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Emergent health challenges related to work Work is not only central to population health but is also a significant driver of social inequality in health (1). In a recent Lancet series on work and health, the authors outlined six emergent challenges concerning work: the impact of technology, the intersection of work with sociodemographic health determinants, migrant work, precarious employment, long working hours, and climate change (1). The authors of the Lancet series also presented recommendations for future research, advocating for the utilization of mixed-methods, innovative analytical approaches (eg, causal modeling), realist evaluation, and interdisciplinary collaboration. Although each of these approaches are highly relevant, their integrated application was only vaguely outlined. We believe that each of these work and health challenges show features of complex adaptive systems. They are multifaceted, constantly evolving, and emerge from our complex and disordered real world, which is often characterized by interactions, non-linearity, interference, feedback loops, and adaptation. Consequently, future research on work and health may benefit from adopting a complex systems perspective to obtain a comprehensive understanding of the drivers of these challenges (2–4). We have recently developed an interdisciplinary framework for knowledge production aimed at understanding complex health issues within the domain of public health, rooted in complex systems theory (5). This framework can serve to organize our thinking, formulate research questions, and integrate methodologies related to each of these six work and health challenges. Briefly outlined, the Health Complexity framework relates to three core dimensions in which complex health issues may be conceptualized: patterns, mechanisms, and dynamics (5). Patterns: Looking for specific patterns of disease or risk factors allows us to empirically identify health issues that emerge from the mechanisms and dynamics of the underlying systems, eventually allowing us to discover vulnerable subgroups, and thereby set boundaries for targeted interventions. Mechanisms: Understanding the core mechanisms that give rise to these emergent health patterns and how they are connected across scales through interactions and interference can help us identify potential leverage points for intervention. Dynamics: Building evidence on the dynamics that make patterns and mechanisms change over time will allow us to identify vicious circles associated with particularly high morbidity. Between them, these dimensions cover seven key features of complex systems (emergence, interactions, non-linearity, interference, feedback loops, adaptation, and evolution), which we have highlighted as central to public health. The Health Complexity framework builds upon the ideas of methodological pluralism (6–8) and is intended to be an overarching framework for interdisciplinary and collaborative research on complex health issues, also in the field of work and health. As an illustration, we will outline the elements needed to examine one of these challenges – precarious employment – through a complex systems lens, particularly highlighting how this approach influences the way we phrase research questions on health problems that do justice to the complexity of the real world. Precarious employment viewed through a complex systems lens With globalization and technological advancements, there has been a shift towards a gig economy. This has led to an increase in temporary, part-time, and freelance work, which often lacks stability and benefits. Precarious employment specifically refers to such work characterized by employment insecurity, income inadequacy, and lack of rights and protection (9). The lack of stability and benefits associated with precarious employment combined with poor working conditions have been shown to have negative effects on physical and mental health (10–13). Workers may experience higher levels of stress, depression, and other health problems due to financial insecurity and lack of access to healthcare, which collectively may be an important driver of health inequality and of health decline. In a life course perspective, there may also be important feedback mechanisms exacerbating such inequality, with poor health not only being a consequence of precarious employment, but workers with poor health may be more likely to be excluded from stable work (14). Overall, the increasing prevalence of precarious employment represents a substantial challenge for public health, which can be seen as a sort of byproduct of larger societal trends. We believe that employing a complex systems lens can help us generate relevant scientific knowledge about the fundahttps://www.sjweh.fi/editoi.sjweh.fi/pics/update_u_3.gifmental drivers of this problem. This essentially entails three interlinked steps organized around the three core dimensions of the Health Complexity Framework (figure 1). Patterns: As a first step, we need to zoom out and understand the health effects associated with emergent patterns of precarious employment in their context across time and space, asking questions such as: •How does precarious employment change over time, and how does this changing pattern affect population health? •Are there certain population groups, defined, eg, by socioeconomic status, age, occupation, migrant status, or geographical regions who experience more adverse health effects by precarious employment than others? Systematically evaluating health patterns associated with precariousness can help us define boundaries for targeted prevention. Employing classical epidemiological surveillance methods alongside data science techniques for uncovering patterns within multidimensional large-scale datasets serves as key examples of such pattern identification. Mechanisms: As a second step, we need to understand what mechanisms underlying the health effects of precariousness and how elements of these mechanisms are connected across scales, from cells to society, asking questions such as: •How do mechanisms interact across biological, behavioral, social, and societal scales to create the rising public health problems associated with precarious employment? •Does precarious employment and its associated health problems cluster and spread across social networks and/or across occupational and economic sectors? Systematically evaluating the interconnectedness between mechanisms and individuals across various scales can help us identify leverage points for intervention. Whereas biomedical studies can contribute to uncovering the biological mechanisms linked to precarious employment, such as the embodiment of stress (15), the social sciences may offer profound insights into macro-scale mechanisms involving political, economic, and social structures. Dynamics: As a third step, we need to explore how the health effects of precarious employment change over time due to dynamic processes like adaptation and feedback, asking questions such as: •How do national political and social contexts adapt to historical changes in the labor market including the increase in precarious employment, and what is the impact of this adaptation when it comes to how and to what extent precarious employment can affect the health of individuals and populations? •Is there a reinforcing feedback mechanism between social disadvantage, precarious employment, and health? This mechanism could create a vicious circle—for example, social disadvantage increasing the likelihood of precarious employment, which then leads to health consequences that may further reinforce social disadvantage. Systematically assessing such dynamism can help us intervene on vicious circles that generate excessive burdens of disease in specific population groups. Systems methodology, including formal conceptual model building and computational simulations, are essential in creating such evidence. Integrating interdisciplinary knowledge across these dimensions will provide a systematic and comprehensive understanding of the patterns of precarious employment and health, the underlying connected mechanisms generating these patterns, and the dynamics that makes them change over time. Some dimensions, like the patterns of precarious employment and health, may already be well-researched, while other dimensions such as dynamics require further investigation. We argue that it is essential to systematically explore all these dimensions to comprehensively understand a complex issue. Leaving out one of these core dimensions may leave blind spots that will render our understanding of precarious employment and health incomplete and thereby impact the efficiency of future interventions. In this editorial, we have focused on how to phrase research questions when applying a complex systems lens on precarious employment and health. This clearly needs to be matched by the integration of an interdisciplinary set of methods and data. An overview of such methods and data can be found in Rod et al (5). Are we at the brink of a ‘complexity turn’ in public health? We believe that we are witnessing a shift in public health away from the traditional model of evidence, which primarily focused on empirically testing predefined hypotheses of single exposures and outcomes. Instead, there is a growing recognition of public health issues as complex, involving the complex interactions of biological, social, psychological, economic, and other processes across various levels and time scales (2–5, 16–20). These dynamics may show nonlinearity and adaptability. This paradigm shift is particularly important to our understanding of the relationship between work and health, including the emergent challenges outlined in the Lancet series, where contextual factors and interactions across micro-, meso- and macro-levels emerge as main drivers of dynamic change in employment condition. Formalizing this turn towards complexity in public health requires not only a realignment of our research questions as outlined for precarious employment above, but also necessitates the integration of traditional epidemiological methods with systems methodologies, such as computational simulation modeling (3, 18). Furthermore, it calls for sustained support for interdisciplinary collaboration and substantial investment in a diverse array of data types. These include multi-scale data, spatial data, time-series data, life-course data, network data, and multi-generational data, among others. This shift in our understanding of public health also impacts our approach to evidence synthesis. Traditionally, evidence synthesis has been relatively straightforward, typically summarized in systematic reviews or meta-analyses focusing on single isolated risk factors. However, with a complex systems perspective, we must transition towards a dynamic evidence synthesis framework. This approach involves an ongoing process of data-driven discoveries, hypothesis testing, and theory building. By adopting this dynamic approach, we can effectively synthesize evidence on complex research questions while continuously assessing which dimensions remain unresolved and understudied. These unresolved or understudied aspects should serve as guiding principles for future studies and research programs, also on work and health. Funding NHR acknowledge funding from the European Union (ERC, LAYERS, project no. 101124807). The views and opinions expressed are, however, those of the author(s) only and do not necessarily reflect those of the European Union or the European Research Council. Neither the European Union nor the granting authority can be held responsible for them. References 1. Frank J, Mustard C, Smith P, et al. Work as a social determinant of health in high-income countries: past, present, and future. The Lancet 2023; 402: 1357-67. https://doi.org/10.1016/S0140-6736(23)00871-1 2. Rutter H, Savona N, Glonti K, et al. The need for a complex systems model of evidence for public health. Lancet 2017; 390: 2602-4. https://doi.org/10.1016/S0140-6736(17)31267-9 3. Stronks K, Crielaard L, Rod NH. Systems Approaches to Health Research and Prevention. In: Ahrens W, Pigeot I, eds. Handbook of Epidemiology. New York, NY: Springer, New York, NY, 2024: 1-29. https://doi.org/10.1007/978-1-4614-6625-3_70-1 4. Roux AVD. Complex Systems Thinking and Current Impasses in Health Disparities Research. Am J Public Health 2011; 101: 1627. https://doi.org/10.2105/AJPH.2011.300149 5. Rod NH, Broadbent A, Rod MH, Russo F, Arah OA, Stronks K. Complexity in Epidemiology and Public Health. Addressing Complex Health Problems Through a Mix of Epidemiologic Methods and Data. Epidemiology 2023; 34: 505-14. https://doi.org/10.1097/EDE.0000000000001612 6. Ogilvie D, Bauman A, Foley L, Guell C, Humphreys D, Panter J. Making sense of the evidence in population health intervention research: Building a dry stone wall. BMJ Glob Health 2020; 5. https://doi.org/10.1136/bmjgh-2020-004017 7. Vandenbroucke JP, Broadbent A, Pearce N. Causality and causal inference in epidemiology: the need for a pluralistic approach. Int J Epidemiol 2016; 45: 1776-86. https://doi.org/10.1093/ije/dyv341 8. Illari PM, Russo F. Causality: philosophical theory meets scientific practice. Oxford: Oxford University Press, 2014. 9. Kreshpaj B, Orellana C, Burström B, et al. What is precarious employment? A systematic review of definitions and operationalizations from quantitative and qualitative studies. Scand J Work Environ Health 2020; 46: 235-47. https://doi.org/10.5271/sjweh.3875 10. Matilla-Santander N, Muntaner C, Kreshpaj B, et al. Trajectories of precarious employment and the risk of myocardial infarction and stroke among middle-aged workers in Sweden: A register-based cohort study. The Lancet Regional Health - Europe 2022; 15. https://doi.org/10.1016/j.lanepe.2022.100314 11. Matilla-Santander N, Matthews AA, Gunn V, et al. Causal effect of shifting from precarious to standard employment on all-cause mortality in Sweden: an emulation of a target trial. J Epidemiol Community Health 2023; 77: 736-43. https://doi.org/10.1136/jech-2023-220734 12. Jonsson J, Muntaner C, Bodin T, et al. Low-quality employment trajectories and risk of common mental disorders, substance use disorders and suicide attempt: a longitudinal study of the Swedish workforce. Scand J Work Environ Health 2021; 47: 509. https://doi.org/10.5271/sjweh.3978 13. Rönnblad T, Grönholm E, Jonsson J, et al. Precarious employment and mental health: a systematic review and meta-analysis of longitudinal studies. Scand J Work Environ Health 2019; 45: 429-43. https://doi.org/10.5271/sjweh.3797 14. Junna L, Moustgaard H, Martikainen P. Health-related selection into employment among the unemployed. BMC Public Health 2022; 22: 1-12. https://doi.org/10.1186/s12889-022-13023-0 15. McEwen BS. Neurobiological and Systemic Effects of Chronic Stress. Chronic Stress (Thousand Oaks) 2017; 1. https://doi.org/10.1177/2470547017692328 16. Page SE, Zelner J. Population Health as a Complex Adaptive System of Systems. In: Apostolopoulos Y, Lich KH, Lemke MK, eds. Complex Systems and Population Health, 1st edn. New York: Oxford University Press, 2020: 33-44. https://doi.org/10.1093/oso/9780190880743.003.0003 17. Rod MH, Rod NH, Russo F, Klinker CD, Reis R, Stronks K. Promoting the health of vulnerable populations: Three steps towards a systems-based re-orientation of public health intervention research. Health Place 2023; 80. https://doi.org/10.1016/j.healthplace.2023.102984 18. El-Sayed AM, Galea S. Systems Science and Population Health. New York: Oxford University Press, 2017. https://doi.org/10.1093/acprof:oso/9780190492397.003.0017 19. Luna Pinzon A, Stronks K, Dijkstra C, et al. The ENCOMPASS framework: a practical guide for the evaluation of public health programmes in complex adaptive systems. Int J Behav Nutr Phys Act 2022; 19. https://doi.org/10.1186/s12966-022-01267-3 20. Stronks K, Nicolaou M. Embracing complexity in social epidemiology. Lancet Public Health 2018; 3: e352-3. https://doi.org/10.1016/S2468-2667(18)30137-3

Abstract Background In Europe, physical activity levels tend to be lower in ethnic minority groups than the general population. Interventions and policies based on research examining isolated determinants of physical activity have had limited success in increasing physical activity levels. This study used systems dynamics theory and the capability approach theoretical framework to develop a conceptual model of how individual characteristics, institutional and physical environments and the migration context may interact to promote or hinder physical activity in ethnic minority groups living in Europe. Methods A systematic update of Langøien et al.’s 2017 review of the determinants of physical activity in ethnic minority groups living in Europe was conducted. Our target population included individuals of all ages who reported a familial migration background from any low- and middle-income countries or belonging to minority indigenous population in Europe. Outcomes pertaining to non-work related physical activity of light, moderate or vigorous intensity performed in any setting were included. Included studies provided an evidence base from which to derive the causal loop diagrams comprising our conceptual model. Sub-system causal loop diagrams were interpreted in co-author review sessions to explicate non-linear system mechanisms, such as reinforcing and balancing feedback loops. Results Forty-one studies were identified, of which the majority was qualitative. The conceptual model consisted of 4 causal loop diagrams relating to psychosocial constructs; sociocultural constructs; health and health communication and social and material resources, in interaction with environmental/migration context. Four hypothetical mechanisms were identified, e.g. hypothesizing that participation in organised activities leads to increased self-efficacy, thereby enabling further participation. Conclusions This study contributes an evidence-based conceptual systems model which elucidates how low levels of physical activity in ethnic minority groups in Europe could be supported by reinforcing and balancing mechanisms involving factors relating to physical and institutional environments, migration context and individuals. A pluralistic approach to literature review, integrating complexity methods such as CLDs into more conventional systematic literature review, supports novel insights into how factors could interact to support persistently low levels of activity, moving beyond the identification of potential relationships between isolated factors to indicating the ways in which these relationships are sustained and could be modified by intervention or policy.

This systematic review and meta-analysis aimed to quantify differences in type 2 diabetes (T2D) complications between ethnic minority populations and European host populations, in both cross-sectional and prospective studies. Following Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines, we searched multiple databases for studies (until July 1, 2024) with T2D complications as outcome. Studies were included if they compared ethnic minority populations to the host population and were conducted in Europe. T2D complications included mortality, macrovascular and microvascular complications and mental disorders. Risk of bias was assessed with the assessment tool for observational cohort and cross-sectional studies. Risk estimates were pooled using random effects models. From a total of 2901 references, 58 studies were included, comprising 805 to 1 230 410 individuals for the meta-analyzed complications. Compared with the host population, ethnic minority populations generally had a lower risk of all-cause mortality (RR 0.70 (95% CI 0.63; 0.77); I2=87%)) and macrovascular complications (RR 0.72 (95% CI 0.58; 0.88); I2=88%). South Asians, however, showed comparable risks for most macrovascular complications and a slighthly higher risk of major adverse cardiovascular events. Increased risks for microvascular complications, nephropathy and retinopathy were observed (eg, in prospective studies RR 1.50 (95% CI 1.14; 1.96); I2=86% for nephropathy). No ethnic differences were observed for mental disorders. Ethnic minority populations with T2D in Europe are generally at reduced risk of all-cause mortality and macrovascular complications, but at higher risk of nephropathy and retinopathy. Our findings may help to further identify high-risk populations and to develop guidelines and future interventions. PROSPERO registration number:PROSPERO 2022 CRD42022366854.

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

PurposeChildhood overweight is considered a complex problem influenced by a range of factors, including energy balance-related behaviours (EBRBs) and interacting drivers of these behaviours. There is growing support that applying a systems approach is required to tackle complex problems resulting in actions that attempt to change the system’s dynamics. Additionally, a participatory approach is advocated to include the lived experience of the population of interest both in the understanding of the system as well as the development, implementation and evaluation of relevant actions. We therefore combined Intervention Mapping, Participatory Action Research (PAR) and system dynamics in the development, implementation and evaluation of actions contributing to healthy EBRBs together with adolescents.MethodsFour PAR groups comprising of 6–8 adolescent co-researchers (10–14 years) and 1–2 adult facilitators met weekly during 3–4 years. The structured Intervention Mapping protocol guided the process of the systematic development, implementation and evaluation of actions. System dynamics tools were included for the creation of Causal Loop Diagrams and development of systemic actions.ResultsOur approach comprised six steps that were executed by the PAR groups: (1) build Causal Loop Diagrams for each EBRB through peer research and identify overarching mechanisms, (2) determine leverage points using the Intervention Level Framework, (3) develop action ideas, (4) develop detailed actions including an implementation plan, (5) implement and, (6) evaluate the actions. PAR ensured that the actions fitted the lived experience of the adolescents, whilst system dynamics promoted actions at different levels of the system. The Intervention Mapping protocol ensured that the actions were theory-based. The main challenge involved integrating system dynamics within our practise in cooperation with adolescent co-researchers.ConclusionWe experienced that combining Intervention Mapping, PAR and system dynamics worked well in developing, implementing and evaluating actions that target different levels of the system that drive adolescents’ EBRBs. This study serves as an example to other studies aimed at developing, implementing and evaluating actions using a participatory and systems approach.

Abstract Network analysis is gaining momentum as an accepted practice to identify which factors in causal loop diagrams (CLDs)—mental models that graphically represent causal relationships between a system’s factors—are most likely to shift system-level behaviour, known as leverage points. This application of network analysis, employed to quantitatively identify leverage points without having to use computational modelling approaches that translate CLDs into sets of mathematical equations, has however not been duly reflected upon. We evaluate whether using commonly applied network analysis metrics to identify leverage points is justified, focusing on betweenness- and closeness centrality. First, we assess whether the metrics identify the same leverage points based on CLDs that represent the same system but differ in inferred causal structure—finding that they provide unreliable results. Second, we consider conflicts between assumptions underlying the metrics and CLDs. We recognise six conflicts suggesting that the metrics are not equipped to take key information captured in CLDs into account. In conclusion, using betweenness- and closeness centrality to identify leverage points based on CLDs is at best premature and at worst incorrect—possibly causing erroneous identification of leverage points. This is problematic as, in current practice, the results can inform policy recommendations. Other quantitative or qualitative approaches that better correspond with the system dynamics perspective must be explored.

Abstract Background Although risk factors for differences in SARS-CoV-2 infections between migrant and non-migrant populations in high income countries have been identified, their relative contributions to these SARS-CoV-2 infections, which could aid in the preparation for future viral pandemics, remain unknown. We investigated the relative contributions of pre-pandemic factors and intra-pandemic activities to differential SARS-CoV-2 infections in the Netherlands by migration background (Dutch, African Surinamese, South-Asian Surinamese, Ghanaians, Turkish, and Moroccan origin). Methods We utilized pre-pandemic (2011–2015) and intra-pandemic (2020–2021) data from the HELIUS cohort, linked to SARS-CoV-2 PCR test results from Public Health Service of Amsterdam (GGD Amsterdam). Pre-pandemic factors included socio-demographic, medical, and lifestyle factors. Intra-pandemic activities included COVID-19 risk aggravating and mitigating activities such as physical distancing, use of face masks, and other similar activities. We calculated prevalence ratios (PRs) in the HELIUS population that was merged with GGD Amsterdam PCR test data using robust Poisson regression (SARS-CoV-2 PCR test result as outcome, migration background as predictor). We then obtained the distribution of migrant and non-migrant populations in Amsterdam as of January 2021 from Statistics Netherlands. The migrant populations included people who have migrated themselves as well as their offspring. We used PRs and the population distributions to calculate population attributable fractions (PAFs) using the standard formula. We used age and sex adjusted models to introduce pre-pandemic factors and intra-pandemic activities, noting the relative changes in PAFs. Results From 20,359 eligible HELIUS participants, 8,595 were linked to GGD Amsterdam PCR test data and included in the study. Pre-pandemic socio-demographic factors (especially education, occupation, and household size) resulted in the largest changes in PAFs when introduced in age and sex adjusted models (up to 45%), followed by pre-pandemic lifestyle factors (up to 23%, especially alcohol consumption). Intra-pandemic activities resulted in the least changes in PAFs when introduced in age and sex adjusted models (up to 16%). Conclusion Interventions that target pre-pandemic socio-economic status and other drivers of health inequalities between migrant and non-migrant populations are urgently needed at present to better prevent infection disparities in future viral pandemics.

Objectives: While status anxiety has received attention as a potential mechanism generating health inequalities, empirical evidence is still limited. Studies have been ecological and have largely focused on mental and not physical health outcomes.Methods: We conducted individual-level analyses to assess status anxiety (feelings of inferiority resulting from social comparisons) and resources (financial difficulties) as mediators of the relationship between socioeconomic status (SES) (education/occupation/employment status) and type 2 diabetes (T2D). We used cross-sectional data of 21,150 participants (aged 18–70 years) from the Amsterdam-based HELIUS study. We estimated associations using logistic regression models and estimated mediated proportions using natural effect modelling.Results: Odds of status anxiety were higher among participants with a low SES [e.g., OR = 2.66 (95% CI: 2.06–3.45) for elementary versus academic occupation]. Odds of T2D were 1.49 (95% CI: 1.12–1.97) times higher among participants experiencing status anxiety. Proportion of the SES–T2D relationship mediated was 3.2% (95% CI: 1.5%–7.0%) through status anxiety and 10.9% (95% CI: 6.6%–18.0%) through financial difficulties.Conclusion: Status anxiety and financial difficulties played small but consistent mediating roles. These individual-level analyses underline status anxiety’s importance and imply that status anxiety requires attention in efforts to reduce health inequalities.

BackgroundIndividuals of South Asian origin are at an increased risk of developing type 2 diabetes mellitus (T2DM) compared with other ethnic minority groups. Therefore, there is a need to develop interventions to address, and reduce, this heightened risk. ObjectiveWe undertook formative work to develop a culturally adapted diet and physical activity text message intervention to prevent T2DM for women of Pakistani origin living in Scotland. MethodsWe used a stepwise approach that was informed by the Six Steps in Quality Intervention Development framework, which consisted of gathering evidence through literature review and focus groups (step 1), developing a program theory for the intervention (step 2), and finally developing the content of the text messages and an accompanying delivery plan (step 3). ResultsIn step 1, we reviewed 12 articles and identified 3 key themes describing factors impacting on diet and physical activity in the context of T2DM prevention: knowledge on ways to prevent T2DM through diet and physical activity; cultural, social, and gender norms; and perceived level of control and sense of inevitability over developing T2DM. The key themes that emerged from the 3 focus groups with a total of 25 women were the need for interventions to provide “friendly encouragement,” “companionship,” and a “focus on the individual” and also for the text messages to “set achievable goals” and include “information on cooking healthy meals.” We combined the findings of the focus groups and literature review to create 13 guiding principles for culturally adapting the text messages. In step 2, we developed a program theory, which specified the main determinants of change that our text messages should aim to enhance: knowledge and skills, sense of control, goal setting and planning behavior, peer support, and norms and beliefs guiding behavior. In step 3, we used both the intervention program theory and guiding principles to develop a set of 73 text messages aimed at supporting a healthy diet and 65 text messages supporting increasing physical activity. ConclusionsWe present a theory-based approach to develop a culturally adapted diet and physical activity text message intervention to prevent T2DM for women of Pakistani origin living in Scotland. This study outlines an approach that may also be applicable to the development of interventions for other ethnic minority populations in diverse settings. There is now a need to build on this formative work and undertake a feasibility trial of a text message–based diet and physical activity intervention to prevent T2DM for women of Pakistani origin living in Scotland.

Digital transformation in health care has a lot of opportunities to improve access and quality of care. However, in reality not all individuals and communities are benefiting equally from these innovations. People in vulnerable conditions, already in need of more care and support, are often not participating in digital health programs. Fortunately, numerous initiatives worldwide are committed to make digital health accessible to all citizens, stimulating the long-cherished global pursuit of universal health coverage. Unfortunately initiatives are not always familiar with each other and miss connection to jointly make a significant positive impact. To reach universal health coverage via digital health it is necessary to facilitate mutual knowledge exchange, both globally and locally, to link initiatives and apply academic knowledge into practice. This will support policymakers, health care providers and other stakeholders to ensure that digital innovations can increase access to care for everyone, leading towards Digital health for all .

Although public health scholars increasingly recognize the importance of the social determinants of health (SDOH), health policy outputs tend to emphasize downstream lifestyle factors instead. We use an automated corpus research approach to analyse fourteen years of health policy debate in the Dutch House of Representatives’ Health Committee, testing three potential causes of the lack of attention for SDOH: political ideology, by which members of parliament (MPs) from some political orientations may prioritize lifestyle factors over SDOH; lifestyle drift, by which early attention for SDOH during problem analysis is replaced by a lifestyle focus in the development of solutions as the challenges in addressing SDOH become clear; and focusing events, by which political or societal chance events, known to the public and political elites simultaneously, bolster the lifestyle perspective on health. Our analysis shows that overall, the committee spent most of its time discussing neither SDOH nor lifestyle: healthcare financing and service delivery dominated instead. When SDOH or lifestyle were referenced, left-leaning MPs referred significantly more to SDOH and right-leaning MPs significantly more to lifestyle. Temporal effects related to election cycles yielded inconsistent evidence. Finally, peak attention for both lifestyle and SDOH coincided with ongoing political debate instead of exogenous, unforeseen focusing events, and these peaks were rendered relatively insignificant by the larger and more consistent attention for health care. This paper provides a first step toward automated analysis of policy debates at scale, opening up new avenues for the empirical study of health political discourse.

Introduction and MethodsTo develop an understanding of the dynamics driving obesity-related behaviours in adolescents, we conducted systems-based analysis on a causal loop diagram (CLD) created from a multi-actor perspective, including academic researchers, adolescents and local stakeholders.ResultsThe CLD contained 121 factors and 31 feedback loops. We identified six subsystems with their goals: (1) interaction between adolescents and the food environment, with profit maximisation as goal, (2) interaction between adolescents and the physical activity environment, with utility maximisation of outdoor spaces as goal, (3) interaction between adolescents and the online environment, with profit maximisation from technology use as goal, (4) interaction between adolescents, parenting and the wider socioeconomic environment, with a goal focused on individual parental responsibility, (5) interaction between healthcare professionals and families, with the goal resulting in treating obesity as an isolated problem, and (6) transition from childhood to adolescence, with the goal centring around adolescents’ susceptibility to an environment that stimulates obesity-related behaviours.DiscussionAnalysis showed that inclusion of the researchers’ and stakeholders’ perspectives contributed to an understanding of how the system structure of an environment works. Integration of the adolescents’ perspective enriched insights on how adolescents interact with that environment. The analysis further showed that the dynamics driving obesity-related behaviours are geared towards further reinforcing such behaviours.

Abstract Socioeconomic inequalities in diets need to be tackled to improve population diets and prevent obesity and diet-related non-communicable diseases. The potential of food environment policies to reduce such inequalities has to date however not been appraised. The objective of this umbrella review was to assess the impact of food environment policies on socioeconomic inequalities in diets and to identify knowledge gaps in the existing literature, using the Healthy Food Environment Policy Index as a conceptual framework. The policies considered in the umbrella review are within six domains: 1) food composition 2) food labelling 3) food promotion 4) food provision 5) food retail 6) food pricing. A systematic search for systematic literature reviews on the effect of food environment policies on dietary-related outcomes across socioeconomic groups and published in English between 2004 and 2019 was conducted. Sixteen systematic literature reviews encompassing 159 primary studies were included, covering food composition (n = 2), food labelling (n = 3), food provision (n = 2), food prices (n = 13) and food in retail (n = 4). Quality assessment using the “Assessing the Methodological Quality of Systematic Reviews” quality rating scale showed that review quality was mainly low or critically low. Results suggest that food taxation may reduce socioeconomic inequalities in diets. For all other policy areas, the evidence base was poor. Current research largely fails to provide good quality evidence on impacts of food environment policies on socioeconomic inequalities in diets. Research to fill this knowledge gap is urgently needed.

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

Summary: Background: Healthy ageing (HA) has been defined using multiple approaches. We aim to produce a comprehensive overview and analysis of the theoretical models underpinning this concept and its associated normative terms and definitions. Methods: We conducted a systematic review of peer-reviewed HA models in Embase.com, Medline (Ovid), Cochrane CENTRAL, CINAHL, PsycINFO, and Web of Science until August 2022. Original theoretical papers, concept analyses, and reviews that proposed new models were included. Operational models/definitions, development psychology theories and mechanisms of ageing were excluded. We followed an iterative approach to extract the models’ characteristics and thematically analyze them based on the approach of Walker and Avant. The protocol was registered in PROSPERO (CRD42021238796). Findings: Out of 10,741 records, we included 59 papers comprising 65 models/definitions, published in English (1960–2022) from 16 countries in Europe, Asia, and America. Human ageing was described using 12 normative terms, mainly (models (%)): successful (34 (52%)), healthy (eight (12%)), well (five (8%)), and active (four (6%)). We identified intrinsic/extrinsic factors interacting throughout the life course, adaptive processes as attributes, and outcomes describing ageing patterns across objective and subjective dimensions (number of models/definitions): cognitive (62), psychological (53), physical (49), social (49), environmental (19), spiritual (16), economic (13), cultural (eight), political (six), and demographic (four) dimensions. Three types of models emerged: health-state outcomes (three), adaptations across the life course (31), or a combination of both (31). Two additional sub-classifications emphasized person-environment congruence and health promotion. Interpretation: HA conceptualizations highlight its multidimensionality and complexity that renders a monistic model/definition challenging. It has become evident that life long person-environment interactions, adaptations, environments, and health promotion/empowerment are essential for HA. Our model classification provides a basis for harmonizing terms and dimensions that can guide research and comparisons of empirical findings, and inform social and health policies enabling HA for various populations and contexts. Funding: MM, ZMRD, and OI are supported by the European Union’s Horizon 2020 Marie Skłodowska-Curie grant No 801076, and MM is also supported by the Swiss National Foundation grant No 189235.

It is unclear to what extent differences in cardiovascular disease (CVD) risk between men and women are explained by differences in smoking, and whether this contribution to risk is consistent across ethnic groups. In this prospective study, we determined the contribution of smoking to differences in CVD incidence between men and women, also in various ethnic groups. We linked baseline data of 18,058 participants of six ethnic groups from the HELIUS study (Amsterdam, the Netherlands) to CVD incidence data, based on hospital admission and death records from Statistics Netherlands (2013–2019). The contribution of smoking to CVD incidence, as estimated by the population attributable fraction, was higher in men than in women, overall (24.1% versus 15.6%) and across most ethnic groups. Among Dutch participants, however, the contribution of smoking was higher among women (21.0%) than men (16.2%). Using Cox regression analyses, we observed that differences in smoking prevalence explained 22.0% of the overall lower hazard for CVD in women compared to men. Smoking contributed minimally to the lower hazards for CVD in women among participants of Dutch (0%), Ghanaian (4.9%) and Moroccan origin (0%), but explained 28.6% and 48.6% of the lower hazards in women in South-Asian Surinamese and African Surinamese groups, respectively. While smoking prevention and cessation may lead to lower CVD incidence in most groups of men and women, it may not substantially reduce disparities in CVD risk between men and women in most ethnic groups.

Background The association between perceived ethnic discrimination (PED) and mental health conditions is well studied. However, less is known about the association between PED and suicidal ideation, or the role of positive psychosocial factors in this association. Aims To examine the association between PED and suicidal ideation among ethnic minority groups in Amsterdam, The Netherlands, and investigate whether ethnicity and mastery (people's extent of feeling in control of their lives and environment) moderate this association. Method Cross-sectional data from the multi-ethnic HELIUS study were analysed (n = 17 053) for participants of South-Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan origin. PED was measured using the Everyday Discrimination Scale, suicidal ideation using item 9 of the Patient Health Questionnaire-9 and mastery using the Pearlin–Schooler Mastery Scale. Results Logistic regression analyses demonstrated a small positive association between PED and suicidal ideation (OR = 1.068, 95% CI 1.059–1.077), which did not differ among ethnic minority groups. Mastery did not moderate the association between PED and suicidal ideation among the ethnic minority groups. Conclusions Our findings support the hypothesis that PED is associated with suicidal ideation and this association does not significantly vary between ethnic minority groups. Although higher levels of mastery were associated with lower suicidal ideation, mastery did not moderate the relationship between PED and suicidal ideation. Besides targeting ethnic discrimination as a societal problem, future longitudinal research is needed to investigate whether interventions aimed at improving mastery could reduce suicidal ideation in ethnic minority groups.

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

Abstract Background Chronic stress increases chronic disease risk and may underlie the association between exposure to adverse socioeconomic conditions and adverse health outcomes. The relationship between exposure to such conditions and chronic stress is complex due to feedback loops between stressor exposure and psychological processes, encompassing different temporal (acute stress response to repeated exposure over the life course) and spatial (biological/psychological/social) scales. We examined the mechanisms underlying the relationship between exposure to adverse socioeconomic conditions and chronic stress from a complexity science perspective, focusing on amplifying feedback loops across different scales. Methods We developed a causal loop diagram (CLD) to interpret available evidence from this perspective. The CLD was drafted by an interdisciplinary group of researchers. Evidence from literature was used to confirm/contest the variables and causal links included in the conceptual framework and refine their conceptualisation. Our findings were evaluated by eight independent researchers. Results Adverse socioeconomic conditions imply an accumulation of stressors and increase the likelihood of exposure to uncontrollable childhood and life course stressors. Repetition of such stressors may activate mechanisms that can affect coping resources and coping strategies and stimulate appraisal of subsequent stressors as uncontrollable. We identified five feedback loops describing these mechanisms: (1) progressive deterioration of access to coping resources because of repeated insolvability of stressors; (2) perception of stressors as uncontrollable due to learned helplessness; (3) tax on cognitive bandwidth caused by stress; (4) stimulation of problem avoidance to provide relief from the stress response and free up cognitive bandwidth; and (5) susceptibility to appraising stimuli as stressors against a background of stress. Conclusions Taking a complexity science perspective reveals that exposure to adverse socioeconomic conditions implies recurrent stressor exposure which impacts chronic stress via amplifying feedback loops that together could be conceptualised as one vicious cycle. This means that in order for individual-level psychological interventions to be effective, the context of exposure to adverse socioeconomic conditions also needs to be addressed.

Abstract Background Inequalities in obesity pertain in part to differences in dietary intake in different socioeconomic groups. Examining the economic, social, physical and political food environment of low-income groups as a complex adaptive system – i.e. a system of multiple, interconnected factors exerting non-linear influence on an outcome, can enhance the development and assessment of effective policies and interventions by honouring the complexity of lived reality. We aimed to develop and apply novel causal loop diagramming methods in order to construct an evidence-based map of the underlying system of environmental factors that drives dietary intake in low-income groups. Methods A systematic umbrella review was conducted on literature examining determinants of dietary intake and food environments in low-income youths and adults in high/upper-middle income countries. Information on the determinants and associations between determinants was extracted from reviews of quantitative and qualitative studies. Determinants were organised using the Determinants of Nutrition and Eating (DONE) framework. Associations were synthesised into causal loop diagrams that were subsequently used to interpret the dynamics underlying the food environment and dietary intake. The map was reviewed by an expert panel and systems-based analysis identified the system paradigm, structure, feedback loops and goals. Results Findings from forty-three reviews and expert consensus were synthesised in an evidence-based map of the complex adaptive system underlying the food environment influencing dietary intake in low-income groups. The system was interpreted as operating within a supply-and-demand, economic paradigm. Five sub-systems (‘geographical accessibility’, ‘household finances’, ‘household resources’, ‘individual influences’, ‘social and cultural influences’) were presented as causal loop diagrams comprising 60 variables, conveying goals which undermine healthy dietary intake. Conclusions Our findings reveal how poor dietary intake in low-income groups can be presented as an emergent property of a complex adaptive system that sustains a food environment that increases the accessibility, availability, affordability and acceptability of unhealthy foods. In order to reshape system dynamics driving unhealthy food environments, simultaneous, diverse and innovative strategies are needed to facilitate longer-term management of household finances and socially-oriented practices around healthy food production, supply and intake. Ultimately, such strategies must be supported by a system paradigm which prioritises health.

Objectives: We assessed the impacts of COVID-19 on multiple life domains across socio-demographic groups in Netherlands.Methods: After the first COVID-19 wave, we distributed online questionnaires among 13,031 participants of the multi-ethnic HELIUS cohort. Questionnaires contained questions on changes in income status, healthy behaviors, mental health, and access to non-COVID-19 health care. We then calculated differences in adjusted proportions of participants that reported negative changes across multiple life domains by migration background, age, sex, education, and occupation.Results: 4,450 individuals (35%) responded, of which 4,294 were included. Older populations and men seemed to be less vulnerable to negative changes in multiple life domains during the COVID-19 pandemic as compared to the pre-pandemic period, while populations with a migration background and lower education/occupation groups seemed to be more vulnerable to negative changes.Conclusion: Not all populations vulnerable to SARS-CoV-2 infection and mortality are also more vulnerable to COVID-19 impacts across multiple other life domains. Targeted interventions are needed in socio-demographic groups that are most impacted by COVID-19 in various life domains to prevent a further increase of their already increased risk of chronic diseases after the pandemic.

Based on a scoping review of empirical studies accompanied by interviews with experts, Rinaldi and Bekker studied the impact of populist radical right (PRR) parties on access to welfare provisions – the latter standing proxy for population health and for health inequalities in particular. We argue that populism can impact on migrant and ethnic minority health in multiple ways, in addition to the welfare mechanism specified in that review. These include institutionalised discrimination affecting individuals’ positions in the social hierarchy, experiences of discrimination in interpersonal relationships, and a weakened legitimacy of health policies. Interdisciplinary teams that include public health scholars and political scientists should take up the challenge of understanding migrant and ethnic minority health from a systems perspective.

This article describes the impact of coronavirus disease 2019 (COVID-19) preventive measures on the undocumented migrant domestic workers in the Netherlands. Undocumented migrants (UDMs) are likely to experience inequalities due to the COVID-19 pandemic. They rely on the informal market for work and housing and are usually not entitled to a healthcare insurance. However, they are not represented in the COVID-19 registrations or surveys. In order to advise the policymakers and healthcare professionals on how to tailor the preventive activities in handling a pandemic, including vaccination strategy, to the needs of this group, an insight into their experiences is needed. In our qualitative study, two focus group discussions were held with 14 UDMs, recruited through a snowball technique. The UDMs perceived the COVID-19 as a threat. Their precarious position affected their perceived vulnerability, which motivated them to seek information on and comply with preventive measures and testing. However, structural barriers decreased their self-efficacy and opportunity to comply. The COVID-19 measures impacted the lives of UDMs on essential domains, resulting in job, food, and housing insecurity, and increased barriers in access to healthcare. An intersectoral approach addressing health communication, access to healthcare, and social support, as well as legal rights for safe employment, is needed to alleviate the impact of the measures on UDMs.

Non-communicable diseases (NCDs) are the largest cause of disability and death globally. The human and financial costs of NCDs have raised questions of sustainability for many health systems. Personalized, preventive health interventions are an innovative way to address NCDs, but it is difficult to measure their effectiveness using standard evaluation methods. This article describes a novel approach to evaluation by coupling transdisciplinary methods with realist theory to design and pilot a health outcomes evaluation for a personalized medicine approach to NCD prevention in Istanbul, Turkey. Research and practice stakeholders contributed to study design, research questions, validation of results, and recommendations through interactive workshops, consistent dialogue, and reflection. They co-created a customized outcome measurement framework and recommendations that promote sustainability and continuous improvement of future evaluations. The participatory methods helped resolve the dichotomy between patient, practitioner, and researcher focus in the evaluation and improved stakeholders' data literacy. This research contributes to the body of evidence advocating for the use of non-standard methods such as transdisciplinary research to evaluate the effectiveness of complex interventions. The results of the pilot evaluation are also presented as a case study.

Summary: Background: Surveillance data in high-income countries have reported more frequent SARS-CoV-2 diagnoses in ethnic minority groups. We examined the cumulative incidence of SARS-CoV-2 and its determinants in six ethnic groups in Amsterdam, the Netherlands. Methods: We analysed participants enrolled in the population-based HELIUS cohort, who were tested for SARS-CoV-2-specific antibodies and answered COVID-19-related questions between June 24-October 9, 2020 (after the first wave) and November 23, 2020-March 31, 2021 (during the second wave). We modelled SARS-CoV-2 incidence from January 1, 2020-March 31, 2021 using Markov models adjusted for age and sex. We compared incidence between ethnic groups over time and identified determinants of incident infection within ethnic groups. Findings: 2,497 participants were tested after the first wave; 2,083 (83·4%) were tested during the second wave. Median age at first visit was 54 years (interquartile range=44–61); 56·6% were female. Compared to Dutch-origin participants (15·9%), cumulative SARS-CoV-2 incidence was higher in participants of South-Asian Surinamese (25·0%; adjusted hazard ratio [aHR]=1·66; 95%CI=1·16–2·40), African Surinamese (28·9%, aHR=1·97; 95%CI=1·37–2·83), Turkish (37·0%; aHR=2·67; 95%CI=1·89–3·78), Moroccan (41·9%; aHR=3·13; 95%CI=2·22–4·42), and Ghanaian (64·6%; aHR=6·00; 95%CI=4·33–8·30) origin. Compared to those of Dutch origin, differences in incidence became wider during the second versus first wave for all ethnic minority groups (all p-values for interaction

BackgroundUrban renewal traditionally involves policy sectors such as housing, transport, and employment, which potentially can enhance the health of residents living in deprived areas. Additional involvement of the public health sector might increase the health impact of these urban renewal activities. This study evaluates the health impact of an additional focus on health, under the heading of Healthy District Experiments (HDE), within districts where an urban renewal programme was carried out.MethodsWe evaluated changes in health outcomes before the start of the HDE and after implementation, and compared these changes with health changes in control areas, e.g. districts from the urban renewal programme where no additional HDE was implemented. Additionally, we gathered information on the content of the experiments to determine what types of activities have been implemented.ResultsThe additional activities from the HDE were mostly aimed at strengthening the health care in the districts and at promoting physical activity. When we compared the prevalence in general health, mental health, overweight, obesity, smoking, and physical activity during the study period between the HDE districts and control districts, we found no significant differences in the rate of change. The study is limited by a small sample size and the cross-sectional nature of the data. These and other limitations are discussed.ConclusionWe found no evidence for a beneficial health impact of the activities that were initiated with a specific focus on health, within a Dutch urban renewal programme. Specific attention for network management and the integration of such activities in the wider programme, as well as an allocated budget might be needed in order to sort a health impact.

ObjectivePopulations of South Asian (SA) origin are at high risk of type 2 diabetes (T2D) and related complications. Analysis of T2D prevention interventions for these populations show that limited attention has been given to facilitating increased physical activity (PA) in a culturally appropriate manner. The aim of this feasibility study was to identify whether culturally tailored dance is acceptable to women of SA origin, and whether it may have an effect on PA and PA-related social cognitive determinants.MethodsA community-based culturally tailored dance intervention choreographed to Bollywood music was evaluated among 26 women of SA origin in the Netherlands for 10 weeks, 2 times per week. This feasibility study was conducted as a before-after, mixed-methods study, combining data from focus groups, individual interviews, questionnaires and accelerometers.ResultsThe majority of participants were in the age of 50-59 years and at moderate-to-high T2D risk. There was high attendance (73%), low drop out (12%) and high satisfaction scores for various program components. Key reasons for participation were the cultural appropriateness, in particular the combination of historically and emotionally embedded Indian music and dance, and the non-competitive nature of the intervention. On average, in each of the 19 one-hour sessions, participants spent 30.8 minutes in objectively assessed light intensity PA, 14.1 minutes in moderate intensity PA and 0.3 minutes in vigorous PA, and took 2,100 steps during a session. At follow-up, total moderate-to-vigorous PA increased by 7.8 minutes per day (95%CI: 3.1, 12.5) and daily steps increased by 784 (95%CI: 173, 1394), with a concomitant reduction in light PA of 12 minutes per day (95%CI: -21.9, -2.2). Positive shifts in some PA-behavioral social cognitive determinants and no negative side-effects were observed.ConclusionsBollywood Dance appears to be a feasible, culturally acceptable and potentially effective approach to increase PA in SA women in the Netherlands. A pilot cluster RCT is needed to confirm these initial findings on effectiveness.

Abstract Objectives Psychosocial factors have been hypothesized to increase the risk of cancer. This study aims (1) to test whether psychosocial factors (depression, anxiety, recent loss events, subjective social support, relationship status, general distress, and neuroticism) are associated with the incidence of any cancer (any, breast, lung, prostate, colorectal, smoking‐related, and alcohol‐related); (2) to test the interaction between psychosocial factors and factors related to cancer risk (smoking, alcohol use, weight, physical activity, sedentary behavior, sleep, age, sex, education, hormone replacement therapy, and menopausal status) with regard to the incidence of cancer; and (3) to test the mediating role of health behaviors (smoking, alcohol use, weight, physical activity, sedentary behavior, and sleep) in the relationship between psychosocial factors and the incidence of cancer. Methods The psychosocial factors and cancer incidence (PSY‐CA) consortium was established involving experts in the field of (psycho‐)oncology, methodology, and epidemiology. Using data collected in 18 cohorts (N = 617,355), a preplanned two‐stage individual participant data (IPD) meta‐analysis is proposed. Standardized analyses will be conducted on harmonized datasets for each cohort (stage 1), and meta‐analyses will be performed on the risk estimates (stage 2). Conclusion PSY‐CA aims to elucidate the relationship between psychosocial factors and cancer risk by addressing several shortcomings of prior meta‐analyses.

Objectives Transnational utilisation of healthcare by people with an immigrant background carries risks, including medicalisation and adverse iatrogenic outcomes. We investigated the drivers behind such transnational healthcare use from a cultural perspective on health systems.Design Qualitative interview study (2018).Setting Two primary care practices in Amsterdam, the Netherlands.Participants Thirteen Dutch patients of Turkish background, who had obtained healthcare in Turkey, and who in general visited the primary care practice more than once a month.Results In the respondents’ stories, we observed how: (1) cross-border healthcare use was encouraged by cultural mismatches between expected and provided services and by differing explanatory models of illness upheld by patients and Dutch providers; (2) both transnationalism in patients and entitlements to insurance reimbursement facilitated the use of Turkish health services to bypass perceived barriers in the Dutch system; (3) cultural mismatches were reinforced during general practitioner consultations after the patients’ return to the Netherlands, thereby inducing further service use abroad.Conclusions Although cultural system influences are difficult to bridge, measures to reduce the unwelcome consequences of transnational healthcare use may include (1) strengthening the provision of culturally sensitive care in the country of residence and (2) restricting the reimbursement of care in the country of origin while maintaining the option to obtain care abroad.

Abstract Background Healthier dietary patterns are generally more costly than less healthy patterns, but dietary costs may be more important for dietary quality in lower educated and ethnic minority groups. The aim of this study was to investigate the association between dietary costs and dietary quality and interactions with ethnicity and socioeconomic position (SEP). Methods We used cross-sectional data from 4717 Dutch, Surinamese, Turkish and Moroccan origin participants of the multi-ethnic HELIUS study (the Netherlands), who completed an ethnic-specific food frequency questionnaire (FFQ). The primary outcome measure was dietary quality according to adherence to the Dutch Healthy Diet index 2015 (DHD15-index, range 0–130). Individual dietary costs (the monetary value attached to consumed diets in Euros) were estimated by merging a food price variable with the FFQ nutrient composition database. Regression analyses were used to examine main and interaction effects. Analyses were adjusted for age, sex, smoking, energy intake, physical activity, ethnicity and educational level. Results Having higher dietary costs was associated with higher dietary quality. Analyses stratified by educational level showed that associations were stronger in higher educated (Btertile3 = 8.06, 95%CI = 5.63; 10.48) than in lower educated participants (Btertile3 = 5.09, 95%CI = 2.74; 7.44). Stratification by ethnic origin showed strongest associations in Turkish participants (Btertile2 = 9.31, 95%CI = 5.96; 12.65) and weakest associations in Moroccan participants (Btertile3 = 4.29, 95%CI = 0.58; 8.01). Regardless of their level of education, Turkish and Moroccan individuals consumed higher quality diets at the lowest cost than Dutch participants. Conclusions The importance of dietary costs for dietary quality differs between socioeconomic and ethnic subgroups. Increasing individual food budgets or decreasing food prices may be effective for the promotion of healthy diets, but differential effects across socioeconomic and ethnic subgroups may be expected.

ObjectiveObesity is highly prevalent among ethnic minorities and acceptance of larger body sizes may put these ethnic minorities at risk of obesity. This study aimed to examine body size ideals and body satisfaction in relation to body weight, in two Sub-Saharan African (SSA)-origin groups in the Netherlands compared to the Dutch. Additionally, in the two SSA-origin groups, this study assessed the mediating role of acculturation in the relation between ethnicity and body size ideals and body satisfaction.MethodsDutch, African Surinamese and Ghanaians living in Amsterdam, the Netherlands, participated in the observational HELIUS study (n = 10,854). Body size ideals were assessed using a validated nine figure scale. Body satisfaction was calculated as the concordance of current with ideal figure. Acculturation was only assessed among SSA-origin participants and acculturation proxies included age of migration, residence duration, ethnic identity and social network. Weight and height were measured using standardised protocols.ResultsSSA-origin women and Ghanaian men had larger body size ideals compared to the Dutch; e.g. Surinamese and Ghanaian women had 0.37 (95%CI 0.32; 0.43) and 0.70 (95%CI 0.63; 0.78) larger body size ideals compared to Dutch women. SSA-origin participants were more often satisfied with their weight compared to the Dutch. Similarly, SSA-origin participants had more than twice the odds of being satisfied/preferring a larger figure compared to the Dutch (e.g. BSurinamese men 2.44, 95%CI 1.99; 2.99). Within the two SSA-origin groups, most acculturation proxies mediated the relation between ethnicity and body size ideals in women. Limited evidence of mediation was found for the outcome body satisfaction.ConclusionPublic health strategies promoting a healthy weight may need to be differentiated according to sex and ethnic differences in body weight perception. Factors other than acculturation may underlie the ethnic differences between African Surinamese and Ghanaians in obesity.

Objectives: To explore the contextual factors that shape uptake of COVID-19 preventive measures, in specific migrant and ethnic minority populations, with a focus on migration-related, sociocultural and socioeconomic conditions. Design: A qualitative design, consisting of three online focus group discussions. Setting: This study was conducted amongst smaller, albeit substantial, migrant and minority ethnic populations in the Netherlands. Participants: A total of 25 participants (12 male; 13 female) of Ghanaian and Eritrean origin, purposively sampled to ensure diversity within groups, with regards to sex, age, educational level, occupation, household size and length of stay in the Netherlands. Focus group discussions were held online, therefore, experience in the use of video conferencing software was a prerequisite. Results: Participants’ awareness and knowledge of COVID-19 and COVID-19 preventive measures was shaped by migration-related factors, such as limited Dutch proficiency, by access to understandable information and interference of misinformation. Participants’ engagement by COVID-19 preventive measures was subject to COVID-19 threat appraisal and the ease with which complex behavioural messages could be translated to individual situations. Lastly, a strong social norm to keep with cultural and religious practices, and limited opportunity for preventive behaviour in the work and home context hinder the uptake of preventive behaviour following a decision to act according to measures. Conclusions: Migration-related, sociocultural, and socioeconomic factors shape uptake of COVID-19 preventive measures amongst persons of Ghanaian and Eritrean origin in The Netherlands. To ensure equitable uptake our results suggest the importance of timely spread of multilingual information tailored to literacy needs; as well as, education and modelling delivered through online platforms and by leading figures in respective communities; and, regulations to ensure continued access to financial and material resources to minimise negative spill-over effects and exacerbation of inequality.

Introduction: Comprehensive national non-communicable disease (NCD) policy development and implementation are crucial for preventing and controlling the increasing NCD burden, particularly in the Africa region where the largest increase in NCD related mortality is expected by 2030. Yet, even where national NCD policies exist, effective implementation remains hindered for reasons not clearly elucidated. This study explored the experiences of key health stakeholders at national and sub-national levels with implementing a national NCD policy in Ghana. Methods: This was an explanatory, cross-sectional and grounded theory study using in-depth interview guides to collect primary data from 39 purposively sampled health policymakers and implementing officials at the national and sub-national levels in Ghana. A thematic approach was used in data analysis. Results: Several interwoven factors including poor policy awareness, poor coordination and intersectoral engagements and inadequate funding for NCD programs and activities are key challenges thwarting the effective implementation of the national NCD policy in Ghana. At the sub-national levels, inadequate clarity and structure for translating policy into action and inadequate integration further affect operationalizing of the national NCD policy. Conclusion: The findings call for policymakers to adopt a series of adaptive measures including sustainable NCD financing mechanisms, effective intersectoral coordination, policy sensitisation and capacity building for implementing health professionals, which should be coupled with governmental and global resource investment in effective implementation of national NCD policies to make sustained population level gains in NCD control in Ghana and in other resource constrained settings.

IntroductionA mounting body of literature emphasizes the potential negative effects of adverse childhood experiences (ACEs) on both mental and physical health throughout life, including an increased risk for developing cardiovascular disease (CVD). Since CVD is one of the leading causes of mortality and morbidity worldwide, it is of great importance to advance our understanding of the effects of on CVD. This holds both for the actual incidence and for intermediate biological pathways that may convey CVD risk, such as imbalance in autonomic nervous system regulation, resulting in a chronically heightened sympathetic activity and lowered reactivity. In a large urban, multi-ethnic population-based cohort study we investigated whether there is an association between child maltreatment, CVD incidence and autonomic regulation.MethodsWithin the Health in an Urban Setting (HELIUS) study, a large, multi-ethnic population cohort study including n = 22,165 Amsterdam residents, we used logistic regression analyses to investigate the association between the number of self-reported types of child maltreatment (range 0–4), and self-reported adverse cardiovascular outcome (aCVO). Self-reported child maltreatment included emotional neglect, emotional abuse, physical abuse, and sexual abuse. Furthermore, in a subsample (n = 10,260), mean age 44.3, we investigated associations between child maltreatment, autonomic regulation, and aCVO using linear regression analyses. Both baroreflex sensitivity (BRS) and heart rate variability (HRV) were assessed as non-invasive indices of autonomic regulation.ResultsThe number of endorsed child maltreatment types was significantly associated with a higher aCVO risk. The association remained significant after adjustment for demographic, socioeconomic, health-behavioral, and psychological covariates (p = 0.011, odds ratio: 1.078, confidence interval: 1.018–1.142). The cumulative exposure to child maltreatment was negatively associated with BRS and HRV, but the association was no longer significant after correction for socioeconomic and demographic covariates.ConclusionIn a large, multi-ethnic urban-population cohort study we observed a positive association between number of endorsed child maltreatment types and self-reported aCVO but not autonomic regulation, over and above the effect of relevant demographic, health, and psychological factors. Future studies should examine the potential role of the dynamics of autonomic dysregulation as potential underlying biological pathways in the association between ACEs and CVD, as this could eventually facilitate the development of preventive and therapeutic strategies for CVD.

BackgroundImmigrants from low- and middle-income countries who have settled in high-income countries show higher risks of depression in comparison with host populations. The risks are associated with adverse social conditions. Indecisive results have been reported on the depression risks of the offspring of immigrant populations.ObjectiveTo assess the prevalence of depressed mood in immigrant offspring relative to the host population and to analyse whether that risk is explained by social conditions.MethodsCross-sectional data from the Dutch HELIUS study were analysed, involving 19,904 men and women of Dutch, South-Asian Surinamese, African Surinamese, Turkish or Moroccan ethnic descent aged 18 to 70. Depressive symptomatology was assessed using the Patient Health Questionnaire-9 (PHQ-9). Indicators of social conditions were socioeconomic position (educational level, occupational level, employment status), perceived ethnic discrimination and sociocultural integration (ethnic identity, cultural orientation, social network). We used logistic regression to assess the risk of depressed mood (PHQ-9 sum score ≥10) in immigrants' offspring, as well as in first generation immigrants, relative to the risk in the host population. Social indicators were stepwise added to the model.ResultsThe prevalence of depressed mood was 13% to 20% among immigrant offspring, with the lowest level for those of African Surinamese descent; prevalence in the Dutch origin population was 7%. Relative risk of depressed mood, expressed as average marginal effects (AMEs), decreased substantially in all offspring groups after adjustment for socioeconomic indicators and discrimination. E.g. the AME of Turkish vs. Dutch decreased from 0.11 (0.08-0.13) to 0.05 (0.03-0.08). Patterns resembled those in first generation immigrants.ConclusionsResults suggest that the observed higher prevalence of depressed mood in immigrants' offspring will decline to the level of the host population as the various populations grow closer in terms of socioeconomic position and as immigrant offspring cease to experience discrimination.

Abstract The establishment of the Determinants of Diet and Physical Activity (DEDIPAC) Knowledge Hub, 2013–2016, was the first action taken by the ‘Healthy Diet for a Healthy Life’ European Joint Programming Initiative. DEDIPAC aimed to provide better insight into the determinants of diet, physical activity and sedentary behaviour across the life course, i.e. insight into the causes of the causes of important, non-communicable diseases across Europe and beyond. DEDIPAC was launched in late 2013, and delivered its final report in late 2016. In this paper we give an overview of what was achieved in terms of furthering measurement and monitoring, providing overviews of the state-of-the-art in the field, and building toolboxes for further research and practice. Additionally, we propose some of the next steps that are now required to move forward in this field, arguing in favour of 1) sustaining the Knowledge Hub and developing it into a European virtual research institute and knowledge centre for determinants of behavioural nutrition and physical activity with close links to other parts of the world; 2) establishing a cohort study of families across all regions of Europe focusing specifically on the individual and contextual determinants of major, non-communicable disease; and 3) furthering DEDIPAC’s work on nutrition, physical activity, and sedentary behaviour policy evaluation and benchmarking across Europe by aligning with other international initiatives and by supporting harmonisation of pan-European surveillance.

Abstract Background Some ethnic minority populations have a higher risk of non-communicable diseases than the majority European population. Diet and physical activity behaviours contribute to this risk, shaped by a system of inter-related factors. This study mapped a systems-based framework of the factors influencing dietary and physical activity behaviours in ethnic minority populations living in Europe, to inform research prioritisation and intervention development. Methods A concept mapping approach guided by systems thinking was used: i. Preparation (protocol and terminology); ii. Generating a list of factors influencing dietary and physical activity behaviours in ethnic minority populations living in Europe from evidence (systematic mapping reviews) and ‘eminence’ (89 participants from 24 academic disciplines via brainstorming, an international symposium and expert review) and; iii. Seeking consensus on structuring, rating and clustering factors, based on how they relate to each other; and iv. Interpreting/utilising the framework for research and interventions. Similar steps were undertaken for frameworks developed for the majority European population. Results Seven distinct clusters emerged for dietary behaviour (containing 85 factors) and 8 for physical activity behaviours (containing 183 factors). Four clusters were similar across behaviours: Social and cultural environment; Social and material resources; Psychosocial; and Migration context. Similar clusters of factors emerged in the frameworks for diet and physical activity behaviours of the majority European population, except for ‘migration context’. The importance of factors across all clusters was acknowledged, but their relative importance differed for ethnic minority populations compared with the majority population. Conclusions This systems-based framework integrates evidence from both expert opinion and published literature, to map the factors influencing dietary and physical activity behaviours in ethnic minority groups. Our findings illustrate that innovative research and complex interventions need to be developed that are sensitive to the needs of ethnic minority populations. A systems approach that encompasses the complexity of the inter-related factors that drive behaviours may inform a more holistic public health paradigm to more effectively reach ethnic minorities living in Europe, as well as the majority host population.

Abstract Background In Western European countries, the prevalence of depressive symptoms is higher among ethnic minority groups, compared to the host population. We explored whether these inequalities reflect variance in the way depressive symptoms are measured, by investigating whether items of the PHQ-9 measure the same underlying construct in six ethnic groups in the Netherlands. Methods A total of 23,182 men and women aged 18–70 of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish or Moroccan origin were included in the HELIUS study and had answered to at least one of the PHQ-9 items. We conducted multiple group confirmatory factor analyses (MGCFA), with increasingly stringent model constraints (i.e. assessing Configural, Metric, Strong and Strict measurement invariance (MI)), and regression analysis, to confirm comparability of PHQ-9 items across ethnic groups. Results A one-factor model, where all nine items reflect a single underlying construct, showed acceptable model fit and was used for MI testing. In each subsequent step, change in goodness-of-fit measures did not exceed 0.015 (RMSEA) or 0.01 (CFI). Moreover, strict invariance models showed good or acceptable model fit (Men: RMSEA = 0.050; CFI = 0.985; Women: RMSEA = 0.058; CFI = 0.979), indicating between-group equality of item clusters, factor loadings, item thresholds and residual variances. Finally, regression analysis did not indicate potential ethnicity-related differential item functioning (DIF) of the PHQ-9. Conclusions This study provides evidence of measurement invariance of the PHQ-9 regarding ethnicity, implying that the observed inequalities in depressive symptoms cannot be attributed to DIF.

Abstract Background Physical activity and sedentary behaviour are associated with health and wellbeing. Studies indicate that ethnic minority groups are both less active and more sedentary than the majority population and that factors influencing these behaviours may differ. Mapping the factors influencing physical activity and sedentary behaviour among ethnic minority groups living in Europe can help to identify determinants of physical activity and sedentary behaviour, research gaps and guide future research. Methods A systematic mapping review was conducted to map the factors associated with physical activity and sedentary behaviour among ethnic minority groups living in Europe (protocol PROSPERO ID = CRD42014014575). Six databases were searched for quantitative and qualitative research published between 1999 and 2014. In synthesizing the findings, all factors were sorted and structured into clusters following a data driven approach and concept mapping. Results Sixty-three articles were identified out of 7794 returned by the systematic search. These included 41 quantitative and 22 qualitative studies. Of these 58 focused on physical activity, 5 on both physical activity and sedentary behaviour and none focused on sedentary behaviour. The factors associated with physical activity and sedentary behaviour were grouped into eight clusters. Social & cultural environment (n = 55) and Psychosocial (39) were the clusters containing most factors, followed by Physical environment & accessibility (33), Migration context (15), Institutional environment (14), Social & material resources (12), Health and health communication (12), Political environment (3). An important finding was that cultural and religious issues, in particular those related to gender issues, were recurring factors across the clusters. Conclusion Physical activity and sedentary behaviour among ethnic minority groups living in Europe are influenced by a wide variety of factors, especially informed by qualitative studies. More comparative studies are needed as well as inclusion of a wider spectrum of the diverse ethnic minority groups resettled in different European countries. Few studies have investigated factors influencing sedentary behaviour. It is important in the future to address specific factors influencing physical activity and sedentary behaviour among different ethnic minority groups in order to plan and implement effective interventions.

Abstract Background Half of the estimated annual 28 million non-communicable diseases (NCDs) deaths in low- and middle-income countries (LMICs) are attributed to weak health systems. Current health policy responses to NCDs are fragmented and vertical particularly in the African region. The World Health Organization (WHO) led NCDs Global action plan 2013–2020 has been recommended for reducing the NCD burden but it is unclear whether Africa is on track in its implementation. This paper synthesizes Africa’s progress towards WHO policy recommendations for reducing the NCD burden. Methods Data from the WHO 2011, 2014 and 2015 NCD reports were used for this analysis. We synthesized results by targets descriptions in the three reports and included indicators for which we could trace progress in at least two of the three reports. Results More than half of the African countries did not achieve the set targets for 2015 and slow progress had been made towards the 2016 targets as of December 2013. Some gains were made in implementing national public awareness programmes on diet and/or physical activity, however limited progress was made on guidelines for management of NCD and drug therapy and counselling. While all regions in Africa show waning trends in fully achieving the NCD indicators in general, the Southern African region appears to have made the least progress while the Northern African region appears to be the most progressive. Conclusion Our findings suggest that Africa is off track in achieving the NCDs indicators by the set deadlines. To make sustained public health gains, more effort and commitment is urgently needed from governments, partners and societies to implement these recommendations in a broader strategy. While donors need to suit NCD advocacy with funding, African institutions such as The African Union (AU) and other sub-regional bodies such as West African Health Organization (WAHO) and various country offices could potentially play stronger roles in advocating for more NCD policy efforts in Africa.

Objectives The association between psychosocial stressors (PS) and chronic kidney disease (CKD) among sub-Saharan African (SSA) populations is unknown. We examined the association between PS and CKD prevalence among rural and urban Ghanaians and Ghanaian migrants living in three European cities. We also assessed if the influence of PS on CKD is partially mediated by primary risk factors (hypertension and diabetes) of CKD.Design A multi-centred cross sectional data from the Research on Obesity and Diabetes among African Migrants study.Setting Rural and urban Ghana and three European cities (Amsterdam, Berlin and London).Participants A random sample of 5659 adults (Europe 3167, rural Ghana 1043 and urban Ghana 1449) aged 25–70 years.Explanatory measures PS defined by negative life events, perceived discrimination, perceived stress at work/home and depressive symptoms. Three CKD outcomes were considered using the 2012 Kidney Disease: Improving Global Outcomes severity of CKD classification. Comparisons between PS and CKD outcomes were made using logistic regression analyses across all sites.Results We observed higher proportion of negative life events (68.7%) and perceived permanent stress (15.9%) among Ghanaians living in Ghana than Ghanaians living in Europe. Depressive symptoms (7.5%) and perceived discrimination (29.7%) were more common among Ghanaians living in Europe than Ghanaians living in Ghana. No significant association was observed between any of the PS constructs and CKD outcomes across sites except for positive association between stress at work/home and albuminuria (2.81, 95% CI 1.46 to 5.40) and CKD risk (2.78, 95% CI 1.43 to 5.43) among Ghanaians living in Berlin.Conclusion Our study found a positive association between stress at work/home and albuminuria and CKD risk. There was no convincing evidence of associations between the other PS constructs and the prevalence of CKD risk. Further studies are needed to identify potential factors driving the high prevalence of CKD among these populations.

African migrants in Europe and continental Africans are disproportionately affected by type 2 diabetes (T2D). Both groups develop T2D at a younger age, and have higher morbidity and mortality from T2D and complications, compared to European populations. To reduce risk, and avoidable disability and premature deaths, culturally congruent and context specific interventions are required. This study aimed to: (a) assess perceptions and knowledge of T2D among Ghanaian migrants in Europe and their compatriots in Ghana and (b) identify specific perceptions and knowledge gaps that might predispose migrants to higher risk of diabetes. Data was gathered through 26 focus groups with 180 individuals, aged 21 to 70, from Amsterdam, Berlin and London and rural and urban Ashanti Region, Ghana. Thematic analysis of the data was informed by Social Representations Theory, which focuses on the sources, content and functions of social knowledge. Three key insights emerged from analysis. First, there was general awareness, across migrant and non-migrant groups, of T2D as a serious chronic condition with life threatening complications, and some knowledge of biomedical strategies to prevent diabetes (e.g healthy eating) and diabetes complications (e.g medication adherence). However, knowledge of T2D prevention and reduction of diabetes complications was not comprehensive. Secondly, knowledge of biomedical diabetes theories and interventions co-existed with theories about psychosocial and supernatural causes of diabetes and the efficacy of herbal and faith-based treatment of diabetes. Finally, migrants' knowledge was informed by both Ghanaian and European systems of T2D knowledge suggesting enculturation dynamics. We discuss the development of culturally congruent and context-specific T2D interventions for the research communities.

Abstract Background To explore changes in utilization patterns for general practice (GP) and hospital care of people living in deprived neighbourhoods when primary care providers work in a more coherent and coordinated manner by applying an integrated approach. Methods We compared expected (based on consumption patterns of a health insurers’ total population) and actual utilization patterns in a deprived Dutch intervention district in the city of Utrecht (Overvecht) with control districts 1 (Noordwest) and 2 (Kanaleneiland) over the period 2006–2011, when an integrated care approach was increasingly provided in the intervention district. Standardized insurance claims data were used to indicate use of GP care and hospital care. Results Our findings revealed that the utilization of total GP care increased more in the intervention district than in the control districts. And that the intervention district showed a more pronounced decreasing trend in total hospital use as compared to what was expected, in particular from 2008 onwards. In addition, we observed a change in type of GP care use in the intervention district in particular: the number of regular consultations, long consultations, GP home visits and evening, night and weekend consultations were increasingly higher than expected. The intervention district also showed the largest decrease between actual and expected use of ambulatory care, clinical care and 1-day hospitalizations. Conclusions Utilization patterns for general practice and hospital care of people living in deprived districts may change when primary care professionals work in a more coherent and coordinated manner by applying a more ‘comprehensive’ integrated care approach. Results support the expectation that a comprehensive integrated care approach might eventually contribute to the future sustainability of healthcare systems.

Abstract Background Public health is to a large extent determined by non-health-sector policies. One approach to address this apparent paradox is to establish healthy public policies. This requires policy makers in non-health sectors to become more aware of the health impacts of their policies, and more willing to adopt evidence-informed policy measures to improve health. We employed a knowledge broker to set the agenda for health and to specify health-promoting policy alternatives. This study aimed at gaining in-depth understanding of how this knowledge broker approach works. Methods In the context of a long-term partnership between the two universities in Amsterdam and the municipal public health service, we employed a knowledge broker who worked part-time at a university and part-time for an Amsterdam city district. When setting an agenda and specifying evidence-informed policy alternatives, we considered three individual policy portfolios as well as the policy organization of the city district. We evaluated and developed the knowledge broker approach through action research using participant observation. Results Our knowledge brokering strategy led to the adoption of several policy alternatives in individual policy portfolios, and was especially successful in agenda-setting for health. More specifically, health became an issue on the formal policy agenda as evidenced by its uptake in the city district’s mid-term review and the appointment of a policy analyst for health. Our study corroborated the importance of process factors such as building trust, clearly distinguishing the knowledge broker role, and adequate management support. We also saw the benefits of multilevel agenda-setting and specifying policy alternatives at appropriate policy levels. Sector-specific responsibilities hampered the adoption of cross-sectoral policy alternatives, while thematically designed policy documents offered opportunities for including them. Further interpretation revealed three additional themes in knowledge brokering: boundary spanning, a ripple effect, and participant observation. Conclusions The employment of a knowledge broker who works simultaneously on both agenda-setting for health as well as the specification of health-promoting policy alternatives seems to be a promising first step in establishing local healthy public policies. Future studies are needed to explore the usefulness of our approach in further policy development and policy implementation.

Background: A combination of increasing urbanization, behaviour change, and lack of health services in slums put the urban poor specifically at risk of cardiovascular disease (CVD). This study aimed to evaluate the impact of a community-based CVD prevention intervention on blood pressure (BP) and other CVD risk factors in a slum setting in Nairobi, Kenya. Design: Prospective intervention study includes awareness campaigns, household visits for screening, and referral and treatment of people with hypertension. The primary outcome was overall change in mean systolic blood pressure (SBP), while secondary outcomes were changes in awareness of hypertension and other CVD risk factors. We evaluated the intervention's impact through consecutive cross-sectional surveys at baseline and after 18 months, comparing outcomes of intervention and control group, through a difference-in-difference method. Results: We screened 1,531 and 1,233 participants in the intervention and control sites. We observed a significant reduction in mean SBP when comparing before and after measurements in both intervention and control groups, −2.75 mmHg (95% CI −4.33 to −1.18, p=0.001) and −1.67 mmHg (95% CI −3.17 to −0.17, p=0.029), respectively. Among people with hypertension at baseline, SBP was reduced by −14.82 mmHg (95% CI −18.04 to −11.61, p

Background: Hypertension is a highly prevalent risk factor for cardiovascular diseases in sub-Saharan Africa (SSA) that can be modified through timely and long-term treatment in primary care. Objective: We explored perspectives of primary care staff and health insurance managers on enablers and barriers for implementing high-quality hypertension care, in the context of a community-based health insurance programme in rural Nigeria. Design: Qualitative study using semi-structured individual interviews with primary care staff (n = 11) and health insurance managers (n=4). Data were analysed using standard qualitative techniques. Results: Both stakeholder groups perceived health insurance as an important facilitator for implementing high-quality hypertension care because it covered costs of care for patients and provided essential resources and incentives to clinics: guidelines, staff training, medications, and diagnostic equipment. Perceived inhibitors included the following: high staff workload; administrative challenges at facilities; discordance between healthcare provider and insurer on how health insurance and provider payment methods work; and insufficient fit between some guideline recommendations and tools for patient education and characteristics/needs of the local patient population. Perceived strategies to address inhibitors included the following: task-shifting; adequate provider payment benchmarking; good provider–insurer relationships; automated administration systems; and tailoring guidelines/patient education. Conclusions: By providing insights into perspectives of primary care providers and health insurance managers, this study offers information on potential strategies for implementing high-quality hypertension care for insured patients in SSA.

AIM:To investigate whether items of the SF-12, widely used to assess health outcome in clinical practice and public health research, provide unbiased measurements of underlying constructs in different demographic groups regarding gender, age, educational level and ethnicity. METHODS:We included 23,146 men and women aged 18-70 of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish, or Moroccan origin from the HELIUS study. Both multiple group confirmatory factor analyses (MGCFA), with increasingly stringent model constraints (i.e. assessing Configural, Metric, Strong and Strict measurement invariance (MI)), and regression analysis were conducted to establish comparability of SF-12 items across demographic groups. RESULTS:MI regarding gender, age and education was tested in the ethnic Dutch group (N = 4,615). In each subsequent step of testing MI, change in goodness-of-fit measures did not exceed 0.010 (RMSEA) or 0.004 (CFI). Moreover, goodness-of-fit indices showed good fit for strict invariance models: RMSEA0.97. Regarding ethnicity, RMSEA values of metric and subsequent models fell above 0.055, indicating violation of measurement invariance in factor loadings, thresholds and residual variances. Regression analysis revealed possible age-, education- and ethnicity-related DIF. Adjustment for this DIF had little impact on the magnitude of age and educational differences in physical and mental health, but ethnic inequalities in physical health-and to a lesser extent mental health-were reduced after DIF adjustment. CONCLUSIONS:We found no evidence of violation of measurement invariance of the SF-12 regarding gender, age and educational level. If minor DIF would remain undetected in our MGCFA analyses, we showed that this would have negligible effect on the magnitude of demographic health inequalities. Regarding ethnicity, the SF-12 was not measurement invariant. After accounting for DIF, we observed a reduction of ethnic inequalities in health, in particular in physical health. Caution is warranted when comparing SF-12 scores across population groups with various ethnic backgrounds.