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Background: Education is an essential part of diabetes care. However, in The Netherlands, no education programme was available for everyone at any time and adaptive to users' specific needs. Aim: To describe the structured development and final content of a type 2 diabetes web-based education programme. Methods: A web-based education programme—the Diabetes Interactive Education Programme (DIEP)—was developed using intervention mapping and involved collaboration between programme planners, Dutch diabetes organisations and potential users (patients and healthcare providers). DIEP incorporates information, multimedia and tools to support self-reflection, goal setting, problem solving and active patient participation. Results:www.diep.info consists of seven chapters with basic and additional information, a dictionary, self-management checklists and a workbook for goal setting and preparation for consultations. The information included is mostly spoken text supported by headlines, images, video and patient experiences. Adoption, implementation and evaluation plans have been made. Outcomes of the process and effect evaluation will be reported in the future. Conclusions: DIEP is a unique education programme, based on theory and planned development, which is supported by diabetes organisations. By using multimedia and incorporating different functionalities, DIEP attempts to meet the current practice requirements. DIEP aims to meet the needs of multiple, specific patient groups in the future, and has already been adapted for use in different countries (eg Belgium). Copyright © 2009 FEND [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

This research examined the role of habit and intention in the prediction of future behaviour by analysing that past behaviour frequency moderates the intention-behaviour relationship to the extent that the context in which the behaviour was performed is stable. In two correlational studies, it was found that habit interacted with intention when context stability was taken into account and not when merely past behaviour frequency was considered: intentions guided future behaviour when habits were weak (low frequency or unstable context), while this was not the case when habits were strong (high frequency and stable context). A third exploratory study investigated and confirmed the idea that, if habitual goal-directed behaviour is directly activated by the context, mental accessibility of the behaviour (i.e. the ease of accessing the goal-directed behaviour in memory) moderates the intention-behaviour relation in a similar way. These findings are discussed against the background of current research on goal-directed habits and the cognitive processes underlying them. [ABSTRACT FROM AUTHOR]

Objectives: To assess participants' acquaintance with and willingness to try healthful food alternatives, and to test the psychometric properties of an adapted Dutch version of the Food Neophobia Scale (FNS) in order to study the role of food neophobia in this context.Design: A cross-sectional study incorporating two web-based questionnaires, including a retest of the FNS one week later. Measures included acquaintance with and willingness to try 15 healthful food alternatives, level of food neophobia, level of education, gender and age. Multiple linear regression analyses were used to study associations between demographics and level of food neophobia as well as associations between level of food neophobia and acquaintance with and willingness to try the healthful alternatives.Setting: The study was conducted in The Netherlands using a representative Internet panel.Participants: A total of 326 participants aged 18-50 years participated.Results: Internal consistency and test-retest reliability of the FNS version used were sufficient. On average participants were acquainted with 7.9 of the products and modestly willing to try the products. Lowly educated participants had significantly higher FNS scores than highly educated participants (beta = -0.23, P < 0.01). FNS score was significantly associated with acquaintance with (beta = -0.21, P < 0.001) and willingness to try the healthful alternatives (beta = -0.26, P < 0.001).Conclusion: Further research into the role of food neophobia is warranted when wanting to stimulate the integration of healthful alternative products in the daily diet, especially among persons with low education. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The aim of the present research was to investigate whether unconsciously presented affective information may cause opposite evaluative responses depending on what social category the information originates from. We argue that automatic comparison processes between the self and the unconscious affective information produce this evaluative contrast effect. Consistent with research on automatic behaviour, we propose that when an intergroup context is activated, an automatic comparison to the social self may determine the automatic evaluative responses, at least for highly visible categories (e.g. sex, ethnicity). Contrary to previous research on evaluative priming, we predict automatic contrastive responses to affective information originating from an outgroup category such that the evaluative response to neutral targets is opposite to the valence of the suboptimal primes. Two studies using different intergroup contexts provide support for our hypotheses. [ABSTRACT FROM AUTHOR]

Background: Internet-delivered interventions can effectively change health risk behaviors and their determinants, but adherence to these interventions once they are accessed is very low. Therefore, it is relevant and necessary to systematically manipulate website characteristics to test their effect on website use. This study focuses on user control as a website characteristic.Objective: To test whether and how user control (the freedom of choice to skip pages) can increase website use and knowledge gained from the website.Methods: Participants older than 18 years were drawn from the Dutch Internet population (in June 2011) and completed a hepatitis knowledge questionnaire. Subsequently, they were randomly assigned to three groups: (1) a tunneled version of the website with less user control; (2) a high user control version of the website where visitors had the freedom of choice to skip pages; and (3) a control group that was not exposed to the website. Participants completed (1) a questionnaire of validated measures regarding user perceptions immediately after exposure to the website (except for the control group), and (2) a hepatitis knowledge questionnaire after one week to test whether participants in the experimental groups only clicked through the website or actually processed and learned its content. Server registrations were used to assess website use. Analyses of covariance (ANCOVA) using all available data were conducted to determine whether user control increases website use. Structural equation models (SEM) using all available data were constructed to test how user control increases website use-a latent variable derived from number of pages visited and time on website.Results: Of the 1044 persons invited to participate, 668 took part (668/1044, 64.0%). One half of participants (332/668 49.7%) were female and the mean age was 49 years (SD 16). A total of 571 participants completed the one-week follow-up measure regarding hepatitis knowledge (571/668, 85.5%). The findings demonstrate that having less user control (ie, a tunneled version of the website) had a negative effect on users' perception of efficiency (F(1,452) = 97.69, P < .001), but a positive effect on number of pages visited (F(1,452) = 171.49, P < .001), time on the website (F(1,452) = 6.32, P = .01), and knowledge gained from the website (F(1,452) = 134.32, P < .001). The direct effect of having less user control appeared to surpass the effect mediated by efficiency, because website use was higher among participants exposed to the tunneled version of the website in comparison with those having the freedom of choice to skip pages.Conclusions: The key finding that visitors demonstrated increased website use in the tunneled version of the website indicates that visitors should be carefully guided through the intervention for future intervention websites. [ABSTRACT FROM AUTHOR]

Background: Self-tests are available to consumers for more than 25 conditions, ranging from infectious diseases to cardiovascular risk factors. Self-tests are defined as in-vitro tests on body materials such as blood, urine, faeces, or saliva that are initiated by consumers to diagnose a particular disorder or risk factor without involving a medical professional. In 2006, 16% of a sample of Dutch Internet users had ever used at least one self-test and 17% intended to use a self-test in the future. The objectives of this study are to determine (1) the frequency of self-test use, (2) the consumers' reasons for using or not using a self-test, (3) the information that is used by self-testers in the different self-test stages and the consumers' interpretation of the quality of this information, (4) the consumers' response to self-test results in terms of their confidence in the result, reassurance by the test result, and follow-up behaviour, (5) the information consumers report to need in the decision making process of using or not using a self-test, and in further management on the basis of the self-test result, and (6) the quality of the currently available consumer information on a selected set of self-tests.Methods: Mixed methods study with (1) a cross-sectional study consisting of a two-phase Internet-questionnaire, (2) semi-structured interviews with self-testers and consumers who intend to use a self-test, and (3) the assessment of the quality of consumer information of self-tests. The Health Belief Model and the Theory of Planned Behaviour will serve as the theoretical basis for the questionnaires and the interview topic guides.Conclusions: The self-testing area is still in a state of flux and therefore it is expected that self-test use will increase in the future. To the best of our knowledge, this is the first study which combines quantitative and qualitative research to identify consumers' information needs and use concerning self-testing, and the consumers' actual follow-up behaviour based on the self-test result, and simultaneously investigates the quality of the currently available consumer information. The results of this study will be used as an input in developing consumer information on self-testing. [ABSTRACT FROM AUTHOR]

Background: The Internet is an attractive medium for delivering individualized, computer-tailored behavior change interventions to large numbers of people. However, the actual numbers of people reached seem to fall behind the high expectations. Insight into factors that determine use of and exposure to these Internet interventions is important to be able to increase the reach and improve exposure.Objective: The aim was to identify potentially important factors that determine whether adults visit an Internet-delivered behavior change intervention, extend their visit, and revisit the intervention.Methods: A systematic, three-round Delphi study was conducted among national and international experts from Internet intervention research and practice, e-marketing/e-commerce, Web design, and technical website development. In the first round, 30 experts completed a structured, open-ended online questionnaire assessing factors that were, in their opinion, important for a first visit, an extended visit, a revisit and for effective promotion strategies. Based on the responses in this first questionnaire, a closed-ended online questionnaire was developed for use in the second round. A total of 233 experts were invited to complete this questionnaire. Median and interquartile deviation (IQD) scores were computed to calculate agreement and consensus on the importance of the factors. The factors for which no consensus was obtained (IQD > 1) were included in the third-round questionnaire. Factors with a median score of six or higher and with an IQD Results: Of the 62 experts invited for the first round, 30 completed the questionnaire (48% response rate); 93/233 experts completed the second-round questionnaire (40% response rate), and 59/88 completed the third round (67% response rate). Being motivated to visit an Internet intervention and perceiving the intervention as personally relevant appeared to be important factors related to a first visit. The provision of tailored feedback, relevant and reliable information, and an easy navigation structure were related to an extended visit. Provision of regular new content and the possibility to monitor personal progress toward behavior change were identified as important factors to encourage a revisit. Primarily traditional promotion strategies, like word-of-mouth by family and friends, a publicity campaign with simultaneous use of various mass media, and recommendation by health professionals, were indicated as effective ways to encourage adults to visit an Internet intervention.Conclusions: This systematic study identified important factors related to the dissemination of and exposure to Internet interventions aimed at adults. In order to improve optimal use of and exposure to Internet interventions, potential users may need to be motivated to visit such an intervention and the information provided needs to be personally relevant. Furthermore, several (technical) aspects of the intervention itself need to be taken into account when developing Internet interventions. [ABSTRACT FROM AUTHOR]

Context: Adolescence is the age period from 10-19 years when lifestyle patterns of behavior are being formed. These behaviors set the stage for future health problems. Behaviors and lifestyles are determinants of future health, illness, disability, and premature mortality. Objectives: To gain new insight into health behaviors, lifestyles and their context in adolescents in order to assess the determinants and barriers to the improvement of health. Methods: A cross-sectional descriptive study. A random sample of 1200 adolescents within the age group of 10-19 years (53.2% girls and 46.8% boys) were interviewed individually. A self-reported questionnaire was developed for data collection by trained interviewers. Bivariate and logistic regression analyses were conducted. Outcomes: The overall prevalence of smoking among adolescents was 4.9%. More boys (9.1%) than girls (1.3%) reported smoking. Older participants and those with higher levels of education reported higher rates of tobacco use (10.4% and 7.9%). Consumption of alcohol was significantly more common for boys (2.3%). More boys than girls reported they were actively engaged in sports. Inactivity was significantly higher among older age groups and was associated with lack of education. 58% of girls and 8.7% of boys were physically inactive. More than half of the boys go hungry due to lack of availability of food in the house and this was somewhat less common for girls (43%). Adolescents 16 years and older reported significantly less consumption of both nutritious and non-nutritious foods than other age groups. Conclusion: Our research contributed to greater understanding of current health-related behaviors of Sudanese adolescents. There are a number of implications for potential interventions (e.g. physical inactivity of girls and hunger experiences). [ABSTRACT FROM AUTHOR]

The present study assessed the relationship between parental feeding styles and dietary intake behaviours of Dutch children aged 6-7. Associations between feeding styles and dietary behaviours of the parents were also examined. We translated the validated 'Parental Feeding Style Questionnaire' and evaluated its factor structure. A cross-sectional survey was completed by one of the parents of 135 children. Results indicated considerable similarity of factor structure, internal reliability and between-subscale correlations with the original instrument. The parental feeding dimensions of 'instrumental feeding' (i.e. using food as a reward) and 'emotional feeding' (i.e. feeding in response to children's emotional distress) were positively related to children's snacking behaviour. The feeding style 'encouragement to eat' was negatively associated with children's snacking behaviour. Various feeding styles were found to be related to parental dietary behaviours. Findings indicate the importance of acknowledging parental feeding styles in future research efforts as well as in the development of family-based interventions promoting healthy eating habits among children. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To assess patients' opinions on a new service in the Dutch health care system, viz., health counseling about behavioral risks and possible lifestyle changes. This was introduced within the framework of the Hartslag Limburg prevention project and was offered to patients at high risk of cardiovascular diseases. METHODS: A questionnaire survey to measure quality, satisfaction, and normative concerns. Questionnaires were distributed among 1,301 patients after they had completed the counseling and returned by 1,056 of them (response rate 81.2%). RESULTS: Patients generally reported rather high levels of quality and satisfaction. They regarded the service as a welcome addition to usual care. However, the accompanying effect studies will have to provide more solid evidence for the effectiveness of the counseling. CONCLUSION: It was concluded that the service was highly acceptable to the patients, but that the health advisors should be careful not to induce less favorable normative concerns. PRACTICE IMPLICATIONS: A quality and satisfaction survey should consist of well-validated instruments, context-specific items, and qualitative measures as well. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The objective in this study was to evaluate a web-based type 2 diabetes self-management education programme aimed at improving knowledge, encouraging active patient participation and providing supportive self-management tools. METHODS: (1) An effect evaluation was conducted using a randomized controlled trial with a pre-test and post-test design (n=99) and a knowledge questionnaire. (2) A user evaluation was conducted using an online questionnaire (n=564) and one-on-one interviews (n=11) to examine the perceived quality, use of functionalities and use of the programme as a supportive tool in education. RESULTS: The effect evaluation showed a significant intervention effect (p<0.01) on knowledge. The user evaluation showed high satisfaction with the programme's content, credibility and user-friendliness. However, functionalities and self-management tools were used by less than half of the participants. CONCLUSION: The programme can improve knowledge, but it is not fully used as intended. A more optimal use of the programme is necessary for higher efficacy. PRACTICE IMPLICATIONS: The use of mostly spoken text instead of written text was highly appreciated and could be used more often for educational websites. Furthermore, health care practitioners need support in implementing new educational programmes during consultations. [ABSTRACT FROM AUTHOR]

PURPOSE: To explore psychosocial correlates and predictors of stage transitions in the precaution adoption process model (PAPM) for fruit intake. DesigN: A cohort completed three electronic questionnaires, at baseline (time 0), 35 days later (time 1), and another 32 days later (time 2). SETTING: Secured Internet Web site. SUBJECTS: A cohort of 735 adults was formed from a random sample of an existing Internet panel. The mean age was 37.5 years, 51% were women, and 90% were of Dutch origin. Most respondents (48%) had a medium level of education. MEASURES: Precaution adoption process model stage, risk perception, perception of own fruit intake level, attitude, pros, cons, subjective norms, social support, modeling, self-efficacy, and fruit intake (assessed using a food frequency questionnaire). ANALYSIS: Cross-sectional differences in psychosocial variables and fruit intake across PAPM stages at baseline were analyzed using analysis of variance with Tukey multiple comparisons tests. Predictors of PAPM stage transitions between time 0 and time 1 and between time 1 and time 2 were analyzed using logistic regression analysis. RESULTS: Factors related to attitude and social influences may be important if one is to decide to act, whereas strong self-efficacy may also be required for acting on the decision to act. CONCLUSION: Although the results should be replicated in a larger and more representative sample, the PAPM seems a good framework for studying fruit intake. [ABSTRACT FROM AUTHOR]

Background: High cognitive activity possibly reduces the risk of cognitive decline and dementia., Aims: To investigate associations between an individual's need to engage in cognitively stimulating activities (need for cognition, NFC) and structural brain damage and cognitive functioning in the Dutch general population with and without existing cognitive impairment., Method: Cross-sectional data were used from the population-based cohort of the Maastricht Study. NFC was measured using the Need For Cognition Scale. Cognitive functioning was tested in three domains: verbal memory, information processing speed, and executive functioning and attention. Values 1.5 s.d. below the mean were defined as cognitive impairment. Standardised volumes of white matter hyperintensities (WMH), cerebrospinal fluid (CSF) and presence of cerebral small vessel disease (CSVD) were derived from 3T magnetic resonance imaging. Multiple linear and binary logistic regression analyses were used adjusted for demographic, somatic and lifestyle factors., Results: Participants ( n = 4209; mean age 59.06 years, s.d. = 8.58; 50.1% women) with higher NFC scores had higher overall cognition scores ( B = 0.21, 95% CI 0.17-0.26, P < 0.001) and lower odds for CSVD (OR = 0.74, 95% CI 0.60-0.91, P = 0.005) and cognitive impairment (OR = 0.60, 95% CI 0.48-0.76, P < 0.001) after adjustment for demographic, somatic and lifestyle factors. The association between NFC score and cognitive functioning was similar for individuals with and without prevalent cognitive impairment. We found no significant association between NFC and WMH or CSF volumes., Conclusions: A high need to engage in cognitively stimulating activities is associated with better cognitive functioning and less presence of CSVD and cognitive impairment. This suggests that, in middle-aged individuals, motivation to engage in cognitively stimulating activities may be an opportunity to improve brain health.

Aims/hypothesis: Type 2 diabetes is a highly heterogeneous disease for which new subgroups ('clusters') have been proposed based on disease severity: moderate age-related diabetes (MARD), moderate obesity-related diabetes (MOD), severe insulin-deficient diabetes (SIDD) and severe insulin-resistant diabetes (SIRD). It is unknown how disease severity is reflected in terms of quality of life in these clusters. Therefore, we aimed to investigate the cluster characteristics and cluster-wise evolution of quality of life in the previously defined clusters of type 2 diabetes., Methods: We included individuals with type 2 diabetes from the Maastricht Study, who were allocated to clusters based on a nearest centroid approach. We used logistic regression to evaluate the cluster-wise association with diabetes-related complications. We plotted the evolution of HbA 1c levels over time and used Kaplan-Meier curves and Cox regression to evaluate the cluster-wise time to reach adequate glycaemic control. Quality of life based on the Short Form 36 (SF-36) was also plotted over time and adjusted for age and sex using generalised estimating equations. The follow-up time was 7 years. Analyses were performed separately for people with newly diagnosed and already diagnosed type 2 diabetes., Results: We included 127 newly diagnosed and 585 already diagnosed individuals. Already diagnosed people in the SIDD cluster were less likely to reach glycaemic control than people in the other clusters, with an HR compared with MARD of 0.31 (95% CI 0.22, 0.43). There were few differences in the mental component score of the SF-36 in both newly and already diagnosed individuals. In both groups, the MARD cluster had a higher physical component score of the SF-36 than the other clusters, and the MOD cluster scored similarly to the SIDD and SIRD clusters., Conclusions/interpretation: Disease severity suggested by the clusters of type 2 diabetes is not entirely reflected in quality of life. In particular, the MOD cluster does not appear to be moderate in terms of quality of life. Use of the suggested cluster names in practice should be carefully considered, as the non-neutral nomenclature may affect disease perception in individuals with type 2 diabetes and their healthcare providers., (© 2024. The Author(s).)

Background: Intervention planners use logic models to design evidence-based health behavior interventions. Logic models that capture the complexity of health behavior necessitate additional computational techniques to inform decisions with respect to the design of interventions., Objective: Using empirical data from a real intervention, the present paper demonstrates how machine learning can be used together with fuzzy cognitive maps to assist in designing health behavior change interventions., Methods: A modified Real Coded Genetic algorithm was applied on longitudinal data from a real intervention study. The dataset contained information about 15 determinants of fruit intake among 257 adults in the Netherlands. Fuzzy cognitive maps were used to analyze the effect of two hypothetical intervention scenarios designed by domain experts., Results: Simulations showed that the specified hypothetical interventions would have small impact on fruit intake. The results are consistent with the empirical evidence used in this paper., Conclusions: Machine learning together with fuzzy cognitive maps can assist in building health behavior interventions with complex logic models. The testing of hypothetical scenarios may help interventionists finetune the intervention components thus increasing their potential effectiveness., (© 2023. The Author(s).)

Background: From a complex systems perspective, implementation should be understood as the introduction of an intervention in a context with which it needs to interact in order to achieve its function in terms of improved health. The presence of intervention-context interactions could mean that during implementation particular patterns of crucial interaction points might arise. We examined the presence of - and regularities in - such 'bottlenecks for implementation', as this could create opportunities to predict and intervene in potential implementation problems., Methods: We conducted a cross-sectional observational study against the background of municipal intersectoral policymaking in the Netherlands. We asked implementers of health promotion interventions to identify bottlenecks by rating the presence and importance of conditions for implementation in a range of intervention systems. We used descriptive statistics to characterize these systems (by their behaviour change method, health theme and implementation setting) and the conditions that acted as bottlenecks. After stratifying bottlenecks by intervention system and the system's characteristics, we tested our hypotheses by comparing the number and nature of the bottlenecks that emerged., Results: More than half of the possible conditions were identified as a bottleneck for implementation. Bottlenecks occurred in all categories of conditions, e.g., relating to the implementer, the intervention, and political and administrative support, and often connected with intersectoral policymaking, e.g., relating to the co-implementer and the co-implementer's organization. Both our hypotheses were supported: (1) Each intervention system came across a unique set of - a limited number of - conditions hampering implementation; (2) Most bottlenecks were associated with the characteristics of the system in which they occurred, but bottlenecks also appeared in the absence of such an association, or remained absent in the presence thereof., Conclusions: We conclude that intervention-context interactions in integrated health policymaking may lead to both regularities and variations in bottlenecks for implementation. Regularities may partly be predicted by the function of an intervention system, and may serve as the basis for building the capacity needed for the structural changes that can bring about long-lasting health improvements. Variations may point at the need for flexibility in further tailoring the implementation approach to the - mostly unpredictable - problems at individual sites., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: The built environment is increasingly recognized as a determinant for health and health behaviors. Existing evidence regarding the relationship between environment and health (behaviors) is varying in significance and magnitude, and more high-quality longitudinal studies are needed. The aim of this study was to evaluate the effects of a major urban redesign project on physical activity (PA), sedentary behavior (SB), active transport (AT), health-related quality of life (HRQOL), social activities (SA) and meaningfulness, at 29-39 months after opening of the reconstructed area., Methods: PA and AT were measured using accelerometers and GPS loggers. HRQOL and sociodemographic characteristics were assessed using questionnaires. In total, 241 participants provided valid data at baseline and follow-up. We distinguished three groups, based on proximity to the intervention area: maximal exposure group, minimal exposure group and no exposure group., Results: Both the maximal and minimal exposure groups showed significantly different trends regarding transport-based PA levels compared to the no exposure group. In the exposure groups SB decreased, while it increased in the no exposure group. Also, transport-based light intensity PA remained stable in the exposure groups, while it significantly decreased in the no exposure group. No intervention effects were found for total daily PA levels. Scores on SA and meaningfulness increased in the maximal exposure group and decreased in the minimal and no exposure group, but changes were not statistically significant., Conclusion: The results of this study emphasize the potential of the built environment in changing SB and highlights the relevance of longer-term follow-up measurements to explore the full potential of urban redesign projects., Trial Registration: This research was retrospectively registered at the Netherlands Trial Register (NL8108)., (© 2023. The Author(s).)

The aim of this study was to explore effects of a major urban reconstruction on physical activity (PA) behavior by comparing PA intensity hotspots before and after the tunneling of a highway with a new infrastructure prioritized for walking and cycling. In total, 126 individuals participated before and after the tunneling. GPS loggers and accelerometers were used to assess location and PA levels. A geographic information system (GIS) was used to perform optimized hotspot analyses on PA data, both on transport and stationary data points. The results showed several changes in PA hotspots on trip data, even if total PA levels did not change. At follow-up, PA intensity hotspots were more connected, with the new infrastructure as a central connection. This was true for higher and lower educated individuals. Therefore, if changes in the built environment do not result in changes on population-level outcomes, this does not imply that they have no impact on behavior., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: People with mental illness have a reduced life expectancy compared to the general population. Despite the increasing evidence for the efficacy of lifestyle interventions there is little change in routine clinical care. This discrepancy is often referred to as the implementation gap and has caused a need for effectiveness and implementation research in real-world settings. Our study assesses the effectiveness and implementation of a multidisciplinary lifestyle focused approach in the treatment of inpatients with mental illness (MULTI +)., Methods: An open cohort stepped wedge cluster randomized trial in inpatients psychiatric wards of GGz Centraal, the Netherlands. The wards are divided into three clusters based on geographical region. These clusters are randomly allocated to one of the three pre-defined steps to integrate MULTI + . MULTI + can be tailored to fit individual psychiatric wards and includes 10 core components aimed at improving lifestyle factors. The primary outcome is to investigate the difference in the mean QRISK3 score of patients receiving MULTI + compared to patients receiving TAU. Secondary outcomes include somatic and mental health outcomes, lifestyle factors, and implementation factors. Findings will be analysed using mixed model analyses., Discussion: The MULTI + study is the first large-scale study evaluating the long-term effects of a multidisciplinary, multicomponent approach aimed at improving lifestyle factors in routine inpatient mental health care. A limitation of this study is the risk of missing data due to the large-scale, real-world setting of this study. Furthermore, implementation monitoring and external events that may influence outcomes could be difficult to account for. Strengths of this study are the focus on effectiveness as well as implementation and the inclusion of both patient and health care professionals' perspectives. Effectiveness studies in routine clinical care can advance our knowledge on lifestyle interventions in real-world settings., Trial Registration: ClinicalTrials.gov registration. Identifier: NCT04922749 . Retrospectively registered 3th of June 2021., (© 2022. The Author(s).)

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 )., (© 2021. The Author(s).)

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.)

Objective: To explore how people experience organ donation decision-making under the conditions of an opt-in, opt-out or no-objection registration system., Design: A between-subjects experimental 3 × 2 design (registration system x preselection). Participants ( N  = 1312) were presented with a description of one of the three registration systems and went through a mock donor registration process. In half of the conditions, the default option of the system was visualized by a ticked box. After, participants answered questions about their perceived autonomy and perceived effective decision-making., Main Outcome Measurements: Perceived autonomy, perceived decision effectiveness and registration choice., Results: The preselected box did not impact any of the outcomes. Participants had higher perceived autonomy under the conditions of an opt-in system. There were no differences in effective decision-making across conditions. Registration choices did differ across conditions and educational levels. In the opt-in system, participants more often made an active decision. Lower-educated participants were more likely to choose to do nothing, while higher-educated people more often made an active decision, especially in the no-objection system., Conclusion: Where the opt-out system potentially leads to the highest number of donors, the opt-in system seems better in terms of preserving people's autonomy and motivating people to make an active decision.

Background: As organ donation registration rates remain low, especially among lower-educated people, it is important to support this group in making their registration decision. To prepare lower-educated students in the Netherlands for making a well-informed decision, an interactive educational program was developed. We aim to understand both the (quality of) implementation as well as to contextualize the effects of this program in a lower-educated school setting., Methods: The process evaluation was part of a Cluster Randomized Controlled Trial, in which 11 schools for Intermediate Vocational Education throughout the Netherlands participated. Teachers who taught a course on Citizenship delivered three intervention elements (i.e. video fragments and discussion, quizzes with tailored feedback and an exercise filling out a registration form) to their students. Implementation was assessed by interviews with teachers, questionnaires from students, logbooks from teachers and user data from Google Analytics., Results: The program was well received and implemented, but on-the-spot adaptations were made by teachers to fit their students better. Within the lower-educated target group, differences between students are high in terms of active participation, reading abilities, knowledge and attention span. The program fit well within their regular teaching activities, but the topic of organ donation is not always prioritized by teachers., Conclusions: We see opportunities to disseminate the program on a larger scale and reach a group that has been neglected in organ donation education before. Within the program, there are possibilities to increase the effectiveness of the program, such as alternative delivery methods for the elements with a lot of text, the addition of booster sessions and guidelines for teachers to adapt the program to students of different levels within Intermediate Vocational Education. Moreover, in order to have an impact on a national level, strategies need to be employed to reach high numbers of students and, therefore, support on a higher level is needed (both within schools and at policy level)., Trial Registration: Dutch Trial Register, NTR6771. Prospectively registered on 24 October 2017.

Background: Organ donation registration rates remain low, especially among people with lower educational levels. An interactive educational intervention was developed to prepare lower-educated students in the Netherlands for making a well-informed decision about organ donation. This article reports on the effects of this intervention on the intention to register (i.e., the primary outcome in the study at hand) and beliefs regarding organ donation., Materials and Methods: The effectiveness was investigated in a post-test-only cluster randomized controlled trial, in which the intervention was offered to the experimental group and after measurement also to the control group. Randomization to the experimental and control groups took place at a class level. Teachers of schools for Intermediate Vocational Education who taught a course on Citizenship delivered three intervention elements (i.e., video fragments and discussion, quizzes with tailored feedback and exercise filling out a registration form) to their students during two 50-min lessons., Results: A total of 1170 students participated in the trial and filled out a questionnaire (45 experimental and 43 control classes). Compared to the control group, students in the experimental group had higher odds of having positive registration intentions (OR = 1.81; 95%CI [1.10-2.96]), their perceived knowledge was higher (B = 0.62; 95%CI [0.23-1.01]) and they had higher intentions to talk to family members (B = 0.68; 95%CI [0.28-1.08]) and friends (B = 0.36; 95%CI [0.07-0.66]) about organ donation. There were no effects on the choice students intended to register (OR = 1.08; 95%CI [0.67-1.73])., Conclusions: Providing education in a classroom setting is an effective tool in increasing registration intentions. Despite uncertainties about the effects on actual registration behavior, a larger-scale dissemination of this intervention is recommended. Providing clear information and opening the discussion about organ donation is an important and promising first step towards higher registration rates., Trial Registration: The Dutch Trial Register, ID: NTR6771. Registered on 24 October 2017. https://www.trialregister.nl/trial/6557.