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

The number of children dealing with behavioural problems is increasing. A major challenge in many health-supportive programmes is the recruitment and retention of these children. In the current study, Sport Mix Club (SMC), an approach to enhance socioemotional disorders of 4- to 12-year-old children through sport classes in municipality Vaals, the Netherlands, is used as an illustration. Where many studies faced difficulties getting and keeping children in their interventions, SMC overcame this challenge. Therefore, we decided to explore “What factors contribute to enhanced recruitment and retention procedures among children with behavioural problems in Sport Mix Club?” A qualitative case study design using the analysis of the administrative logbook of the SMC coach and trainees, individual interviews with the SMC coach, trainees (n = 2), school teachers (n = 3) and parents of participating children (n = 9), and four focus group interviews with children (n = 13) were carried out. During the recruitment and retention of SMC, the human psychological need of relatedness seemed to be of crucial value. The fact that the SMC coach: (1) made efforts to become a familiar face for children, parents and community partners beforehand; (2) showed enthusiasm; and (3) placed her focus on having fun as opposed to the children's problems, seemed to be decisive in the process of getting children to participate in SMC and retaining their participation.

Although personality is associated with the onset of substance use (i.e., conventional smoking, alcohol use, and cannabis use) during adolescence, it is unclear whether personality traits are also associated with the onset of use of alternative tobacco products (ATPs), i.e., electronic cigarettes, shisha-pens, and water pipes. This study examines whether personality traits are associated with the onset of use of both conventional cigarettes and ATPs. Longitudinal data (baseline and 18-month follow-up) were used. The sample consisted of 1114 non-user adolescents (mean age = 13.36, SD = 0.93, 56% female) at baseline. To measure personality traits, the Substance Use Risk Profile Scale was used with four subscales: anxiety sensitivity, hopelessness, sensation seeking, and impulsivity. Structural equation models were conducted using Mplus 7.3. Results showed that both hopelessness and sensation seeking were associated with the onset of use of e-cigarettes and conventional cigarettes. Further, sensation seeking and impulsivity were associated with the onset of use of shisha-pens and water pipes. In conclusion, to prevent adolescents from using ATPs and/or conventional cigarettes, it is important to take their personality traits into account. More research on other (shared) risk factors and on more advanced stages of ATP use is needed before effective prevention strategies can be developed.

Loneliness is a growing public health issue. It is more common in disadvantaged groups and has been associated with a range of poor health outcomes. Loneliness may also form an independent pathway between socio-economic disadvantage and poor health. Therefore, the aim of this study was to explore the contribution of loneliness to socio-economic health inequalities. These contributions were studied in a Dutch national sample (n = 445,748 adults (≥19 y.o.)) in Poisson and logistic regression models, controlling for age, gender, marital status, migration background, BMI, alcohol consumption, smoking, and physical activity. Loneliness explained 21% of socioeconomic health inequalities between the lowest and highest socio-economic groups in self-reported chronic disease prevalence, 27% in poorer self-rated health, and 51% in psychological distress. Subgroup analyses revealed that for young adults, loneliness had a larger contribution to socioeconomic gaps in self-rated health (37%) than in 80+-year-olds (16%). Our findings suggest that loneliness may be a social determinant of health, contributing to the socioeconomic health gap independently of well-documented factors such as lifestyles and demographics, in particular for young adults. Public health policies targeting socioeconomic health inequalities could benefit from integrating loneliness into their policies, especially for young adults.

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

Background: The current study investigated the moderating role of the school context on the effects of a Dutch health promoting school initiative on children&rsquo, s health and health behaviors. Methods: The study used a mixed-methods design. The school context (n = 4) was assessed by the characteristics of the school population, teacher&rsquo, s health-promoting (HP) practices, implementers&rsquo, perceived barriers, school&rsquo, s HP elements, and dominating organizational issues. Outcomes included objectively assessed BMI z-scores and physical activity (PA), and parent and child-reported dietary intake. Analyses included linear mixed models (four intervention schools versus four control schools), and qualitative comparisons between intervention schools with similar HP changes. Results: Effects on outcomes varied considerably across schools (e.g., range in effect size on light PA of 0.01&ndash, 0.26). Potentially moderating contextual aspects were the child&rsquo, s socioeconomic background and baseline health behaviors, practices and perceived barriers of employees, and organizational issues at a school level. Conclusions: Similar HP changes lead to different outcomes across schools due to differences in the school context. The adoption of a complex adaptive systems perspective contributes to a better understanding of the variation in effects and it can provide insight on which contextual aspects to focus on or intervene in to optimize the effects of HP initiatives.

Schools can help to improve children&rsquo, s health. The &lsquo, Healthy Primary School of the Future&rsquo, (HPSF) aims to sustainably integrate health and well-being into the school system. This study examined the effects of HPSF on children&rsquo, s dietary and physical activity (PA) behaviours after 1 and 2 years&rsquo, follow-up. The study (n = 1676 children) has a quasi-experimental design with four intervention schools, i.e., two full HPSF (focus: nutrition and PA) and two partial HPSF (focus: PA), and four control schools. Accelerometers and child- and parent-reported questionnaires were used at baseline, after 1 (T1) and 2 (T2) years. Mixed-model analyses showed significant favourable effects for the full HPSF versus control schools for, among others, school water consumption (effect size (ES) = 1.03 (T1), 1.14 (T2)), lunch intake of vegetables (odds ratio (OR) = 3.17 (T1), 4.39 (T2)) and dairy products (OR = 4.43 (T1), 4.52 (T2)), sedentary time (ES = &minus, 0.23 (T2)) and light PA (ES = 0.22 (T2)). Almost no significant favourable effects were found for partial HPSF compared to control schools. We conclude that the full HPSF is effective in promoting children&rsquo, s health behaviours at T1 and T2 compared with control schools. Focusing on both nutrition and PA components seems to be more effective in promoting healthy behaviours than focusing exclusively on PA.

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

BackgroundResearch on the effectiveness of school smoking policies on adolescents’ smoking behaviour remain inconclusive. This study evaluates the results of an outdoor school ground smoking ban at secondary schools on adolescents smoking behaviour, taking individual characteristics into account.MethodsData on 2684 adolescents from 18 Dutch secondary schools (nine with and nine without an outdoor smoking ban) were obtained at two moments. Associations between outdoor school ground smoking bans, individual characteristics, and smoking prevalence and frequency were measured. Multilevel logistic regression analyses were used. At schools with a ban implementation fidelity was checked.ResultsAlthough smoking prevalence and frequency appeared to make a slower increase at schools with an outdoor smoking ban compared with schools without an outdoor smoking ban, the differences were not significant. Differences between schools in the prevalence of smoking behaviour of students could mainly be explained by individual characteristics. Smoking prevalence and frequency were higher among adolescents with a positive attitude towards smoking and when significant others were more positive about smoking. Smoking prevalence and frequency were significantly lower when adolescents perceived it as easy not to smoke. Implementation fidelity was good at schools with a ban.ConclusionsNo short-term effects were found of an outdoor smoking ban. A longer follow-up time than 6 months is needed. In addition, future research should investigate effectiveness in relation to the enforcement of the ban, comprehensiveness of the ban and when it is prohibited to leave school grounds, as smoking behavior might be transferred off school grounds.

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

Background:Although outdoor smoking bans at school are becoming important, it remains unclear whether successful implementation is feasible and what conditions promote it. Therefore, this study evaluates the implementation process by identifying important factors.Methods:Interviews were held with directors of 24 secondary schools that had decided to implement an outdoor school ground smoking ban, to identify important factors during implementation. Additionally, observations were made before and (about 4 weeks) after implementation to evaluate adherence to guidelines. Data were analyzed using a thematic approach.Results:During implementation, the following items were important: smoking ban (eg, guidelines), school (eg, policy, enforcement, environmental factors, resources, etc), and external factors (eg, social environment). Four schools were unable to implement the ban, 20 schools implemented the ban but student adherence was low, and at 4 schools, staff members still smoked on school grounds.Conclusions:Although implementation is feasible, there are challenges. Schools need to apply a phased/dynamic process with ample lead time and clear communication of the policy. Directors should deal with offenders by strictly enforcing the ban and helping them stop smoking. This study offers information to help institutes implement an outdoor smoking ban to further protect adolescents from the harm of smoking.

To study school lifestyle interventions for elementary school children (The Healthy Primary School of the Future).What are the effects of the introduction of increased physical activity with or without healthy nutrition on health behaviour and BMI of young children and what are the costs of this program?Prospective controlled non-randomized study with nearly 1700 children in Parkstad (South-East Netherlands).Preliminary results after two years show that the combination of increased physical activity and healthy nutrition result in a decreased BMIz-score (-0.036), increased physical activity alone in hardly any change (-0.10) while in the control group the BMIz-score increased (0.052). The net societal costs of the combination of physical activity and health nutrition costs were 1 euro per child per day.The study contributes to the increasing amount of evidence proving that lifestyle interventions are effective in reducing the obesity epidemic. Future studies will show whether a weight reduction in children will result in the prevention of chronic disease later on in life and what the cost reduction related to this result will be.

Objectives: Loneliness has been associated with unhealthy behavior, poorer health, and increased morbidity. However, the costs of loneliness are poorly understood.Methods: Multiple sources were combined into a dataset containing a nationally representative sample (n = 341,376) of Dutch adults (18+). The association between loneliness and total, general practitioner (GP), specialized, pharmaceutical, and mental healthcare expenditure was tested using Poisson and Zero-inflated negative binomial models, controlling for numerous potential confounders (i.e., demographic, socioeconomic, lifestyle-related factors, self-perceived health, and psychological distress), for four age groups.Results: Controlling for demographic, socioeconomic, and lifestyle-related factors, loneliness was indirectly (via poorer health) associated with higher expenditure in all categories. In fully adjusted models, it showed a direct association with higher expenditure for GP and mental healthcare (0.5 and 11.1%, respectively). The association with mental healthcare expenditure was stronger in younger than in older adults (for ages 19–40, the contribution of loneliness represented 61.8% of the overall association).Conclusion: Loneliness contributes to health expenditure both directly and indirectly, particularly in younger age groups. This implies a strong financial imperative to address this issue.

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

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

School health promotion is advocated. Implementation studies on school health promotion are less often conducted as effectiveness studies and are mainly conducted conventionally by assessing fidelity of &ldquo, one size fits all&rdquo, interventions. However, interventions that allow for local adaptation are more appropriate and require a different evaluation approach. We evaluated a mutual adaptation physical activity and nutrition intervention implemented in eight primary schools located in low socioeconomic neighborhoods in the Netherlands, namely the KEIGAAF intervention. A qualitative, multiple-case study design was used to evaluate implementation and contextual factors affecting implementation. We used several qualitative data collection tools and applied inductive content analysis for coding the transcribed data. Codes were linked to the domains of the Consolidated Framework for Implementation Research. NVivo was used to support data analysis. The implementation process varied greatly across schools. This was due to the high level of bottom-up design of the intervention and differing contextual factors influencing implementation, such as differing starting situations. The mutual adaptation between top-down and bottom-up influences was a key element of the intervention. Feedback loops and the health promotion advisors played a crucial role by navigating between top-down and bottom-up. Implementing a mutual adaptation intervention is time-consuming but feasible.

In health-promoting interventions, a main difficulty is that low socioeconomic status (SES) groups especially seem to experience barriers to participation. To overcome this barrier, the current study focused on the success factors and obstacles in the process of supporting low-SES families in becoming partners, while carrying out small-scale activities based on their needs. A retrospective case study design was used to construct a timeline of activities organized by and together with low-SES families based on mainly qualitative data. Next, key events were grouped into the four attributes of the resilience activation framework: human, social, political, and economic capital. The following key lessons were defined: professionals should let go of work routines and accommodate the talents of the families, start doing, strive for small successes, create a functional social network surrounding the families, maintaining professional support over time as back-up, and create collaborative governance to build upon accessibility, transparency and trust among the low-SES families. Continuous and flexible &lsquo, navigating the middle&rsquo, between bottom-up and top-down approaches was seen as vital in the partnership process between low-SES families and local professional partners. Constant feedback loops made the evaluation points clear, which supported both families and professionals to enhance their partnership.

Trypanosoma cruzi, the protozoan agent of Chagas disease in the Americas, is comprised of six genetic lineages (TcI-TcVI) and a possible seventh (TcBat, related to TcI). Identification of T. cruzi lineages infecting reservoir mammalian species is fundamental to resolving transmission cycles. However, this is hindered by the limited sensitivity and technical complexity of parasite isolation and genotyping. An alternative approach is serology using T. cruzi lineage-specific epitopes, such as those of the trypomastigote small surface antigen (TSSA). For surveillance of T. cruzi lineage infections in mammal species from diverse Brazilian regions, we apply a novel rapid diagnostic test (RDT, Chagas Sero K-SeT), which incorporates the TSSA peptide epitope specific to TcII/V/VI (TSSApep-II/V/VI) and Protein G detection of antibodies. Chagas Sero K-SeT RDT results with sera from experimentally infected mice, from tamarin primates (Leontopithecus spp.) and from canines (Canis familiaris) were concordant with corresponding TSSApep-II/V/VI ELISAs. The Chagas Sero K-Set detected TcII/V/VI infections in Leontopithecus spp. from the Atlantic forest (n = 46), in C. familiaris (n = 16) and Thrichomys laurentius (n = 2) from Caatinga biome and Chiroptera (n = 1) from Acre, Amazonia. The Chagas Sero K-SeT RDT is directly applicable to TcII/V/VI-specific serological surveillance of T. cruzi infection in several different mammalian Orders. It can replace ELISAs and provides efficient, point-of-sampling, low-cost detection of TcII/V/VI infections, with at least equivalent sensitivity, although some mammals may be difficult to trap, and, not unexpectedly, Chagas Sero K-SeT could not recognise feline IgG. Knowledge of sylvatic hosts of T. cruzi can be expanded, new reservoir species discovered, and the ecology of transmission cycles clarified, particularly with adaptation to further mammalian Orders.

Trypanosomatids are ancient parasitic eukaryotes that still maintain prokaryotic characteristics. Trypanosoma cruzi, a primarily wild mammal parasite, infected humans already long before European colonization of the Americas. T. cruzi heterogeneity remains an unsolved question, and until now, it has still not been possible to associate T. cruzi genotypes with any biological or epidemiological feature. One of the first biochemical attempts to cluster the T. cruzi subpopulations recognized three main subpopulations (zymodemes) that have been associated with the transmission cycles in the wild (Z1; Z3) and in the domestic environment (Z2). The description of wild mammal species harboring Z2 two decades later challenged this assemblage attempt. Currently, the genotypes of T. cruzi are assembled in seven discrete typing units (DTUs). The biology of T. cruzi still shows novelties such as the description of epimastigotes multiplying and differentiating to metacyclic trypomastigotes in the lumen of the scent glands of Didelphis spp. and the capacity of the true meiosis in parallel to clonal reproduction. The study of the transmission cycle among wild animals has broken paradigms and raised new questions: (i) the interaction of the T. cruzi DTUs with each of its mammalian host species displays peculiarities; (ii) the impact of mixed genotypes and species on the transmissibility of one or another species or on pathogenesis is still unknown; (iii) independent T. cruzi transmission cycles may occur in the same forest fragment; (iv) the capacity to act as a reservoir depends on the peculiarities of the host species and the parasite genotype; and (v) faunistic composition is a defining trait of the T. cruzi transmission cycle profile. The development of models of environmental variables that determine the spatial distribution of the elements that make up T. cruzi transmission by spatial analysis, followed by map algebra and networking, are the next steps toward interpreting and dealing with the new profile of Chagas disease with its many peculiarities. There is no way to solve this neglected disease once and for all if not through a multidisciplinary look that takes into account all kinds of human and animal activities in parallel to environmental variations.

Ageing-in-place is considered important for the health of older adults. In this paper, inspired by a constructivist approach to ageing-in-place, we unravel professionals’ and older adults’ constructions of ageing-in-place. Their perspectives are studied in relation to a policy that aims to develop so-called ‘lifecycle-robust neighbourhoods’ in the southern part of the Netherlands. We conducted a photovoice study in which 18 older adults (70–85 years) living independently and 14 professionals (social workers, housing consultants, neighbourhood managers and community workers) were asked to photograph and discuss the places they consider important for ageing-in-place. Based on a theoretically informed analysis of the data, we found that professionals primarily consider objective characteristics of neighbourhoods such as access to amenities, mobility and meeting places as important enablers for older adults to remain living independently. Analysis of older adults’ photographs and stories show that they associate ageing-in-place with specific lived experiences and attachments to specific, intangible and memory-laden public places. We conclude that exploring these experiences helps to increase current knowledge about place attachment in old age.

Objective: Fatigue is an important health outcome in public and occupational health care. To correctly understand and treat high levels of (prolonged) fatigue it is important to disentangle the state of fatigue into a time varying (occasion) and -invarying (trait) component. Not only for understanding of the construct itself over time but also for its relation with (health) outcomes such as sickness absence.Methods: Longitudinal data (n = 2316) from the Maastricht Cohort Study (MCS) study was used, which assessed fatigue across 4-month intervals using the Checklist Individual Strength (CIS).Results: It was found that the occasion component explains 27.60% (95%-CI [25.80%; 29.40%]) of the variance of fatigue and the trait component 71.00% (95%-CI [69.00%; 72.90%]). The trait component was, furthermore, found to be a significant predictor of sickness absence.Conclusion: Fatigue has a considerable time-invariant component. As this component is also related with other adverse health outcomes, preventive measures and interventions should take the difference between the occasion and trait component of fatigue into account.

Background: It has been suggested that prenatal exposure to n-3 long-chain fatty acids protects against asthma and other allergy-related diseases later in childhood. The extent to which fish intake in pregnancy protects against child asthma and rhinitis symptoms remains unclear. We aimed to assess whether fish and seafood consumption in pregnancy is associated with childhood wheeze, asthma and allergic rhinitis. Methods: We pooled individual data from 60 774 mother-child pairs participating in 18 European and US birth cohort studies. Information on wheeze, asthma and allergic rhinitis prevalence was collected using validated questionnaires. The time periods of interest were: infancy (0-2 years), preschool age (3-4 years), and school age (5-8 years). We used multivariable generalized models to assess associations of fish and seafood (other than fish) consumption during pregnancy with child respiratory outcomes in cohort-specific analyses, with subsequent random-effects meta-analyses. Results: The median fish consumption during pregnancy ranged from 0.44 times/week in The Netherlands to 4.46 times/week in Spain. Maternal fish intake during pregnancy was not associated with offspring wheeze symptoms in any age group nor with the risk of child asthma [adjusted meta-analysis relative risk (RR) per 1-time/week = 1.01, 95% confidence interval 0.97-1.05)] and allergic rhinitis at school age (RR = 1.01, 0.99-1.03). These results were consistently found in further analyses by type of fish and seafood consumption and in sensitivity analyses. Conclusion: We found no evidence supporting a protective association of fish and seafood consumption during pregnancy with offspring symptoms of wheeze, asthma and allergic rhinitis from infancy to mid childhood. This work was supported by the European Community’s Seventh Framework Program [EU- FP7- HEALTH-2009-single-stage-241604]. Details of funding per cohort are available at IJE online.

Background: Parents influence their children&rsquo, s nutrition behavior. The relationship between parental influences and children&rsquo, s nutrition behavior is often studied with a focus on the dyadic interaction between the parent and the child. However, parents and children are part of a broader system: the family. We investigated the relationship between the family nutrition climate (FNC), a family-level concept, and children&rsquo, s nutrition behavior. Methods: Parents of primary school-aged children (N = 229) filled in the validated family nutrition climate (FNC) scale. This scale measures the families&rsquo, view on the consumption of healthy nutrition, consisting of four different concepts: value, communication, cohesion, and consensus. Parents also reported their children&rsquo, s nutrition behavior (i.e., fruit, vegetable, water, candy, savory snack, and soda consumption). Multivariate linear regression analyses, correcting for potential confounders, were used to assess the relationship between the FNC scale (FNC-Total, model 1) and the different FNC subscales (model 2) and the child&rsquo, s nutrition behavior. Results: FNC-Total was positively related to fruit and vegetable intake and negatively related to soda consumption. FNC-value was a significant predictor of vegetable (positive) and candy intake (negative), and FNC-communication was a significant predictor of soda consumption (negative). FNC-communication, FNC-cohesion, and FNC-consensus were significant predictors (positive, positive, and negative, respectively) of water consumption. Conclusions: The FNC is related to children&rsquo, s nutrition behavior and especially to the consumption of healthy nutrition. These results imply the importance of taking the family-level influence into account when studying the influence of parents on children&rsquo, s nutrition behavior. Trial registration: Dutch Trial Register NTR6716 (registration date 27 June 2017, retrospectively registered), METC163027, NL58554.068.16, Fonds NutsOhra project number 101.253.

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

Background While schools have potential to contribute to children’s health and healthy behaviour, embedding health promotion within complex school systems is challenging. The ‘Healthy Primary School of the Future’ (HPSF) is an initiative that aims to integrate health and well-being into school systems. Central to HPSF are two top-down changes that are hypothesized as being positively disruptive to the Dutch school system: daily free healthy lunches and structured physical activity sessions. These changes are expected to create momentum for bottom-up processes leading to additional health-promoting changes. Using a programme theory, this paper explores the processes through which HPSF and the school context adapt to one another. The aim is to generate and share knowledge and experiences on how to implement changes in the complex school system to integrate school health promotion. Methods The current study involved a mixed methods process evaluation with a contextual action-oriented research approach. The processes of change were investigated in four Dutch primary schools during the development year (2014–2015) and the first two years of implementation (2015–2017) of HPSF. The schools (each with 15–26 teachers and 233–389 children) were in low socio-economic status areas. Measurements included interviews, questionnaires, observations, and analysis of minutes of meetings. Results Top-down advice, combined with bottom-up involvement and external practical support were key facilitators in embedding HPSF within the schools’ contexts. Sufficient coordination and communication at the school level, team cohesion, and feedback loops enhanced implementation of the changes. Implementation of the healthy lunch appeared to be disruptive and create momentum for additional health-promoting changes. Conclusions Initiating highly visible positive disruptions to improve school health can act as a catalyst for wider school health promotion efforts. Conditions to create a positive disruption are enough time, and sufficient bottom-up involvement, external support, team cohesion and coordination. The focus should be on each specific school, as each school has their own starting point and process of change. Trial registration The study was retrospectively registered in the ClinicalTrials.gov database on 14 June 2016 (NCT02800616).

Objective To describe the experiences of South African patients living with head and neck cancer. Methods We used a qualitative descriptive design and conducted unstructured interviews with 18 (n = 18) purposive selected participants. Data saturation determined the sample size. Qualitative content analysis was used to analyse the data. Results The majority of the sample were Black males; on average, 50.8 years (SD ± 13.6) old. Two themes and eight subthemes arose from the data. The themes were living with the consequences of the illness and treatment, and coping with a changed life. The lives the participants knew before becoming sick changed and became a living hell; pain was a major problem as was eating and for some, communicating. The participants were stigmatised, ridiculed and rejected which added to their suffering. Receiving support from family and friends and their faith in God assisted them to cope with their changed lives. Conclusion Our study poses various challenges to clinical practice. Pain management is of the utmost importance; the nutritional status of these patients should be monitored and best practices in terms of management applied. Raising awareness of cancer and its complications could improve knowledge and decrease blame, stigmatisation and rejection and improve patient outcomes.

High healthcare expenditures due to population ageing and chronic complex health complaints are a challenge on a global scale. To improve the quality of healthcare, population health, and professionals’ work satisfaction and to reduce healthcare costs (Quadruple Aim), the Dutch Ministry of Health, Welfare and Sport designated nine pioneer site regions across the Netherlands. One of these pioneer sites is the integrated community approach (ICA) known as ‘Blue Care’. This article describes the design of a prospective study investigating the effects of Blue Care ICA on Quadruple Aim outcomes and a process evaluation focussing on its implementation in deprived neighbourhoods. A mixed-methods approach, combining both quantitative and qualitative research methods, is applied to yield an enriched understanding of the various processes that will take place in the neighbourhoods. A prospective, quasi-experimental study is conducted within a natural experiment. Blue Care ICA is being implemented between 2017 and 2020 and research activities are taking place parallel to the implementation process. Effects of Blue Care ICA are measured at T0 (baseline), T1 (after 1 year), T2 (after 2 years) and at T3 (after 3 years) using a questionnaire. The primary outcome measure is health-related quality of life (SF-12v2), secondary outcomes are health status (EQ-5D-5 L), resilience (RS-Scale), Positive Health (Spiderweb diagram) and quality of care (grade 0–10). As part of the process evaluation, the Consolidated Framework for Implementation Research guided the formulation of process evaluation questions. Participant observations, interviews and focus groups with all stakeholders active in the Blue Care ICA will be conducted during the whole implementation period (2017–2020). The evaluation takes into account the interconnections between content, application, context and outcomes to understand how the Blue Care ICA unfolds over time in a complex, dynamic setting. Results of the effect and process evaluation will become available in 2020. NTR 6543 , registration date; 25 July 2017.

Purpose: This study aimed to identify opportunities to improve the current health and social situation of low socioeconomic status (SES) families and to gain a better understanding of the main needs regarding health promotion. Low-SES families were approached to participate in a photovoice study. Method: The study took place in the municipality of Vaals, which is located in the southernmost part of the Netherlands. A diverse group of ten people from eight different families took about 150 photographs within their community on topics they considered important for their health and quality of life. This was followed by individual interviews and a focus group interview. Results: Four main needs were identified: meeting each other, helping each other, feeling safe and being mobile. The photographs showed that health-related themes had low priority for these families. Conclusion: The low-SES families focused on upstream factors relating to independence, self-resilience and a sense of belonging, to help them cope with their current situation. This study represents a first step towards the development of a community approach to health promotion in low-SES families.

Background Alcohol withdrawal can lead to severe complications including seizures, delirium tremens, and death if not treated appropriately. Nurses are critical to the safety and outcomes of these patients. Objective The objective of this retrospective study was to determine if nursing education on a community hospital's alcohol withdrawal protocol led to improved nursing compliance. Methods This is a quality improvement project involving a two-part retrospective review-an initial needs assessment followed by nursing education and a subsequent posteducation retrospective review. The initial needs assessment included 65 patients. The subsequent posteducation group included 50 patients. Results Nursing compliance of 1-hour assessments increased after the educational intervention; however, there was no statistically significant difference in 6-hour assessment or medication administration protocol compliance between preeducation and posteducation groups. Conclusion Nursing education is a good place to start in improving compliance with an alcohol withdrawal protocol, but physicians need to be included to increase standardization within the institution. Future study should look at the effectiveness of different assessment frequency intervals and its impact on patient-centered outcomes.

BACKGROUND: Unhealthy lifestyles in early childhood are a major global health challenge. These lifestyles often persist from generation to generation and contribute to a vicious cycle of health-related and social problems. This design article presents a study evaluating the effects of two novel healthy school interventions. The main outcome measure will be changes in children's body mass index (BMI). In addition, lifestyle behaviours, academic achievement, child well-being, socio-economic differences, and societal costs will be examined.METHODS: In close collaboration with various stakeholders, a quasi-experimental study was developed, for which children of four intervention schools (n = 1200) in the southern part of the Netherlands are compared with children of four control schools (n = 1200) in the same region. The interventions started in November 2015. In two of the four intervention schools, a whole-school approach named 'The Healthy Primary School of the Future', is implemented with the aim of improving physical activity and dietary behaviour. For this intervention, pupils are offered an extended curriculum, including a healthy lunch, more physical exercises, and social and educational activities, next to the regular school curriculum. In the two other intervention schools, a physical-activity school approach called 'The Physical Activity School', is implemented, which is essentially similar to the other intervention, except that no lunch is provided. The interventions proceed during a period of 4 years. Apart from the effectiveness of both interventions, the process, the cost-effectiveness, and the expected legal implications are studied. Data collection is conducted within the school system. The baseline measurements started in September 2015 and yearly follow-up measurements are taking place until 2019.DISCUSSION: A whole-school approach is a new concept in the Netherlands. Due to its innovative, multifaceted nature and sound scientific foundation, these integrated programmes have the potential to form a template for primary schools worldwide. The effects of this approach may extend further than the outcomes associated with well-being and academic achievement, potentially impacting legal and cultural aspects in our society.TRIAL REGISTRATION: The study protocol was registered in the database ClinicalTrials.gov on 14-06-2016 with the reference number NCT02800616 .

Objectives To identify behavioral and personal characteristics of child health care (CHC) practitioners that influences the effect of early overweight prevention in children. Methods In total 216 questionnaires were filled out by CHC practitioners from four organizations in the Netherlands. Results There is a gap between awareness of the problem overweight in early childhood and actually discussing this with parents, as well as a gap between the existing recommendations and the perceived importance of early overweight prevention. Despite the fact that nurses have a more central task in life-style support than physicians, they reported to have less knowledge and skills than physicians. Conclusions While both CHC physicians and nurses need support in improving their knowledge and skills, it is the nurses who need more support. A more structured and tailored implementation strategy with more emphasis on the needs of the nurses and physicians may improve early overweight management.

Trypanosoma cruzi is a widespread protozoan in Latin America causing Chagas disease in humans and able to infect several other mammal species. The objective of this study was to investigate the T. cruzi infection in triatomine fauna as well as in dogs from distinct areas of Acre, western Brazilian Amazonia, which recently reported acute cases of human CD as well as an area that have not notify this disease recently. Triatomines were collected and the intestinal contents were evaluated for the presence of trypanosomatids by optical microscopy and polymerase chain reaction (PCR) targeting the mini-exon gene. Blood smear, hemoculture, PCR and serology were performed in the studied mammals. Fecal content of four triatomines were positive (11.6%) in the fresh examination. Molecular analysis identified Trypanosoma cruzi TCI in two specimens. Blood samples from 90 dogs were obtained. Trypanosoma sp. was observed in six blood smears (6/83, 7.22%). Seropositivity for T. cruzi was 8/89 (8.98). One dog's hemoculture was obtained and characterized as T. rangeli. PCR reactions in blood clots resulted in one positive dog (1/75, 1.3%) infected by T. janseni, providing a new mammalian host for a recently described Trypanosoma species. The results demonstrate the low exposition and prevalence for T. cruzi suggesting that dogs are not important to T. cruzi transmission cycle in the studied áreas.

Background: Schools can play an important role in promoting children’s health behaviours. A Dutch initiative, ‘The Healthy Primary School of the Future’, aims to integrate health and well-being into the school system. We use a contextual action-oriented research approach (CARA) to study the implementation process. Properties of CARA are its focus on contextual differences and the use of monitoring and feedback to support and evaluate the process of change. The aim of this article is to describe the use of the approach. Methods: Four schools (each with 200–300 children, aged 4–12 years) were included; all located in low socio-economic status areas in the south of the Netherlands. Data collection methods include interviews, observations, questionnaires, and health and behavioural measurements. Research contributions include giving feedback and providing schools with a range of possibilities for additional changes. The contextual data we examine include schools’ health promoting elements, practices of teachers and parents, dominating organisational issues, and characteristics of the student population; process data include the presence of potential barriers to changes. Discussion: CARA is an adaptive research approach that generates knowledge and experiences on how to deal with health promotion in complex systems. We think this approach can set an example for research efforts in comparable initiatives.

Trypanosoma cruzi (Kinetoplastea: Trypanosomatidae) infects all tissues of its hosts, which along with humans, include hundreds of mammalian species in the Americas. The epidemiology of T. cruzi has been changing in that currently the majority of the cases and/or outbreaks of Chagas disease occur by the ingestion of comestibles contaminated by T. cruzi metacyclic forms. These cases/outbreaks occur in distinct regional scenarios, mainly in the Amazon biome and are related to the local interaction mode of humans with their surroundings, as well as with the overall local ecological peculiarities. As trypanosomiasis caused by T. cruzi is primarily a zoonosis, understanding the variables that influences its transmission in the wild as well as the role played by the extant fauna in the maintenance of the parasite, is critical in establishing control measures. Here, we present the results of our studies of T. cruzi infection of free ranging wild mammalian fauna in the five biomes of Brazil, a country of continental dimensions. From 1992 up to 2017, we examined a total of 6587 free-ranging non-volant wild mammal specimens. Our studies found that 17% of mammals were seropositive and 8% of all animals displayed positive hemocultures indicative of high parasitemia and, consequently, of infectivity potential. We observed that opossums, mainly Philander spp. and Didelphis spp., the coati Nasua nasua, the capuchin monkey Sapajus libidinosus and the golden lion tamarin Leontopithecus rosalia, were mammal taxa that demonstrated higher rates of positive hemocultures. Additionally, Didelphis spp. demonstrated to be a competent bioaccumulator of TcI diversity. Chiroptera were distinguished for hosting the greatest diversity of species and genotypes of Trypanosoma spp. Additionally the observation of the higher host range of some Trypanosoma spp., shows the need to reassess the ecology of representatives of the taxon. Altogether, our results showed that each locality, may display distinct enzootiological and epidemiological scenarios that must be taken into account when it comes to establishing control and/or clarification campaigns of the local population.

Background The environment affects children’s energy balance-related behaviors to a considerable extent. A context-based physical activity and nutrition school- and family-based intervention, named KEIGAAF, is being implemented in low socio-economic neighborhoods in Eindhoven, The Netherlands. The aim of this study was to investigate: 1) the effectiveness of the KEIGAAF intervention on BMI z-score, waist circumference, physical activity, sedentary behavior, nutrition behavior, and physical fitness of primary school children, and 2) the process related to the implementation of the intervention. Methods A quasi-experimental, controlled study with eight intervention schools and three control schools was conducted. The KEIGAAF intervention consists of a combined top-down and bottom-up school intervention: a steering committee developed the general KEIGAAF principles (top-down), and in accordance with these principles, KEIGAAF working groups subsequently develop and implement the intervention in their local context (bottom-up). Parents are also invited to participate in a family-based parenting program, i.e., Triple P Lifestyle. Children aged 7 to 10 years old (grades 4 to 6 in the Netherlands) are included in the study. Effect evaluation data is collected at baseline, after one year, and after two years by using a child questionnaire, accelerometers, anthropometry, a physical fitness test, and a parent questionnaire. A mixed methods approach is applied for the process evaluation: quantitative (checklists, questionnaires) and qualitative methods (observations, interviews) are used. To analyze intervention effectiveness, multilevel regression analyses will be conducted. Content analyses will be conducted on the qualitative process data. Discussion Two important environmental settings, the school environment and the family environment, are simultaneously targeted in the KEIGAAF intervention. The combined top-down and bottom-up approach is expected to make the intervention an effective and sustainable version of the Health Promoting Schools framework. An elaborate process evaluation will be conducted alongside an effect evaluation in which multiple data collection sources (both qualitative and quantitative) are used. Trial registration Dutch Trial Register NTR6716 (registration date 27/06/2017, retrospectively registered), METC163027, NL58554.068.16, Fonds NutsOhra project number 101.253. Electronic supplementary material The online version of this article (10.1186/s12889-018-5764-3) contains supplementary material, which is available to authorized users.

Background Trypanosoma cruzi, the causal agent of Chagas disease, is monophyletic but genetically heterogeneous. It is currently represented by six genetic lineages (Discrete Typing Units, DTUs) designated TcI-TcVI. TcI is the most geographically widespread and genetically heterogeneous lineage, this as is evidenced by a wide range of genetic markers applied to isolates spanning a vast geographic range in Latin America. Methodology/Principal findings In total, 78 TcI isolated from hosts and vectors distributed in 5 different biomes of Brazil, were analyzed using 6 nuclear housekeeping genes, 25 microsatellite loci and one mitochondrial marker. Nuclear markers reveal substantial genetic diversity, significant gene flow between biomes, incongruence in phylogenies, and haplotypic analysis indicative of intra-DTU genetic exchange. Phylogenetic reconstructions based on mitochondrial and nuclear loci were incongruent, and consistent with introgression. Structure analysis of microsatellite data reveals that, amongst biomes, the Amazon is the most genetically diverse and experiences the lowest level of gene flow. Investigation of population structure based on the host species/genus, indicated that Didelphis marsupialis might play a role as the main disperser of TcI. Conclusions/Significance The present work considers a large TcI sample from different hosts and vectors spanning multiple ecologically diverse biomes in Brazil. Importantly, we combine fast and slow evolving markers to contribute to the epizootiological understanding of TcI in five distinct Brazilian biomes. This constitutes the first instance in which MLST analysis was combined with the use of MLMT and maxicircle markers to evaluate the genetic diversity of TcI isolates in Brazil. Our results demonstrate the existence of substantial genetic diversity and the occurrence of introgression events. We provide evidence of genetic exchange in TcI isolates from Brazil and of the relative isolation of TcI in the Amazon biome. We observe the absence of strict associations with TcI genotypes to geographic areas and/or host species., Author summary T. cruzi is a zoonotic protozoan parasite infecting mammals and widely dispersed throughout endemic Latin America. It is known to possess considerable genetic diversity, comprising six discrete genetic lineages designated Discrete Typing Units (DTUs) TcI-TcVI. TcI is the most genetically diverse DTU and the most frequently sampled lineage in Brazil. We use a combination of high resolution molecular techniques to analyze the genetic diversity of Brazilian TcI isolates obtained from a wide geographical area encompassing five distinct biomes isolated from different mammal hosts and insect vectors. The results reveal significant genetic diversity and no clear association of genotypes with areas or host/vector species. Evidence from incongruent phylogenetic topologies based on nuclear and mitochondrial markers are indicative of genetic exchange and/or introgression events. The relevance of these findings in the context of population structure, ecology and epizootiology is discussed.

The ability to predict upper respiratory infections (URI), lower respiratory infections (LRI), and gastrointestinal tract infections (GI) in independently living older persons would greatly benefit population and individual health. Social network parameters have so far not been included in prediction models. Data were obtained from The Maastricht Study, a population-based cohort study (N = 3074, mean age (±s.d.) 59.8 ± 8.3, 48.8% women). We used multivariable logistic regression analysis to develop prediction models for self-reported symptomatic URI, LRI, and GI (past 2 months). We determined performance of the models by quantifying measures of discriminative ability and calibration. Overall, 953 individuals (31.0%) reported URI, 349 (11.4%) LRI, and 380 (12.4%) GI. The area under the curve was 64.7% (95% confidence interval (CI) 62.6–66.8%) for URI, 71.1% (95% CI 68.4–73.8) for LRI, and 64.2% (95% CI 61.3–67.1%) for GI. All models had good calibration (based on visual inspection of calibration plot, and Hosmer–Lemeshow goodness-of-fit test). Social network parameters were strong predictors for URI, LRI, and GI. Using social network parameters in prediction models for URI, LRI, and GI seems highly promising. Such parameters may be used as potential determinants that can be addressed in a practical intervention in older persons, or in a predictive tool to compute an individual's probability of infections.

The effectiveness of outdoor smoking bans on smoking behavior among adolescents remains inconclusive. This study evaluates the long-term impact of outdoor school ground smoking bans among adolescents at secondary schools on the use of conventional cigarettes, e-cigarettes (with/without nicotine) and water pipes. Outdoor smoking bans at 19 Dutch secondary schools were evaluated using a quasi-experimental design. Data on 7733 adolescents were obtained at baseline, and at 6 and 18-month follow-up. The impact of outdoor smoking bans on ‘ever use of conventional cigarettes’, ‘smoking onset’, ‘ever use of e-cigarette with nicotine’, ‘e-cigarette without nicotine’, and ‘water pipe’ was measured. Multilevel logistic regression analysis was used. At schools with a ban, implementation fidelity was checked. At schools where a ban was implemented, at 18-month follow-up more adolescents had started smoking compared to the control condition. No effect of implementation of the ban was found for smoking prevalence, e-cigarettes with/without nicotine, and water pipe use. Implementation fidelity was sufficient. No long-term effects were found of an outdoor smoking ban, except for smoking onset. The ban might cause a reversal effect when schools encounter difficulties with its enforcement or when adolescents still see others smoking. Additional research is required with a longer follow-up than 18 months.

Bats are ancient hosts of Trypanosoma species and their flying ability, longevity and adaptability to distinct environments indicate that they are efficient dispersers of parasites. Bats from Acre state (Amazon Biome) were collected in four expeditions conducted in an urban forest (Parque Zoobotânico) and one relatively more preserved area (Seringal Cahoeira) in Rio Branco and Xapuri municipalities. Trypanosoma sp. infection was detected by hemoculture and fresh blood examination. Isolated parasite species were identified by the similarity of the obtained DNA sequence from 18S rDNA polymerase chain reaction and reference strains. Overall, 367 bats from 23 genera and 32 species were examined. Chiropterofauna composition was specific to each municipality, although Artibeus sp. and Carollia sp. prevailed throughout. Trypanosoma sp. infection was detected in 85 bats (23·2%). The most widely distributed and prevalent genotypes were (in order) Trypanosoma cruzi TcI, T. cruzi marinkellei, Trypanosoma dionisii, T. cruzi TcIV and Trypanosoma rangeli. At least one still-undescribed Trypanosoma species was also detected in this study. The detection of T. cruzi TcI and TcIV (the ones associated with Chagas disease in Amazon biome) demonstrates the putative importance of these mammal hosts in the epidemiology of the disease in the Acre State.

Background: The aim of the study was to test the 12-month effects of a multicomponent physical activity (PA) intervention at schoolyards on morning recess PA levels of sixth- and seventh-grade children in primary schools, using accelerometry and additional global positioning system data. Methods: A quasi-experimental study design was used with 20 paired intervention and control schools. Global positioning system confirmatory analyses were applied to validate attendance at schoolyards during recess. Accelerometer data from 376 children from 7 pairs of schools were included in the final analyses. Pooled intervention effectiveness was tested by multilevel linear regression analyses, whereas effectiveness of intervention components was tested by multivariate linear regression analyses. Results: Children exposed to the multicomponent intervention increased their time spent in light PA (+5.9%) during recess. No pooled effects on moderate to vigorous PA were found. In-depth analyses of intervention components showed that physical schoolyard interventions particularly predicted a decrease in time spent in sedentary behavior during recess at follow-up. Intervention intensity and the school’s commitment to the project strengthened this effect. Conclusions: The multicomponent schoolyard PA intervention was effective in making children spend a larger proportion of recess time in light PA, which was most likely the result of a shift from sedentary behavior to light PA.

Objective:Quality of life (QoL) is a multidimensional, subjective, and highly individual phenomenon. The current study speaks to the QoL domains identified by palliative patients living in Africa. The need to identify these domains has been recognized but seemed to still be lacking. This study filled this knowledge gap by providing the domains and by giving directions in terms of the assessment of QoL in palliative patients living in resource-restricted communities in South Africa.Method:We followed a multi-method approach and conducted a literature review to identify and describe the multidimensional QoL instruments used in African palliative care. A secondary analysis design and open-coding method was employed to identify the domains influencing the QoL of palliative patients living in a resource-restricted South African community, after which we compared these domains to the domains assessed by the identified QoL instruments.Results:We found that two multidimensional QoL of life instruments—the Missoula–Vitas Quality of Life Index (MVQoLI) and the Functional Assessments of Chronic Illness Therapy–Palliative Care (FACIT–Pal)—have been used in African palliative care and have identified various domains, grouped as four themes: physical concerns, psychosocial issues, financial restraints, and existential issues. The patient-identified QoL domains were to a great extent not assessed by the MVQoLI and FACIT–Pal.Significance of Results:Our study highlights the complexity of QoL and QoL assessment. A more accurate representation of the QoL of palliative patients living in resource-restricted communities might be obtained by using individualized measures or exploring what QoL means to these patients and selecting QoL instruments accordingly.

BACKGROUND: Need for recovery (NFR) and prolonged fatigue are two important concepts for monitoring short- and long-term outcomes of psychological job demands within employees. For effective monitoring it is, however, important to gain insight in the reproducibility of the instruments that are used.OBJECTIVE: The objective was to assess reproducibility of the NFR scale and Checklist Individual Strength (CIS), measuring NFR and prolonged fatigue respectively, in the working population.METHODS: Longitudinal data from the Maastricht Cohort Study (MCS) study was used, capturing 12,140 employees from 45 different companies at baseline. A 'working' and 'returning to work' sample was conceived for different intervals; 4-month, 1-year, and 2-year.RESULTS: Reliability, assessed with the interclass correlation, was high within employees with a stable work environment for the NFR scale (0.78) and CIS (0.75). The smallest detectable change, assessing the agreement, was 41.20 for the NFR scale and 31.10 for the CIS.CONCLUSIONS: Reliability was satisfactory for both the NFR scale and CIS. The agreement of both scales to detect a changes within employees was, however, less optimal. It is, therefore, suggested that, ideally, both instruments are placed within a broader range of instruments to effectively monitor the outcomes of psychological job demands.

Background The DNA barcoding system using the cytochrome c oxidase subunit 1 mitochondrial gene (cox1 or COI) is highly efficient for discriminating vertebrate and invertebrate species. In the present study, we examined the suitability of cox1 as a marker for Trypanosoma cruzi identification from other closely related species. Additionally, we combined the sequences of cox1 and the nuclear gene glucose-6-phosphate isomerase (GPI) to evaluate the occurrence of mitochondrial introgression and the presence of hybrid genotypes. Methods Sixty-two isolates of Trypanosoma spp. obtained from five of the six Brazilian biomes (Amazon Forest, Atlantic Forest, Caatinga, Cerrado and Pantanal) were sequenced for cox1 and GPI gene fragments. Phylogenetic trees were reconstructed using neighbor-joining, maximum likelihood, parsimony and Bayesian inference methods. Molecular species delimitation was evaluated through pairwise intraspecific and interspecific distances, Automatic Barcode Gap Discovery, single-rate Poisson Tree Processes and multi-rate Poisson Tree Processes. Results Both cox1 and GPI genes recognized and differentiated T. cruzi, Trypanosoma cruzi marinkellei, Trypanosoma dionisii and Trypanosoma rangeli. Cox1 discriminated Tcbat, TcI, TcII, TcIII and TcIV. Additionally, TcV and TcVI were identified as a single group. Cox1 also demonstrated diversity in the discrete typing units (DTUs) TcI, TcII and TcIII and in T. c. marinkellei and T. rangeli. Cox1 and GPI demonstrated TcI and TcII as the most genetically distant branches, and the position of the other T. cruzi DTUs differed according to the molecular marker. The tree reconstructed with concatenated cox1 and GPI sequences confirmed the separation of the subgenus Trypanosoma (Schizotrypanum) sp. and the T. cruzi DTUs TcI, TcII, TcIII and TcIV. The evaluation of single nucleotide polymorphisms (SNPs) was informative for DTU differentiation using both genes. In the cox1 analysis, one SNP differentiated heterozygous hybrids from TcIV sequences. In the GPI analysis one SNP discriminated Tcbat from TcI, while another SNP distinguished TcI from TcIII. Conclusions DNA barcoding using the cox1 gene is a reliable tool to distinguish T. cruzi from T. c. marinkellei, T. dionisii and T. rangeli and identify the main T. cruzi genotypes. Electronic supplementary material The online version of this article (10.1186/s13071-017-2457-1) contains supplementary material, which is available to authorized users.

Background Although increasing numbers of countries are implementing outdoor school ground smoking bans at secondary schools, less attention is paid to the post-implementation period even though sustainability of a policy is essential for long-term effectiveness. Therefore, this study assesses the level of sustainability and examines perceived barriers/facilitators related to the sustainability of an outdoor school ground smoking ban at secondary schools. Methods A mixed-method design was used with a sequential explanatory approach. In phase I, 438 online surveys were conducted and in phase II, 15 semi-structured interviews were obtained from directors of relevant schools. ANOVA (phase I) and a thematic approach (phase II) were used to analyze data. Results Level of sustainability of an outdoor school ground smoking ban was high at the 48% Dutch schools with an outdoor smoking ban. Furthermore, school size was significantly associated with sustainability. The perceived barriers/facilitators fell into three categories: (i) smoking ban implementation factors (side-effects, enforcement, communication, guidelines and collaboration), (ii) school factors (physical environment, school culture, education type and school policy) and (iii) community environment factors (legislation and social environment). Conclusions Internationally, the spread of outdoor school ground smoking bans could be further promoted. Once implemented, the ban has become ‘normal’ practice and investments tend to endure. Moreover, involvement of all staff is important for sustainability as they function as role models, have an interrelationship with students, and share responsibility for enforcement. These findings are promising for the sustainability of future tobacco control initiatives to further protect against the morbidity/mortality associated with smoking.

Background: RealFit is a 13-week weight reduction program for youth that focuses on nutrition, physical activity (PA), psychology, and parental participation. The short-term effectiveness of the RealFit intervention, in terms of body composition, aerobic fitness, and dietary and PA behavior, having been proven, the present study evaluated the long-term effects of the intervention. METHODS: The study had a quasi-experimental design. Height, weight, waist circumference, aerobic fitness, and self-reported dietary and PA behavior were assessed at baseline (T0), immediately after the 13-week RealFit intervention (T1), after 5 months (T2), and 1 year (T3) of follow-up. A total of 86 adolescents participated in the intervention group. The control group (n=32) comprised overweight adolescents who did not receive any treatment. RESULTS: One year after the RealFit intervention, significant decreases in BMI z-score (mean difference [MD]: -0.39) and waist circumference (MD, -3.24) were found. The comparison between the intervention and control groups, controlling for confounders, resulted in a significant difference (BMI z-score: -0.41; 95% confidence interval [CI]: -0.67 to -0.15; waist circumference: -8.07; 95% CI: -11.58 to -4.56). The results for dietary and PA behavior consistently showed favorable changes in the intervention group. CONCLUSIONS: The RealFit intervention appears to have significant favorable long-term effects on BMI z-score and waist circumference. These changes in body composition obviously represent changes in adolescents' energy balance-related behavior. Taking all results and limitations into account, it may cautiously be concluded that RealFit is an effective weight loss intervention.

BACKGROUND: Physical activity (PA) is decreasing among children, while sedentary behavior (SB) is increasing. Schoolyards seem suitable settings to influence children's PA behavior. This study investigated the associations between schoolyard characteristics and moderate-to-vigorous physical activity (MVPA) and SB of children aged 8-11 years at schoolyards.METHODS: Twenty primary schools in the Netherlands were involved. A total of 257 children wore an accelerometer and global positioning system (GPS) device for 5 consecutive days to objectively assess their PA levels and presence at the schoolyard, respectively. Accelerometer and GPS data were merged using the personal activity and location measurement system. Multilevel linear regression analyses were used to study correlates of MVPA and SB at schoolyards.RESULTS: On average, children spent 54 minutes a day at the schoolyard, 9 minutes of which were spent in MVPA and 20 minutes in SB. Boys engaged in MVPA longer than girls at the schoolyard. Fixed equipment, such as high bars and soccer goals, teacher-initiated activities, and the presence of a ball games policy were correlates of more MVPA and less SB.CONCLUSION: Well-designed schoolyards, including PA-enhancing fixed equipment, a supportive PA climate created by teachers, and supportive schoolyard policies may contribute to increased PA and decreased SB during school recess among school-aged children.

Funda??o Oswaldo Cruz. Centro de Pesquisa Ren? Rachou. Belo Horizonte, MG, Brasil. Universidade Federal do Cear?. Faculdade de Medicina. Fortaleza, CE, Brasil. Universidade Federal de Minas Gerais. Faculdade de Medicina. Belo Horizonte, MG, Brasil. Universidade Federal de Goi?s. Instituto de Patologia Tropical e Sa?de P?blica. Goi?nia, GO, Brasil. Universidade de S?o Paulo. Faculdade de Medicina. S?o Paulo, SP, Brasil. Funda??o Oswaldo Cruz. Instituto Oswaldo Cruz. Rio de Janeiro, RJ. Brasil. Universidade Federal de Minas Gerais. Faculdade de Medicina. Belo Horizonte, MG, Brasil. Universidade Federal de Minas Gerais. Faculdade de Medicina. Belo Horizonte, MG, Brasil. Universidade Estadual de Campinas. Faculdade de Ci?ncias M?dicas. Campinas, SP, Brasil. Universidade de Pernambuco. Faculdade de Ci?ncias M?dicas de Pernambuco. Recife, PE, Brasil. Organiza??o Pan American de Sa?de. Bras?lia, DF, Brasil. Universidade Federal de Goi?s. Faculdade de Medicina. Hospital das Cl?nicas. Goi?nia, GO, Brasil. Universidade Federal de Minas Gerais. Faculdade de Medicina. Hospital das Cl?nicas. Belo Horizonte, MG, Brasil. Universidade de S?o Paulo, S?o Paulo. Instituto de Medicina Tropical de S?o Paulo. S?o Paulo, SP, Brasil. Hospital Anis Rassi. Goi?nia, GO, Brasil. Instituto de Cardiologia Dante Pazzanese. S?o Paulo, SP, Brasil. Funda??o Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Rio de Janeiro, RJ, Brasil. Universidade Federal do Tri?ngulo Mineiro. Faculdade de Medicina. Uberaba, MG, Brasil Funda??o Oswaldo Cruz. Instituto Oswaldo Cruz. Rio de Janeiro, RJ. Brasil. Universidade Federal de Minas Gerais. Faculdade de Medicina. Belo Horizonte, MG, Brasil. Funda??o Oswaldo Cruz. Instituto Oswaldo Cruz. Rio de Janeiro, RJ. Brasi Minist?rio da Sa?de. Secretaria de Vigil?ncia em Sa?de. Instituto Evandro Chagas. Bel?m, PA, Brasil. Hospital Anis Rassi. Goi?nia, GO, Brasil. Universidade Federal de Goi?s. Faculdade de Medicina. Hospital das Cl?nicas. Goi?nia, GO, Brasil Funda??o Oswaldo Cruz. Centro de Pesquisa Ren? Rachou. Belo Horizonte, MG, Brasil. Universidade Federal de Minas Gerais. Faculdade de Medicina. Belo Horizonte, MG, Brasil. Universidade Federal de Minas Gerais. Instituto de Ci?ncias Biol?gicas. Belo Horizonte, MG, Brasil. Funda??o Oswaldo Cruz. Instituto Nacional de Infectologia Evandro Chagas. Rio de Janeiro, RJ, Brasil. Secretaria de Estado de Sa?de de Minas Gerais. Funda??o Ezequiel Dias. Belo Horizonte, MG, Brasil. Universidade Estadual de Londrina. Faculdade de Medicina. Londrina, PA, Brasil Universidade Federal do Tri?ngulo Mineiro. Departamento de Ci?ncias Biol?gicas. Uberaba, MG, Brasil. Universidade de S?o Paulo. Faculdade de Medicina de Ribeir?o Preto. Ribeir?o Preto, SP, Brasil. Universidade Federal de Minas Gerais. Instituto de Ci?ncias Biol?gicas. Belo Horizonte, MG, Brasil. Universidade Federal do Rio de Janeiro. Hospital Universit?rio Clementino Fraga Filho. Rio de Janeiro, RJ, Brasil. Minist?rio da Sa?de. Secretaria de Vigil?ncia em Sa?de. Instituto Evandro Chagas. Bel?m, PA, Brasil. Universidade de S?o Paulo. Faculdade de Medicina. Hospital das Cl?nicas. S?o Paulo, SP, Brasil. Minist?rio da Sa?de. Secretaria de Vigil?ncia em Sa?de. Bras?lia, DF, Brasil. Minist?rio da Sa?de. Secretaria de Vigil?ncia em Sa?de. Bras?lia, DF, Brasil. Minist?rio da Sa?de. Secretaria de Vigil?ncia em Sa?de. Bras?lia, DF, Brasil. Minist?rio da Sa?de. Secretaria de Vigil?ncia em Sa?de. Bras?lia, DF, Brasil. Minist?rio da Sa?de. Empresa Brasileira de Hemoderivados e Biotecnologia. Bras?lia, DF, Brasil. Minist?rio da Sa?de. Secretaria de Vigil?ncia em Sa?de. Instituto Evandro Chagas. Bel?m, PA, Brasil. Minist?rio da Sa?de. Secretaria de Vigil?ncia em Sa?de. Bras?lia, DF, Brasil. Minist?rio da Sa?de. Secretaria de Vigil?ncia em Sa?de. Bras?lia, DF, Brasil. Chagas disease is a neglected chronic condition with a high burden of morbidity and mortality. It has considerable psychological, social, and economic impacts. The disease represents a significant public health issue in Brazil, with different regional patterns. This document presents the evidence that resulted in the Brazilian Consensus on Chagas Disease. The objective was to review and standardize strategies for diagnosis, treatment, prevention, and control of Chagas disease in the country, based on the available scientific evidence. The consensus is based on the articulation and strategic contribution of renowned Brazilian experts with knowledge and experience on various aspects of the disease. It is the result of a close collaboration between the Brazilian Society of Tropical Medicine and the Ministry of Health. It is hoped that this document will strengthen the development of integrated actions against Chagas disease in the country, focusing on epidemiology, management, comprehensive care (including families and communities), communication, information, education, and research.

Chagas disease is a neglected chronic condition that presents high morbidity and mortality burden, with considerable psychological, social, and economic impact. The disease represents a significant public health issue in Brazil, with different regional patterns. This document presents the evidence that resulted in the Brazilian Consensus on Chagas Disease. The objective was to review and standardize strategies for diagnosis, treatment, prevention, and control of Chagas disease in the country, based on the available scientific evidence. The consensus is based on collaboration and contribution of renowned Brazilian experts with vast knowledge and experience on various aspects of the disease. It is the result of close collaboration between the Brazilian Society of Tropical Medicine and the Ministry of Health. This document shall strengthen the development of integrated control measures against Chagas disease in the country, focusing on epidemiology, management, comprehensive care (including families and communities), communication, information, education, and research.

• The aim was to examine whether ill people with a low income report less social resources than ill people with a high income.