of the policy), 3) determinants related to the sports club (i.e., communication of the policy, characteristics of the sports club), and 4) determinants related to the wider community (i.e., change of social norm with regard to smoking, support from local and national organizations).ConclusionImplementation of an outdoor SFP at sports clubs is feasible because there is a high level of support and experiences are mainly positive. Nevertheless, some situations present challenges to compliance and enforcement. We identified a number of determinants that may facilitate implementation of an outdoor SFP at sports clubs.

Aims: The Kettil Bruun Society (KBS) is a leading international society, known in full as the Kettil Bruun Society for Social and Epidemiological Research on Alcohol. This paper aims to analyse research presented at KBS annual meetings and provide an overview of the developments in the research agenda in the field. In this way we try to gain insight into worldwide developments in the research agenda on social and epidemiological research on alcohol between 1983 and 2017.Methods: For the period 1983–1992, all annual meetings were the object of study. For the period after 1993, three sample periods of the annual meetings were used. The current paper is the fourth overview paper in a series. All papers have been reviewed with regard to their content, the research methods used, the country of origin, and the gender of the presenting authors.Results: The number of papers presented at the annual KBS meetings increased from 35 in 1983 to over 160 in the years after2009. In the period 1983–2017, the percentage of papers on policy and prevention doubled. Surveys have been the most popular research method in the period reviewed here.Conclusions: The KBS is the international society for this type of research, and developments within the KBS give an indication of the worldwide developments in the research agenda on social and epidemiological research on alcohol between 1983 and 2017.

BackgroundPrevious evaluation showed insufficient use of a national guideline for integrated local health policy by Regional Health Services (RHS) in the Netherlands. The guideline focuses on five health topics and includes five checklists to support integrated municipal health policies. This study explores the determinants of guideline use by regional Dutch health professionals.MethodsA web survey was send to 304 RHS health professionals. The questionnaire was based on a theory- and research-based framework of determinants of public health innovations. Main outcomes were guideline use and completeness of use, defined as the number of health topics and checklists used. Associations between determinants and (completeness of) guideline use were explored by multivariate regression models.ResultsThe survey was started by 120 professionals (39%). Finally, results from 73 respondents (24%) were eligible for analyses. All 28 Dutch RHS organizations were represented in the final dataset. About half of the respondents (48%) used the guideline. The average score for completeness of use (potential range 1–10) was 2.37 (sd = 1.78; range 1–7). Knowledge, perceived task responsibility and usability were significantly related to guideline use in univariate analyses. Only usability remained significant in the multivariate model on guideline use. Only self-efficacy accounted for significant proportions of variance in completeness of use.ConclusionsThe results imply that strategies to improve guideline use by RHSs should primarily target perceived usability. Self-efficacy appeared the primary target for improving completeness of guideline use. Methods for targeting these determinants in RHSs are discussed.Keywords: Local health policy, Regional health service, Guideline use, Web based survey, Implementation, determinants, Implementation strategy, The Netherlands

BACKGROUND: Children with overweight often do not receive appropriate integrated care. An innovative integrated network approach of preventive care for overweight children aged 4-12 years old has been developed and implemented in four neighbourhoods of 's-Hertogenbosch, The Netherlands. This new approach focusses on self-management of the family and is based on the principles of stepped and matched care. Youth health care (YHC) nurses support the families in their new role as central care providers. The aim of this study is to evaluate the implementation and effectiveness of this network approach.METHODS: The implementation of the new approach (reach, functioning of the central care provider, network functioning and patient satisfaction) is assessed by interviews and checklists with professionals and parents of 4-12 year old overweight or obese children. To evaluate effectiveness, we aim to compare 120 overweight or obese children in 's-Hertogenbosch with 60 overweight or obese children outside 's-Hertogenbosch during one year of YHC involvement. Quality of life, psychosocial problems of the child and parental empowerment are the main outcomes of the effectiveness study. Outcomes are measured with digital questionnaires at inclusion, at three months and one year after inclusion. BMI measurements and referrals are distracted from medical files.DISCUSSION: Integrated care for overweight and obese children is high on the agenda of many municipalities in The Netherlands. The new approach is expected to have beneficial effects for overweight children, their parents and professionals. With the results of this study, we can optimize the support for overweight and obese children and their parents. The first results are expected to be available in 2019.TRIAL REGISTRATION: This study is registered in the Dutch Trial Register on 10 November 2017 (NTR number NTR6813). https://www.trialregister.nl/trial/6596 Word count: 281 (max 350).

BackgroundThe preferences of diabetes type 2 patients and cardiovascular disease patients for a financial incentive added to a specified combined lifestyle intervention were investigated.MethodsA discrete choice experiment questionnaire was filled out by 290 diabetes type 2 patients (response rate 29.9%). Panel-mixed-logit models were used to estimate the preferences for a financial incentive. Potential uptake rates of different financial incentives and relative importance scores of the included attributes were estimated. Included attributes and levels were: form of the incentive (cash money and different types of vouchers), value of the incentive (ranging from 15 to 100 euros), moment the incentive is received (start, halfway, after finishing the intervention) and prerequisite for receiving the incentive (registration, attendance or results at group or individual level).ResultsPrerequisites for receiving the financial incentive were the most important attribute, according to the respondents. Potential uptake rates for different financial incentives ranged between 37.9% and 58.8%. The latter uptake rate was associated with a financial incentive consisting of cash money with a value of €100 that is handed out after completing the lifestyle program with the prerequisite that the participant attended at least 75% of the scheduled meetings.ConclusionsThe potential uptake of the different financial incentives varied between 37.9% and 58.8%. The value of the incentive does not significantly influence the potential uptake. However, the potential uptake and associated potential effect of the financial incentive is influenced by the type of financial incentive. The preferred type of incentive is €100 in cash money, awarded after completing the lifestyle program if the participant attended at least 75% of the scheduled meetings.

To develop a targeted implementation strategy for a municipal health policy guideline, implementation targets of two guideline users [Regional Health Services (RHSs)] and guideline developers of leading national health institutes were made explicit. Therefore, characteristics of successful implementation of the guideline were identified. Differences and similarities in perceptions of these characteristics between RHSs and developers were explored. Separate concept mapping procedures were executed in two RHSs, one with representatives from partner local health organizations and municipalities, the second with RHS members only. A third map was conducted with the developers of the guideline. All mapping procedures followed the same design of generating statements up to interpretation of results with participants. Concept mapping, as a practical implementation tool, will be discussed in the context of international research literature on guideline implementation in public health. Guideline developers consider implementation successful when substantive components (health issues) of the guidelines, content are visible in local policy practice. RHSs, local organizations and municipalities view the implementation process itself within and between organizations as more relevant, and state that usability of the guideline for municipal policy and commitment by officials and municipal managers are critical targets for successful implementation. Between the RHSs, differences in implementation targets were smaller than between RHSs and guideline developers. For successful implementation, RHSs tend to focus on process targets while developers focus more on the thematic contents of the guideline. Implications of these different orientations for implementation strategies are dealt with in the discussion.Keywords:policy and implementation, municipality, integrated health promotion, network analysis, evidence-based guidelines

Alcohol policy research all over the world is often funded by national or local governments. Researchers involved may be confronted with several ethical questions. These questions can have quite a different character. Ethical questions may have a severe character that can be quite “clear” for the researchers involved. Miller et al. [1] for instance recently studied interference of funders, like governments or industrial and charitable organizations, in addiction research. Results show that activities occur such as censorship of research outputs, interference with the wording in reports and articles and interventions in when and how findings are released. Governments funding policy research may interfere in a way as described by Miller et al. [1]. but also less obvious ethical issues may occur: What if the research question is formulated in a “questionable” or “suggestive” way? What if policy makers deliberately ignore results of scientific research?The purpose of this contribution is to elaborate on these less obvious ethical issues, not primarily to give clear-cut answers but to raise consciousness and stimulate reflection and debate among researchers and policy makers.

An adequate approach to reducing school absenteeism should focus on medical absenteeism as this is the most prevalent form of school absenteeism. The objective of this study is to explore the health condition of pre-vocational secondary students with extensive medical absenteeism from a biopsychosocial perspective. Data were obtained from medical assessments and Strengths and Difficulties Questionnaires (SDQs) of students with medical absence above threshold criteria (i.e. reported sick four times in 12 school weeks or more than six consecutive school days) who were referred to a youth health care physician. The results showed that the students had a mean absence rate of 14% in 12 school weeks. Of all students, 43.5% had a diagnosed disease and 81.5% had problems such as physical complaints not yet diagnosed, psychosocial problems, lifestyle problems and sleeping difficulties. Four groups could be distinguished: 13.4% with a diagnosed disease and no problem, 30.1% with a diagnosed disease and a problem, 51.5% with a problem and no diagnosed disease and 5.1% without a diagnosed disease or problem. Significantly higher scores of the Total difficulties-scale on the SDQ were found (mean 10.5; SD 5.8) in the study group, compared to a reference group (mean 9.1; SD 4.9). In conclusion, this study shows that when using the aforementioned criteria for extensive medical absenteeism to intervene with the absence, students with a mean absence rate of 14% in 12 school weeks are identified. If there was a diagnosed disease, it was accompanied by problems about twice as often. More than half of the students’ absence was caused by problems rather than a disease. The great diversity of these problems calls for a personalized approach. A broad perspective, including medical expertise, is needed to distinguish between emerging mental and physical diseases, psychosocial and lifestyle problems.Keywords: Adolescent Health, Preventive Pediatric Primary Care, School Absenteeism, Public Health, Psychosocial Problems

Background: Facilitating and enhancing interaction between stakeholders involved in the policymaking process to stimulate collaboration and use of evidence, is important to foster the development of effective Health Enhancing Physical Activity (HEPA) policies. Performing an analysis of real-world policymaking processes will help reveal the complexity of a network of stakeholders. Therefore, the main objectives were to unravel the stakeholder network in the policy process by conducting three systems analyses, and to increase insight into the similarities and differences in the policy processes of these European country cases.Methods: A systems analysis of the local HEPA policymaking process was performed in three European countries involved in the 'REsearch into POlicy to enhance Physical Activity' (REPOPA) project, resulting in three schematic models showing the main stakeholders and their relationships. The models were used to compare the systems, focusing on implications with respect to collaboration and use of evidence in local HEPA policymaking. Policy documents and relevant webpages were examined and main stakeholders were interviewed.Results: The systems analysis in each country identified the main stakeholders involved and their position and relations in the policymaking process. The Netherlands and Denmark were the most similar and both differed most from Romania, especially at the level of accountability of the local public authorities for local HEPA policymaking. The categories of driving forces underlying the relations between stakeholders were formal relations, informal interaction and knowledge exchange.Conclusions: A systems analysis providing detailed descriptions of positions and relations in the stakeholder network in local level HEPA policymaking is rather unique in this area. The analyses are useful when a need arises for increased interaction, collaboration and use of knowledge between stakeholders in the local HEPA network, as they provide an overview of the stakeholders involved and their mutual relations. This information can be an important starting point to enhance the uptake of evidence and build more effective public health policies.

Background. The role of health broker is a relatively new one in public health. Health brokers aim to create support for efforts to optimise health promotion in complex or even “wicked” public health contexts by facilitating intersectoral collaborations and by exchanging knowledge with different stakeholders. The current study aimed to explore the role of health brokers, by examining the motivational, contextual, and behaviour-related factors they have to deal with. Methods. Fifteen professionals from various backgrounds and from various policy and practice organisations were recruited for a semistructured interview. To structure the interviews, we developed the “Health Broker Wheel” (HBW), a framework we then specified with more details derived from the interviews. Results. We identified seven primary types of behaviour that health brokers need to engage in: recognizing opportunities, agenda setting, implementing, network formation, intersectoral collaboration, adaptive managing, and leadership. Determinants of health brokers’ behaviours were identified and categorised as capability, opportunities, motivation, and local or national contextual factors. Conclusion. The health brokers’ role can be seen as an operational approach and is visualised in the HBW. This framework can assist further research to monitor and evaluate this role, and health promotion practitioners can use it as a tool to implement the health brokers’ role and to facilitate intersectoral collaboration.

This study investigated whether Dutch and Norwegian parents differ in their perceptions on parental measures and how parents view governmental responsibility to prevent adolescents from substance use. Data were derived from a cross-sectional internet survey conducted in the Netherlands and Norway. A subsample of Dutch (n = 2017) and Norwegian parents (n = 844) was selected. Parents were asked about their perceptions on different parental measures in relation to substance use, e.g. setting the right example, setting rules, parental behavior in the presence of adolescents, and how they view governmental responsibility compared with parental responsibility in relation to substance use among adolescents. The parental responsibility for taking parental measures against adolescents’ substance use was emphasized by both the Dutch and Norwegian parents. Compared to Dutch parents, Norwegian parents were slightly more positive about taking parental measures. Dutch frequent and heavy drinkers and Norwegian men were the most negative about parental perceptions on alcohol measures. Regarding perceptions on parental measures on drug use, Dutch and Norwegian lifetime cannabis users and current cannabis users supported parental measures to a lesser extent. Overall, the results suggest that both Dutch and Norwegian parents feel the responsibility to provide measures to prevent children from alcohol and drug use, irrespective of the alcohol and drug policy in their own country. Both the Dutch and Norwegian supported parental measures to prevent adolescents from substance use.

BackgroundStudents’ health and school absenteeism affect educational level, with adverse effects on their future health. This interdependence is reflected in medical absenteeism. In the Netherlands, a public health intervention has been developed to address medical absenteeism in pre-vocational secondary education. This study aims to investigate the effectiveness of this intervention on students’ medical absenteeism, compared to “medical absenteeism policy as usual”.MethodsA quasi-experimental design with an intervention group (493 students) and a control group (445 students) was applied. Multilevel analysis was used to study differences in the development of the level of a student’s medical absence over time (after 3 and 12 months).ResultsIn the intervention group, the level of absenteeism decreased from 8.5 days reported sick in 12 school weeks to 5.7 days after 3 months, and to 4.9 days after 12 months. The number of absence periods fell from 3.9 in 12 school weeks to 2.5 after 3 months, and to 2.2 after 12 months. In the control group, the absence days initially decreased from 9.9 days reported sick in 12 school weeks to 8.4 days after 3 months, after which an increase to 8.9 days was measured. The number of absence periods initially decreased from 4.5 in 12 school weeks to 3.5, after which an increase to 3.7 was measured. The number of absence days per period remained about the same in both groups.ConclusionsThe study provides first indications for the intervention to be effective for Dutch pre-vocational secondary students with increased medical absence rates. The intervention, which consists of personalised management of medical absenteeism by systematic identification of students with extensive medical absenteeism and consistent referral to youth health care physicians, appears to reduce the absence rates more effectively than “medical absenteeism policy as usual”. The effectiveness of the intervention is shown primarily by a decrease in the number of periods reported sick.

BackgroundReducing school absenteeism benefits the health and educational opportunities of young people. The Dutch intervention Medical Advice for Sick-reported Students (abbreviated as MASS) was developed to address school absenteeism due to sickness reporting, also called medical absenteeism. This study is part of a research project on the effectiveness of MASS and explores factors that influence the implementation and dissemination of the intervention, from schools' perspectives. The research questions include reasons schools have to implement MASS, their experiences in the implementation of MASS and their views on what is needed to ensure sustainable implementation.MethodsA qualitative research method was used. Semi-structured interviews were held with nine principals and eight special education needs coordinators, working in nine secondary schools that apply MASS. Inductive content analysis was carried out.FindingsThe main reasons for schools to address medical absenteeism were their concerns about students' well-being and future prospects and their wish to share these concerns with students' parents. Participants also mentioned the wish to raise the threshold for reporting sick. According to the participants, MASS makes it easier for teachers to enter into conversation with students and their parents about medical absence. MASS prevents damage to the relationship with parents and medical problems being missed. In implementing MASS the main obstacles are teachers' dialogue about medical absence with students and their parents, teachers' follow-up of the feedback of the youth health care physicians (YHCPs), and correct registration. The participants were convinced that MASS also improves collaboration with parents regarding the optimization of care for students.ConclusionsMASS allows schools to identify students at risk of dropout at an early stage and to optimise guidance of these students. The intervention matches schools' need to address medical absenteeism by providing a clear framework, an approach from concern rather than control, and socio-medical expertise through the collaboration with YHCPs. MASS can support schools to maximize the number of students graduating and to improve parental involvement in school. These outcomes may help to put the subject of addressing medical absenteeism on the agenda of all schools, and contribute to prioritization, support adoption and secure sustainable implementation and dissemination of MASS.

Objectives: The aim of this study is (1) to gain insight into current multi-sector policy initiatives that contribute to activity-friendly environments for children in four Dutch municipalities, (2) to investigate the role of multi-sector collaboration in multi-sector policy action and (3) to gain insight into critical facilitators and possible challenges for multi-sector policy action aimed at creating activity-friendly environments for children.Methods: A policy analysis was conducted in four Dutch municipalities by means of semi-structured interviews with 25 policy officers from different policy sectors. Interviews were transcribed ad verbatim and analyzed using qualitative data coding software.Results: Each policy sector carried out policy measures related to (the environmental determinants of) physical activity among children, but most respondents were not aware of the potential effectiveness of their policy measures regarding this topic. In two municipalities structural collaboration between policy sectors was present, but the number of sectors involved was limited. Awareness and support among all policy sectors, a stimulating political environment, and knowing each other and being informed about other sectors' policies were mentioned as facilitators for multi-sector policy action. The main challenge for multi-sector policy action was lack of time and resources.Conclusions: This study shows that multi-sector policy action aimed at activity-friendly environments could be stimulated by raising awareness and defining problem ownership, enhancing multi-sector collaboration and paying attention to facilitators and challenges.

Scand J Caring Sci; 2010; 24; 164–174 Quality of care and service trajectories for people with intellectual disabilities: defining the aspects of quality from the client’s perspective Background: Care and service trajectories for people with intellectual disabilities (i.e. people with mental retardations) are routes within the healthcare delivery system that consist of all the steps that people with intellectual disabilities and their families have to take in order to realise the needed care and services. Aim: This article aims to identify the quality aspects of trajectories that are considered important by people with intellectual disabilities and their parents/relatives. In addition, it examines how these aspects are related to quality determinants mentioned in the literature on integrated care and to authoritative models for quality assessment of care and service delivery. Methods: Quality aspects were collected during eight focus group discussions with people with intellectual disabilities or their parents/relatives. In addition, quality determinants of integrated care and authoritative models for quality assessment were selected by means of a thorough review of the literature. Finally, the quality aspects identified using focus groups were compared to the determinants and models found in the literature. Results: The quality aspects presented by people with intellectual disabilities referred particularly to the immediate situation in receiving care and services, such as ‘keeping appointments’ and ‘time and attention’, whereas parents/relatives also referred to broader ‘organisational issues’, such as ‘access to support’ and ‘problems with placement’. The quality aspects, however, are minimally related to the quality determinants of integrated care, probably because clients and their parents/relatives find it difficult to have an overview of the coherence between the various actions that have to be performed, when going through the trajectories. In contrast, the quality aspects seem to fit into the domains of the authoritative models for quality assessment, probably because of the minimal focus of the models on long-term aspects in care and service delivery.

Background: Although public health and primary care share the goal of promoting the health and wellbeing of the public, the two health sectors find it difficult to develop mutually integrated plans and to collaborate with each other. The aim of this multiple case study was to compare seven neighbourhoods in which a stepwise approach based on two central tools (district health profile and policy dialogue) was used to develop integrated district plans and promote collaboration.Methods: The stepwise approach involved the following steps: 1 Getting to know the neighbourhood, 2 Assembling the workgroup, 3 Analysing the neighbourhood, 4 Developing a district health profile, 5 Preparing policy dialogue, 6 Holding local dialogues, 7 Embedding integrated district plans and collaboration. To supervise this process, a core team was assembled for each neighbourhood, consisting of people drawn from both public health and primary care. Both the use of the two tools and the collaboration were studied by means of documentary analysis, interviews, questionnaires and observations.Results: The seven neighbourhoods differed in the way the two tools of the stepwise approach were used: general versus focused profiles, the actors involved, the aims of the dialogue or the intensity of the steps. There were also similarities: profile indicators (e.g., population prognosis, vulnerability) and dialogue themes (e.g., obesity, social cohesion). The local actors experienced that the combination of both tools facilitates the process of bringing public health and primary care closer together, and that it is essential to invest sufficiently in the integration of profile data and in involving appropriate actors in the dialogue (e.g., GPs, residents). Collaboration was perceived as positive (e.g., feels involved, focus on consensus), but a starting process. Local actors also believe that the stepwise approach supported the process.Conclusion: A stepwise approach involving the combined use of district health profiles and policy dialogues promotes the integrated planning of health activities and facilitates collaboration between public health and primary care at the local level. Local differences may arise in the intensity and form of the various steps, but because they are practical and clearly defined, they remain transferrable to other neighbourhoods.

BackgroundContemporary 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.MethodsOur 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.ResultsThe 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.ConclusionsA 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.KeywordsCollaborative networks in public health Knowledge production Mode-2 Push and pull Scientific and socially robust evidence

Background and aims: Interferential care differs from the current community-based care programs in that it targets a larger, heterogeneous group and combines brokerage and full service elements in a multi-organizational care team. The team provides all the services itself, but with the aim to prepare clients within a few months for referral to regular (ambulant) healthcare services. The aim of this study was to assess the effectiveness of interferential care. Methods: In a multisite, pretest–posttest design, 523 patients of three interferential care teams were followed. Quality of life, problem severity, problems with referral and engagement were assessed at baseline, at referral and again after 6 months. Analyses were performed using linear mixed modeling. Results: Interferential care showed moderate to strong effects on quality of life and problem severity. These effects persisted (quality of life) or further improved (problem severity) until follow-up 6 months after referral to regular services. There were also small effects on both engagement and problems with referral. Conclusion: Interferential care offers significant improvements in quality of life and problem severity in persons who have severe problems on several life areas and who are currently not reached by healthcare services. It is a promising community-based care program for healthcare systems in which regular care already contains many elements of home-based practice.

Background: Research ethics review practices vary considerably across countries and this variability poses a challenge for international research programmes. Although published guidelines exist, which describe underlying principles that should be considered and pragmatic approaches that could be followed in seeking ethics approval, most have roots in biomedical and clinical research. The result is that there is generally less clarity around institutional and/or country-level structures for ethics review of health policy and social sciences research. This is an important gap that needs to be addressed in order to ensure ethical practices in multi-country research programmes.Context and purpose: This paper explores research ethics requirements for a multicountry health policy research programme and provides recommendations based on experiences in seeking ethics approval. The context for this paper is a five-year, cross-country, European Commission-funded international programme: Research into Policy to enhance Physical Activity (REPOPA).Results: Ethics requirements and review processes for health policy and social sciences research varied considerably across the seven REPOPA countries. Specifically, requirements and infrastructure for ethics approval have been influenced by how the purpose and domain of health research are defined in legislation, what types of research have been most prominently funded, and international requirements for ethics approval by external funders and journal editors.Significance: Multi-country research programmes provide an opportunity to enhance and build transparent ethics review practices and to strengthen ethics review structures at all levels. Such programmes also enable reciprocal learning about relevant practices and processes for the ethical conduct of research.Keywords: Ethics committee, research, health policy, physical activity, multi-country research, research programme

Background: In the Netherlands, municipal health assessments are carried out by 28 Regional Health Services, serving 418 municipalities. In the absence of guidelines, regional public health reports were developed in two pilot regions on the basis of the model and experience of national health reporting. Though they were well received and positively evaluated, it was not clear which specific characteristics determined ‘good public health reporting’. Therefore, this study was set up to develop a theoretical framework for the quality of regional public health reporting in The Netherlands. Methods: Using concept mapping as a standardized tool for conceptualization, 35 relevant reporting experts formulated short statements in two different brainstorming sessions, describing specific quality criteria of regional public health reports. After the removal of duplicates, the list was supplemented with international criteria, and the statements were sent to each participant for rating and sorting. The results were processed statistically and represented graphically. The output was discussed and interpreted, leading to the final concept map. Results: The final concept map consisted of 97 criteria, grouped into 13 clusters, and plotted in two dimensions: a ‘product’ dimension, ranging from ‘production’ to ‘content’, and a ‘context’ dimension, ranging from ‘science’ to ‘policy’. The three most important clusters were: (i) ‘solution orientation’, (ii) ‘policy relevance’ and (iii) ‘policy impact’. Conclusion: This study provided a theoretical framework for the quality of regional public health reporting, indicating relevant domains and criteria. Further work should translate domains and criteria into operational indicators for evaluating regional public health reports.

Background Although multi-sector policy is a promising strategy to create environments that stimulate physical activity among children, little is known about the feasibility of such a multi-sector policy approach. The aims of this study were: to identify a set of tangible (multi-sector) policy measures at the local level that address environmental characteristics related to physical activity among children; and to assess the feasibility of these measures, as perceived by local policy makers. Methods In four Dutch municipalities, a Delphi study was conducted among local policy makers of different policy sectors (public health, sports, youth and education, spatial planning/public space, traffic and transportation, and safety). In the first Delphi round, respondents generated a list of possible policy measures addressing three environmental correlates of physical activity among children (social cohesion, accessibility of facilities, and traffic safety). In the second Delphi round, policy makers weighted different feasibility aspects (political feasibility, cultural/community acceptability, technical feasibility, cost feasibility, and legal feasibility) and assessed the feasibility of the policy measures derived from the first round. The third Delphi round was aimed at reaching consensus by feedback of group results. Finally, one overall feasibility score was calculated for each policy measure. Results Cultural/community acceptability, political feasibility, and cost feasibility were considered most important feasibility aspects. The Delphi studies yielded 16 feasible policy measures aimed at physical and social environmental correlates of physical activity among children. Less drastic policy measures were considered more feasible, whereas environmental policy measures were considered less feasible. Conclusions This study showed that the Delphi technique can be a useful tool in reaching consensus about feasible multi-sector policy measures. The study yielded several feasible policy measures aimed at physical and social environmental correlates of physical activity among children and can assist local policy makers in designing multi-sector policies aimed at an activity-friendly environment for children.

Background. Physical inactivity in children is a major health problem in The Netherlands as well as in many other Western countries. In addition to health promotion among parents and children, creating "active" neighbourhoods can contribute to the solution of this health problem. However, changing environmental characteristics is often the responsibility of policy sectors outside the Public Health domain. Therefore this project identifies and evaluates the possibilities of multi-sector policy measures to stimulate physical activity in children. Methods and design. The project consists of quantitative as well as qualitative research methods and is conducted in four medium sized Dutch cities. To identify perceived environmental determinants of physical activity in children, a large scale health survey was conducted at 42 primary schools. Written questionnaires including topics on the children's physical activity behaviour (i.e. sports participation, outdoor play, active commuting, television watching and computer usage) and physical and social environmental characteristics were completed by 6,601 parents of children aged 3-13 years old and 3449 children aged 9-13 years old. In addition, 33 neighbourhood audits (systematic observations) were conducted to assess objective neighbourhood characteristics. Furthermore, a policy analysis was conducted in the four participating municipalities to provide an overview of the current local policy measures directed at stimulation of physical activity in children. Policy plans of six different policy sectors (Public Health, Sports, Education & Youth, Spatial Planning, Traffic & Transport, and Safety) were screened for their content on physical activity in children. In addition, semi-structured interviews were conducted with policy makers of each of these sectors to identify critical success factors in the development and realization of multi-sector policy plans aimed at stimulating physical activity in children. The results of all these research activities will be discussed with local policy makers during interactive workshop sessions in order to identify clear cut multi-sector policy measures that stimulate physical activity in children. Discussion. This paper describes the study design of a project that focuses on multi-sector policy measures that stimulate physical activity in children. Next to extensive research into the environmental determinants of physical activity in children, much emphasis is placed on the translation of the research outcomes into concrete and feasible policy plans. © 2009 Aarts et al; licensee BioMed Central Ltd.

Engagement is a determinant of how well a person will respond to professional input. This study investigates whether, in practice, routinely measured data predict initial client engagement with community mental health services. Engagement, problem severity, client characteristics, and duration before the first contact were measured at team entrance with clients (n = 529) of three community mental health teams. Regression analysis was used to predict engagement. Gender, age, referrer, having children, having a partner, and ethnicity showed a minor relationship with engagement. Higher problem severity measured by the team members with the Health of the Nation Outcome Scales, being referred for having psychiatric problems and/or causing severe and long-lasting trouble (as ‘assessed’ by the often non-professional referrer), and a longer duration between enrollment and the first conversation with a client, were indicative for a lower engagement. The final model explained 19.2 % of the variance in engagement. It can be concluded that initial client engagement with community mental health services can be predicted, in part, by routinely measured data. The findings can be used by community mental healthcare teams to create an awareness system.Keywords: Assertive outreach, Interferential care, Community mental health, Engagement

Background So far, audience segmentation of adolescents with respect to alcohol has been carried out mainly on the basis of socio-demographic characteristics. In this study we examined whether it is possible to segment adolescents according to their values and attitudes towards alcohol to use as guidance for prevention programmes. Methods A random sample of 7,000 adolescents aged 12 to 18 was drawn from the Municipal Basic Administration (MBA) of 29 Local Authorities in the province North-Brabant in the Netherlands. By means of an online questionnaire data were gathered on values and attitudes towards alcohol, alcohol consumption and socio-demographic characteristics. Results We were able to distinguish a total of five segments on the basis of five attitude factors. Moreover, the five segments also differed in drinking behavior independently of socio-demographic variables. Conclusions Our investigation was a first step in the search for possibilities of segmenting by factors other than socio-demographic characteristics. Further research is necessary in order to understand these results for alcohol prevention policy in concrete terms.