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Intersectoral policymaking to improve public health includes integrated health promotion (HP) intervention packages that address a variety of health behavior determinants. The involvement of different partners is assumed to be necessary to implement such integrated packages. We examined how partnership diversity was associated with the composition of intervention packages implemented in Dutch municipalities. In a longitudinal multiple-case study (2012-14), we collected questionnaire data among 31 project leaders and 152 intervention implementers in 31 (alliances of) municipalities. Package composition was assessed in terms of intervention strategies, implementation settings and targeted behavioral determinants. Partnership diversity during the adoption and implementation phases was assessed in terms of the actors and sectors, as well as private partners and citizens involved. The association between partnership diversity and package composition was examined using crosstabs. Almost all packages integrated multiple strategies, but mostly education, facilitation and case finding, in multiple, but mostly health and public settings, such as schools. The packages targeted diverse behavioral determinants, although mainly personal and social environmental factors. A variety of partners from multiple sectors was involved, during both adoption and implementation of the packages. However, partners from the health, welfare and education sectors were mostly involved. More partnership diversity, especially during implementation, was associated with more integrated intervention packages. In intersectoral policymaking, investment in diversely composed partnerships seems worthwhile for implementing integrated intervention packages. However, investments in other conditions, like framing health issues and network management, are also needed to make environmental determinants of health behavior the object of HP., (© The Author(s) 2020. Published by Oxford University Press.)

Unlabelled: Currently, there are many diagnostic self-tests on body materials available to consumers. The aim of this study was to assess the effect of an online decision aid on diagnostic self-testing for cholesterol and diabetes on knowledge among consumers with an intention to take these tests. A randomized controlled trial was designed. A total of 1259 consumers with an intention to use a diagnostic cholesterol or diabetes self-test were selected from an existing Dutch Internet panel. The intervention group was invited to view an online decision aid offering general information on self-testing and test-specific information on cholesterol and diabetes self-testing, including indications for testing, how to perform the test and interpreting the result. The placebo condition consisted of a limited information sheet. Multiple regression analysis showed that the knowledge level in the diabetes arm was higher in the intervention group than in the control group (B = 0.657; 95% CI, 0.011-1.303), as was the number of participants with an informed choice (OR, 1.672; 95% CI, 1.134-2.465). No differences were found in the cholesterol arm. Consumers who are considering doing a self-test should have access to independent information on self-testing and be encouraged to read this information., Trial Registration: Dutch Trial Register: NTR 3149., (© The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

We assessed the perceived sustainability of community health programs organized by local intersectoral coalitions, as well as the factors that collaborating partners think might influence sustainability. Semi-structured interviews were conducted among 31 collaborating partners of 5 community health programs in deprived neighborhoods in the southern part of the Netherlands. The interview guide was based on a conceptual framework that includes factors related to the context, the leading organization, leadership, the coalition, collaborating partners, interventions and outcomes. Interviews were recorded, transcribed and content analyzed using NVivo 8.0. Participants in each of the programs varied in their perceptions of the sustainability of the program, but those people collaborating in pre-existing neighborhood structures expressed relatively high faith in their continuation. The participating citizens in particular believed that these structures would continue to address the health of the community in the future. We found factors from all categories of the conceptual framework that were perceived to influence sustainability. The program leaders appeared to be crucial to the programs, as they were frequently mentioned in close interaction with other factors. Program leaders should use a motivating and supportive leadership style and should act as 'program champions'., (© The Author (2013). Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: The objective of this study was to review methodological quality of economic evaluations of lifestyle behavior change interventions (LBCIs) and to examine how they address methodological challenges for public health economic evaluation identified in the literature., Methods: Pubmed and the NHS economic evaluation database were searched for published studies in six key areas for behavior change: smoking, physical activity, dietary behavior, (illegal) drug use, alcohol use and sexual behavior. From included studies (n = 142), we extracted data on general study characteristics, characteristics of the LBCIs, methodological quality and handling of methodological challenges., Results: Economic evaluation evidence for LBCIs showed a number of weaknesses: methods, study design and characteristics of evaluated interventions were not well reported; methodological quality showed several shortcomings and progress with addressing methodological challenges remained limited., Conclusions: Based on the findings of this review we propose an agenda for improving future evidence to support decision-making. Recommendations for practice include improving reporting of essential study details and increasing adherence with good practice standards. Recommendations for research methods focus on mapping out complex causal pathways for modeling, developing measures to capture broader domains of wellbeing and community outcomes, testing methods for considering equity, identifying relevant non-health sector costs and advancing methods for evidence synthesis., (© The Author 2013. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The aim of the study was to identify promoting and impeding factors for successful implementation of a Dutch primary health care-based lifestyle programme called 'BeweegKuur'. BeweegKuur aims to increase the physical activity and change the diet of people at increased health risk due to overweight or obesity., Objective: To determine perceived promoting and impeding factors in the implementation of the BeweegKuur programme for overweight and obese people., Methods: This study consisted of 3 focus group meetings with intervention participants, 15 interviews with health care professionals (HCPs) and 1 focus group session with dieticians. The interviews and focus groups were recorded and transcribed verbatim. The data were analysed with the Nvivo qualitative research software package., Results: For some intervention participants, the invitation to participate in BeweegKuur came unexpectedly, as they had not been diagnosed with an illness. HCPs were aware of this and took time to explain to participants that the programme was appropriate and safe for them. Participants as well as professionals were generally positive about the feasibility of the programme for overweight and obese people., Conclusions: HCPs as well as intervention participants were motivated to participate in the programme, and generally indicated that the intervention was in accordance with their needs. The multidisciplinary approach and the combination of physical activity and dietary behaviour change can make the BeweegKuur programme a success if potential impeding factors like those identified in the present study are overcome.

This paper describes the evaluation of an adoption strategy for the school-based healthy diet programme Krachtvoer. Health promotion (HP) professionals from five Regional Public Health Services (RPHSs) in The Netherlands were asked to recruit a total of 25 schools to adopt the Krachtvoer programme in accordance with this strategy. Afterwards, they were interviewed about their adherence to and subjective evaluation of the strategy. The adoption rate of the programme was calculated and 10 adopting and 9 rejecting teachers were interviewed about the reasons for their decision. The HP professionals' adherence to the strategy was good, as well as their appreciation and the perceived feasibility of the strategy. The person-to-person approach that characterized this strategy was considered important. The strategy led to an adoption rate of 53.2%. On average, adopters mentioned 4.4 reasons and rejecters mentioned 5.4 reasons for their decision. Most reasons were school related and programme related and in case of the adopters also teacher related. The diversity of reasons revealed the complexity of teachers' decision making. Although there is some room for improvement of the adoption strategy and the programme itself, especially socio-political conditions in schools and in RPHSs need change for a further increase in programme adoption.

The Internet has become important for the delivery of behavior change interventions. This observational study examines how many people visited, registered and revisited a web-based computer-tailored intervention promoting heart-healthy behaviors when it is implemented for use by the general public. Among registered visitors, the association between visitors' characteristics and initiating, completing and revisiting the website and/or its behavior-specific modules was analyzed. Server statistics showed that 285 146 visitors from unique IP addresses landed on the home page in a 36-month period; of these, >50% left the intervention website within 30 s. In total, 81 574 (28.6%) visitors completed the registration procedure and gained access to the intervention; 99% of registered visitors initiated one module, 91% completed at least one module and 6% revisited the intervention. The majority of the registered visitors were women, medium to highly educated, with a body mass index (BMI) <25. Women, visitors aged 40-50 years, visitors with a medium educational level and visitors with a BMI <25 were more likely to initiate and finish the modules. It is concluded that a heart-healthy computer-tailored Internet program can reach substantial numbers of people, but additional research is needed to develop promotional strategies that reach the high-risk population, i.e. men, older and lower educated persons.

Although exposure is crucial to improve the public health impact of Internet-delivered interventions, it appears that in practice exposure to such interventions is low. Therefore, a conceptual framework, which incorporates elements of user experience of websites, is applied to Internet-delivered health behaviour change interventions aimed at adolescents and results from previous explorative research are incorporated. This framework, described from the point of view of an intervention's development team, can be used in practice to optimize user experience and therewith improving exposure rates to Internet-delivered interventions and increasing the number of revisiting users.

The aim of this study was to evaluate and compare the effectiveness of two primary school-based interventions on children's fruit and vegetable (F&V) consumption on the long term (2 years after the start of the interventions). Six primary schools were recruited and randomly assigned to (i) a daily free distribution program for the whole school or (ii) a multicomponent program consisting of a classroom curriculum and parental involvement (without free F&V), and six schools served as controls. Follow-up measurements were conducted at the end of the intervention (Follow-up I) and 1 year later (Follow-up II). Random coefficient analyses for longitudinal data showed that the effects of both interventions did not differ between the two follow-up measurements. The results showed similar effects for the free distribution program and the multicomponent program in increasing children's fruit consumption over time (respectively, 7.2 and 15.2 g day(-1)). The distribution program also increased children's vegetable consumption over time (3.25 g day(-1)), even after repeating the analyses using a pessimistic scenario. Despite the large dropout and its consequences for generalizability of our results, the distribution program is considered as the preferred intervention of the two, and implementation on a larger scale should be investigated.

It appears that in practice exposure to Internet-delivered behaviour change interventions, encouraging a healthy lifestyle for adolescents with regard to health risk behaviours, is quite low. There is, however, a lack of evidence-based insight into how to disseminate such interventions and how to reach optimal exposure. A more extensive exploration is therefore timely since this knowledge is crucial to improve the public health impact of such interventions. By means of a three-round Delphi study factors associated with dissemination of and exposure (first visit, stay long enough and revisit) to Internet-delivered interventions aimed at adolescents had been identified, as well as the extent to which experts agree on the importance of these factors. Results showed that there was a high rate of consensus among experts from several disciplines with regard to the importance of factors like word of mouth recommendation, the interface of the intervention and utilization of all features provided by the Internet. Experts do not agree, however, on a gold standard for successful dissemination. Overall, the results of this exploration serve as a handle for the formation of further research questions to be tested and answered in research among adolescents.

The explosive increase in Internet accessibility and use offers unique opportunities for providing health information to adolescents via the Internet. The purpose of this evaluation study was to explore the opinions of adolescents regarding an Internet-based health monitoring instrument and its individually tailored electronic feedback so that recommendations for improvement can be provided. A self-administered evaluation questionnaire was completed by 672 adolescents aged 12-18 years the Dutch equivalent of the 8th and 10th grade of secondary education. Semistructured group interviews were conducted with 53 adolescents to obtain more in-depth information regarding the monitoring questionnaire and the individually tailored feedback. All the respondents preferred the electronic monitoring questionnaire to a paper and pencil questionnaire and the individually tailored feedback was appraised rather favorably. However, 28% of the respondents claimed that the information was not new to them and 39% indicated that the information failed to provide them with additional insight into their behavior. In order to increase the number of adolescents reached, we recommend (i) embedding monitoring and feedback in school curriculum, (ii) providing immediate feedback and (iii) adapting tailored messages to educational levels and age. Although several improvements can and should be made, we conclude that the Internet-based monitoring questionnaire and the individually tailored feedback were appreciated by adolescents and are therefore a promising method for engaging adolescents in health promotion.

A match-mismatch test was conducted to test the transtheoretical model applied to fruit intake. Precontemplators and contemplators were randomly assigned to receive a web-based individualized precontemplation feedback (PCF), contemplation feedback (CF) or action feedback (AF) letter promoting fruit intake. Immediately and 1 week after reading this letter, post-test measures were obtained. Fruit intake increased significantly between pre- and post-test in contemplators, but not in precontemplators. No differences between the feedback conditions were found in fruit intake, stage progression, use or credibility of the feedback in precontemplators and contemplators. In precontemplators, also no differences between the conditions were found in personal relevance of the feedback. Contemplators, however, rated AF as more personally relevant than PCF or CF. To conclude, the present study failed to show superiority of stage-matched information in the promotion of fruit intake.

We explored if the pre-action Transtheoretical stages of change are indeed discrete stages for fruit intakes. In a longitudinal design, a cohort of 735 adults completed electronic questionnaires assessing fruit intake, stages of change and intention to increase fruit intake at baseline and 35 and 67 days follow-up. A dichotomization of a continuous intention measure ('pseudostages') was compared with precontemplation and contemplation stages. The results showed (i) that pseudostages and stages of change were strongly associated; (ii) that for most respondents, stability and transitions in stages of change resembled transitions in pseudostage, while test-retest reliabilities for both measures were similar and (iii) that pseudostages and the continuous intention measure were stronger predictors of fruit intake than stage of change. We conclude that pre-action stages of change for fruit are not different from a mere categorization of a continuous intention measure.

Although much research has been done on the existence and formation of risk and issue based health policies, there is only little insight in health policy development processes in a broader context. This hampers intervention in these policy processes to adequately develop integrated and effective health policies. Legislation in the Netherlands requires municipalities to develop and implement local health policies. These policies are supposed to aim at the promotion of health across sectors and with a strong community involvement. Health policy development processes have been studied in four Dutch municipalities. For each case, we identified a range of stakeholders and monitored the change or stability of their characteristics over 3 years. In addition, for each case, three overlaying maps of networks were made addressing communication and collaboration actions within the defined set of stakeholders. We point out a number of barriers which impede integrated policy development at the local level: the importance given to local health policy, the medical approach to health development, the organizational self-interest rather than public health concern, the absence of policy entrepreneurial activity. Furthermore, this article advocates the use of complementary theoretical frameworks and the expansion of the methodological toolbox for health promotion. The value of stakeholder and network analysis in the health promotion domain, at this stage, is two-fold. First, mapping relevant actors, their positions and connections in networks provides us with insight into their capacity to participate and contribute to health policy development. Second, these new tools contribute to a further understanding of policy entrepreneurial roles to be taken up by health promotion professionals and health authorities in favour of the socio-environmental approach to health. Notwithstanding the value of this first step, more research is required into both the practical application as well as in the theoretical connections with, for example, Multiple Streams theory.

This paper describes a new way of monitoring the health status of Dutch adolescents in order to stimulate the development of health policies at school and local levels and providing individual feedback using modern technology. The project is called E-MOVO that stands for Electronic Monitor and Health Education, in which seven Regional Health Authorities and the University of Maastricht collaborate. In this project, adolescents completed an electronic questionnaire via the Internet which measured topics related to demographics, school, physical health, mental health, well-being, lifestyle, criminality and leisure time activities. These data were used for feedback at three levels. On the basis of their answers, adolescents received tailored feedback on lifestyle in a personal 'E-MOVO score', including links to relevant websites or other tailored information. The aggregated data were used to provide schools and municipalities with information on the health and well-being of their adolescent population. These data were used to encourage the development of health promoting policies and activities at both levels. This project was evaluated and is now adapted to implement at a national level.

Insight into stage transition determinants is necessary to develop and evaluate stage-tailored health-promoting interventions. A three-round Delphi study among stages of change researchers was conducted to make an inventory of opinions and examine agreement on determinants of forward transitions between Transtheoretical stages of change. In the first round, 10 experts completed an electronic questionnaire with open-ended questions about potential determinants for each stage transition. In the second round, a structured electronic questionnaire based on the first round results was sent to authors of scientific papers on stages of change, published between 1995 and May 2002. In the third round, participants were presented feedback about the second round and were asked to re-rate their answers based on the information provided. Results showed that participants agreed on various transition determinants, but that determinants were not always stage-specific, e.g. control-related issues and social support were identified as determinants of all transitions from contemplation to maintenance. The results further showed lower consensus about determinants of earlier stage transitions than about determinants of later stage transitions. The Delphi study identified hypotheses worthy of further examination in longitudinal observational and experimental studies.

Self-evaluation is crucial to mental and social well-being. It influences aspirations, personal goals and interaction with others. This paper stresses the importance of self-esteem as a protective factor and a non-specific risk factor in physical and mental health. Evidence is presented illustrating that self-esteem can lead to better health and social behavior, and that poor self-esteem is associated with a broad range of mental disorders and social problems, both internalizing problems (e.g. depression, suicidal tendencies, eating disorders and anxiety) and externalizing problems (e.g. violence and substance abuse). We discuss the dynamics of self-esteem in these relations. It is argued that an understanding of the development of self-esteem, its outcomes, and its active protection and promotion are critical to the improvement of both mental and physical health. The consequences for theory development, program development and health education research are addressed. Focusing on self-esteem is considered a core element of mental health promotion and a fruitful basis for a broad-spectrum approach.

To date, comprehensive community health projects have not been evaluated in terms of their effect at the individual level, because outcomes are usually not defined at this level. In a community health project in The Netherlands, evaluation outcome mapping, a technique derived from intervention mapping, was used to identify distal as well as proximal programme objectives from which outcome measures could be derived. The intervention took place in a deprived area, where community members themselves defined stress, lack of area safety and parenting problems as the health-related problems they wanted to see addressed in the project. Local organizations wrote and implemented an action plan. The effects among residents were studied in a quasi-experimental design. Although no significant effects on improved perceived health or health-related problems were found at the level of the residents, the problems identified and their assumed causes showed significant coherence. This study is believed to be of relevance to evidence-based health promotion theory and practice as it demonstrates that it is possible to conduct an individual effect evaluation in a comprehensive community approach without jeopardizing the process of the intervention.