Equity-specific effects of 26 Dutch obesity-related lifestyle interventions

Intergenerational transmission of health inequalities: towards a life course approach to socioeconomic inequalities in health - a review

Adult health inequalities are a persistent public health problem. Explanations are usually sought in behaviours and environments in adulthood, despite evidence on the importance of early life conditions for life course outcomes. We review evidence from a broad range of fields to unravel to what extent, and how, socioeconomic health inequalities are intergenerationally transmitted.We find that transmission of socioeconomic and associated health (dis)advantages from parents to offspring, and its underlying structural determinants, contributes substantially to socioeconomic inequalities in adult health. In the first two decades of life-from conception to early adulthood-parental socioeconomic position (SEP) and parental health strongly influence offspring adult SEP and health. Socioeconomic and health (dis)advantages are largely transmitted through the same broad mechanisms. Socioeconomic inequalities in the fetal environment contribute to inequalities in fetal development and birth outcomes, with lifelong socioeconomic and health consequences. Inequalities in the postnatal environment-especially the psychosocial and learning environment, physical exposures and socialisation-result in inequalities in child and adolescent health, development and behavioural habits, with health and socioeconomic consequences tracking into adulthood. Structural factors shape these mechanisms in a socioeconomically patterned and time-specific and place-specific way, leading to distinct birth-cohort patterns in health inequality.Adult health inequalities are for an important part intergenerationally transmitted. Effective health inequality reduction requires addressing intergenerational transmission of (dis)advantage by creating societal circumstances that allow all children to develop to their full potential.

Professionals' perspectives on interventions to reduce problematic alcohol use in older adults: a realist evaluation of working elements

OBJECTIVES

This study set out to understand how (which elements), in what context and why (which mechanisms) interventions are successful in reducing (problematic) alcohol use among older adults, from the perspective of professionals providing these interventions.

DESIGN

Guided by a realist evaluation approach, an existing initial programme theory (IPT) on working elements in alcohol interventions was evaluated by conducting semistructured interviews with professionals.

SETTING AND PARTICIPANTS

These professionals (N=20) provide interventions across several contexts: with or without practitioner involvement; in-person or not and in an individual or group setting. Data were coded and links between contexts, elements, mechanisms and outcomes were sought for to confirm, refute or refine the IPT.

RESULTS

From the perspective of professionals, there are several general working elements in interventions for older adults: (1) pointing out risks and consequences of drinking behaviour; (2) paying attention to abstinence; (3) promoting contact with peers; (4) providing personalised content and (5) providing support. We also found context-specific working elements: (1) providing personalised conversations and motivational interviewing with practitioners; (2) ensuring safety, trust and a sense of connection and a location nearby home or a location that people are familiar with in person and (3) sharing experiences and tips in group interventions. Furthermore, the mechanisms awareness and accessible and low threshold participation were important contributors to positive intervention outcomes.

CONCLUSION

In addition to the IPT, our findings emphasise the need for social contact and support, personalised content, and strong relationships (both between client and practitioner, and client and peers) in interventions for older adults.

Implementation of a group-based lifestyle intervention programme (Healthy Heart) in general practices in The Netherlands: a mixed-methods study

BACKGROUND

Lifestyle intervention programmes target behavioural risk factors that contribute to cardiovascular diseases (CVDs). Unfortunately, sustainable implementation of these programmes can be challenging. Gaining insights into the barriers and facilitators for successful implementation is important for maximising public health impact of these interventions. The Healthy Heart (HH) programme is an example of a combined lifestyle intervention programme.

AIM

To analyse the reach, adoption, and implementation of the HH programme.

DESIGN & SETTING

A mixed-methods study conducted in a general practice setting in The Netherlands.

METHOD

Quantitative data were collected from the Healthy Heart study (HH study), a non-randomised cluster stepped-wedge trial to assess the effect of the HH programme on patients at high risk of developing CVDs at practice level. Qualitative data were obtained through focus groups.

RESULTS

Out of 73 approached general practices, 55 implemented the HH programme. A total of 1082 patients agreed to participate in the HH study, of whom 64 patients were referred to the HH programme and 41 patients participated. Several barriers for participation were identified such as time investment, lack of risk perception, and being confident in changing lifestyle on their own. Important barriers for healthcare providers (HCPs) to refer a patient were time investment, lack of information to sufficiently inform patients, and preconceived notions regarding which patients the programme was suitable for.

CONCLUSION

This study has offered insights from a patient and HCP perspective regarding barriers and facilitators for implementation of the group-based lifestyle intervention programme. The identified barriers and facilitators, and the suggested improvements, can be used by others who wish to implement a similar programme.

Reach and effectiveness of a worksite health promotion program combining a preventive medical examination with motivational interviewing; a quasi-experimental study among workers in low socioeconomic position

BACKGROUND

This study aimed to evaluate individual characteristics associated with participation and effectiveness of a worksite health promotion program with motivational interviewing targeting health and health behaviour among Dutch workers in low socioeconomic position.

METHODS

In a production company and a hospital, 838 workers were invited for a Preventive Medical Examination and subsequent coaching with motivational interviewing up to 7 sessions within 6 months. Follow-up information was collected after 6 months. Characteristics associated with participation in coaching were assessed with logistic regression models. The effectiveness of coaching on body mass index (BMI), bodyweight, self-rated health, vigorous physical activity, smoking, alcohol intake, fruit- and vegetable consumption, work ability, and sickness absence was evaluated with linear regression models and on participation in health promotion activities with logistic regression analysis. The analyses on effectiveness were performed without and with propensity score adjustment.

RESULTS

Of the 838 invited workers, 313 workers participated in the Preventive Medical Examination and follow-up data were available for 176 workers, of whom 100 workers with increased cardiovascular risk attended coaching. The majority of workers with obesity (73%), overweight (60%), and unhealthy behaviours (58%-69%) at baseline participated in motivational interviewing. Males, workers with overweight or obesity, workers at the production company, workers with insufficient vigorous physical activity, and workers with a low educational level were most likely to participate in coaching. Coaching with motivational interviewing after the Preventive Medical Examination was associated with a 4.74 times higher likelihood [95% confidence interval (CI): 1.99;11.32] to participate in health promotion activities and 10.9% (95%CI: 0.6;21.3) more persons who quit smoking compared to workers without coaching. No statistically significant effects were observed on BMI, bodyweight, health, health behaviour, work ability and sickness absence.

CONCLUSIONS

The program combining a Preventive Medical Examination with follow-up coaching reached - as intended - workers with obesity or overweight, those with a low education and with unhealthy behaviours. Adding coaching with motivational interviewing to a Preventive Medical Examination contributed to higher participation in health promotion activities and an increase in smoking cessation after 6 months among workers with a lower socioeconomic position, but was not effective on other outcomes.

TRIAL REGISTRATION

The study was registered retrospectively in the Netherlands Trial Register as NL8178 on 22/11/2019.

Changes in Fruit and Vegetable Consumption and Leisure Time Physical Exercise after a Citizen Science-Based Worksite Health Promotion Program for Blue-Collar Workers

Blue-collar workers have, on average, poorer health than white-collar workers. Existing worksite health promotion programs (WHPPs) are often not successful among blue-collar workers. This study evaluates the effect of the Citizen Science-based WHPP on the targeted lifestyle behaviors among construction workers. The data of 114 participants were retrieved from questionnaires before (T0) and after (T1) the WHPP. Outcome measures were mean and categorical changes in daily fruit and vegetable intake and weekly leisure time physical exercise. Changes were tested using Wilcoxon signed rank tests and McNemar tests. No statistically significant changes were found between T0 and T1. In total, 73.7% of the participants felt involved in the WHPP. Changes in the outcome measures were not significantly different between subgroups based on age, nor in subgroups based on feelings of involvedness. The low intensity of the developed program could be an explanation for this lack of significant change. Future studies using the Citizen Science approach in an occupational setting should aim at developing a more intensified program and should test its effectiveness by comparing changes in a (randomized) controlled trial.

Perceptions of employees with a low and medium level of education towards workplace health promotion programmes: a mixed-methods study

BACKGROUND

Understanding the perceptions of lower socioeconomic groups towards workplace health promotion is important because they are underrepresented in workplace health promotion activities and generally engage in unhealthier lifestyle behaviour than high SEP groups. This study aims to explore interest in workplace health promotion programmes (WHPPs) among employees with a low and medium level of education regarding participation and desired programme characteristics (i.e. the employer's role, the source, the channel, the involvement of the social environment and conditions of participation).

METHODS

A mixed-methods design was used, consisting of a questionnaire study (n = 475) and a sequential focus group study (n = 27) to enrich the questionnaire's results. Multiple logistic regression analysis was performed to analyse the associations between subgroups (i.e. demographics, weight status) and interest in a WHPP. The focus group data were analysed deductively through thematic analysis, using MAXQDA 2018 for qualitative data analysis.

RESULTS

The questionnaire study showed that 36.8% of respondents were interested in an employer-provided WHPP, while 45.1% expressed no interest. Regarding subgroup differences, respondents with a low level of education were less likely to express interest in a WHPP than those with a medium level of education (OR = .54, 95%, CI = .35-.85). No significant differences were found concerning gender, age and weight status. The overall themes discussed in the focus groups were similar to the questionnaires (i.e. the employer's role, the source, the channel, the involvement of the social environment and conditions of participation). The qualitative data showed that participants' perceptions were often related to their jobs and working conditions.

CONCLUSIONS

Employees with a medium level of education were more inclined to be interested in a WHPP than those with a low level of education. Focus groups suggested preferences varied depending on job type and related tasks. Recommendations are to allow WHPP design to adapt to this variation and facilitate flexible participation. Future research investigating employers' perceptions of WHPPs is needed to enable a mutual understanding of an effective programme design, possibly contributing to sustainable WHPP implementation.

The process evaluation of a citizen science approach to design and implement workplace health promotion programs

BACKGROUND

Many workplace health promotion programs (WHPPs) do not reach blue-collar workers. To enhance the fit and reach, a Citizen Science (CS) approach was applied to co-create and implement WHPPs. This study aims to evaluate i) the process of this CS approach and ii) the resulting WHPPs.

METHODS

The study was performed in two companies: a construction company and a container terminal company. Data were collected by questionnaires, interviews and logbooks. Using the framework of Nielsen and Randall, process measures were categorized in the intervention, context and mental models. Interviews were transcribed and thematically coded using MaxQDA software.

RESULTS

The involvement in the CS approach and co-creating the WHPPs was positively experienced. Information provision, sustained engagement over time and alignment with the workplace's culture resulted in barriers in the CS process. As to the resulting WHPPs, involvement and interaction during the intervention sessions were particularly experienced in small groups. The reach was affected by the unfavorable planning off the WHPPs and external events of re-originations and the covid-19 pandemic.

DISCUSSION

Continuous information provision and engagement over time, better alignment with the workplace's culture and favorable planning are considered to be important factors for facilitating involvement, reach and satisfaction of the workers in a Citizen science approach to design and implement a WHPP. Further studies continuously monitoring the process of WHPPs using the CS approach could be helpful to anticipate on external factors and increase the adaptability.

CONCLUSIONS

Workers were satisfied with the involvement in WHPPs. Organizational and social cultural factors were barriers for the CS approach and its reach. Involvement and interaction in WHPPs were particularly experienced in small grouped sessions. Consequently, contextual and personal factors need be considered in the design and implementation of WHPPs with CS approach among blue-collar workers.

A Theoretical Perspective on Why Socioeconomic Health Inequalities Are Persistent: Building the Case for an Effective Approach

Despite policy intentions and many interventions aimed at reducing socioeconomic health inequalities in recent decades in the Netherlands and other affluent countries, these inequalities have not been reduced. Based on a narrative literature review, this paper aims to increase insight into why socioeconomic health inequalities are so persistent and build a way forward for improved approaches from a theoretical perspective. Firstly, we present relevant theories focusing on individual determinants of health-related behaviors. Thereafter, we present theories that take into account determinants of the individual level and the environmental level. Lastly, we show the complexity of the system of individual determinants, environmental determinants and behavior change for low socioeconomic position (SEP) groups and describe the next steps in developing and evaluating future effective approaches. These steps include systems thinking, a complex whole-system approach and participation of all stakeholders in system change.

Recruiting residents from disadvantaged neighbourhoods for community-based health promotion and disease prevention services in Denmark-How, why and under what circumstances does an active door-to-door recruitment approach work?

Residents living in disadvantaged neighbourhoods have higher mortality and morbidity and participate less in health services than people living in more prosperous areas. Studies on how and why different approaches work for recruiting residents from disadvantaged neighbourhoods to health services are needed. Conducting face-to-face meetings with obliging health professionals (HPs) as part of an active recruitment strategy increases interest in service use, particularly among the most vulnerable residents. The services offered must be free, flexible and easily accessible for residents from disadvantaged neighbourhoods to consider their use. Residents immediately consider and 'translate' the relevance and acceptability of health services presented to them in light of their current situation, which affects their response. Individual contextual circumstances such as current health issues or difficult life circumstances, either promote or dampen their interest in using the services. This study is a realist evaluation of active face-to-face recruitment where HPs go from door-to-door to visit residents in disadvantaged neighbourhoods and offer them community-based health promotion and disease prevention services. A programme theory explicating the assumptions behind this recruitment approach was tested empirically in the present study. Eight direct observations of the active recruitment process in three different neighbourhoods and 17 realist interviews with residents were conducted. Sampling of residents was purposeful and opportunistic. Data were collected between March and August 2018. The findings support the use of active face-to-face recruitment in disadvantaged neighbourhoods to increase participation in health interventions. A broad range of health services should be presented to residents to accommodate their different needs and interests. Refusal to have services presented during active recruitment was rare, but more knowledge about these reasons for declining services is needed.

Using storytelling methodology to identify barriers and facilitators of sustained physical activity in patients with a chronic disease: a qualitative study

OBJECTIVES

To identify implicit and more profound barriers and facilitators and involving context elements to accomplish sustained physical activity (PA) in patients with a chronic disease. Understanding these barriers and facilitators may help develop future strategies to be used by healthcare professionals in primary care to support patients with a chronic disease to reach sustained PA.

DESIGN AND METHODS

The qualitative, narrative research method storytelling was applied. Perspectives of both patients with a chronic disease (n=12) and involved healthcare professionals (n=11) were collected. Stories were audiotaped and retrieved from the transcriptions. Analysis involved a cyclic process of constant comparison. Main themes were arranged in the theoretical framework of the Capability, Opportunity, Motivation and Behaviour (COM-B) model.

PARTICIPANTS

Patients were adults with a chronic disease or at high risk of developing a chronic disease who participated in a PA promoting programme. Eligible healthcare professionals were those involved in these PA promoting programmes in primary care, such as physiotherapists, nurse practitioners or sports consultants.

RESULTS

From 176 stories, 62 relevant and unique stories were selected for further analysis. Eleven main themes were identified and afterwards linked to the COM-B model. Trust in one's own capabilities and in the healthcare professional were relevant themes. Also, health literacy and coping with temporary interruption were important capabilities. Important motivators were customised PA, increasing awareness, meaningful activities, exercising in a group and success experiences. Aversion to sports was seen as a barrier. Interprofessional collaboration and prerequisites can be a facilitator or a barrier.

CONCLUSIONS

This study provides insight into deeper motivations, barriers and facilitators of sustained PA from both the patients' and healthcare professionals' perspective. Comparing these perspectives revealed different views and beliefs on some themes. Attention for temporary interruptions, aversion to sports and health literacy were identified to be important for sustained PA.

Do recommended interventions widen or narrow inequalities in musculoskeletal health? An equity-focussed systematic review of differential effectiveness

Background

It is unclear whether seven interventions recommended by Public Health England for preventing and managing common musculoskeletal conditions reduce or widen health inequalities in adults with musculoskeletal conditions.

Methods

We used citation searches of Web of Science (date of ‘parent publication’ for each intervention to April 2021) to identify original research articles reporting subgroup or moderator analyses of intervention effects by social stratifiers defined using the PROGRESS-Plus frameworks. Randomized controlled trials, controlled before-after studies, interrupted time series, systematic reviews presenting subgroup/stratified analyses or meta-regressions, individual participant data meta-analyses and modelling studies were eligible. Two reviewers independently assessed the credibility of effect moderation claims using Instrument to assess the Credibility of Effect Moderation Analyses. A narrative approach to synthesis was used (PROSPERO registration number: CRD42019140018).

Results

Of 1480 potentially relevant studies, seven eligible analyses of single trials and five meta-analyses were included. Among these, we found eight claims of potential differential effectiveness according to social characteristics, but none that were judged to have high credibility.

Conclusions

In the absence of highly credible evidence of differential effectiveness in different social groups, and given ongoing national implementation, equity concerns may be best served by investing in monitoring and action aimed at ensuring fair access to these interventions.

Stakeholder dialogue on dilemmas at work as a workplace health promotion intervention including employees with a low SEP: a Responsive Evaluation

Background

The aim of this study was to evaluate the perceived changes of an innovative workplace health promotion intervention and evaluation. In this study, a bottom-up approach was taken to define the central themes and relevant outcomes of an intervention. These central themes and relevant outcomes of the intervention were defined together with stakeholders, including employees with a low socioeconomic position.

Methods

The intervention consisted of a series of structured stakeholder dialogues in which dilemmas around the – by employees defined —health themes were discussed. The intervention was implemented in a harbor service provider with approximately 400 employees. Over a two-year period, 57 participants engaged in eight dialogues of one hour. 15 interviews and six participant observations took place for the evaluation of the intervention.

Results

Together with the stakeholders, high workload and mental health were defined as central themes for the dialogue intervention in the male-dominated workplace. The dialogue intervention contributed to changes, on different levels: individual, team, and organization. Overall, the stakeholder dialogues advanced the understanding of factors contributing to high workload and mental health. In reply to this, several actions were taken on a organizational level.

Conclusions

Taking a bottom-up approach in WHP allows to understand the health issues that are important in the daily reality of employees with a low socioeconomic position. Through this understanding, workplace health promotion can become more suitable and relevant for employees with a low socioeconomic position.

Trial registration

Netherlands Trial Register (NRT): NL8051. Registration date: 28/09/2019, Retrospectively registered https://www.trialregister.nl

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12802-z.

Healthy eating strategies for socioeconomically disadvantaged populations: a meta-ethnography

Purpose: In developed countries, diet-related health inequalities between people with different levels of socioeconomic advantage persist. However, there is limited qualitative evidence to inform the design of effective healthy eating (HE) strategies in socioeconomically disadvantaged populations (SDPs). The purpose of this review was to explore the characteristics influencing HE strategies for SDPs and develop a new understanding of how and why they influence their success.

Methods: A qualitative evidence synthesis using a systematic meta-ethnographic approach. The twelve studies included were conducted in the USA, Canada, Australia, and UK.

Results: The studies described a range of HE strategies, including nutrition education programs, food vouchers, and community gardens. Personal values and sense of pride and autonomy were found to have an influence on participants’ attitudes towards HE strategies. Similarly, social characteristics such as level of social support and opportunities for shared benefits influenced participants’ engagement. Structural characteristics such as the affordability and accessibility of healthy foods determined strategy acceptability and success. Finally, organizational characteristics such as flexibility influenced how well strategies supported the circumstances of participants.

Conclusions: These overlapping characteristics may be used to inform the development, implementation, and evaluation of strategies to improve healthy eating in SDPs.

Equity-specific effects of interventions to promote physical activity among middle-aged and older adults: results from applying a novel equity-specific re-analysis strategy

BACKGROUND

Reducing inequalities in physical activity (PA) and PA-associated health outcomes is a priority for public health. Interventions to promote PA may reduce inequalities, but may also unintentionally increase them. Thus, there is a need to analyze equity-specific intervention effects. However, the potential for analyzing equity-specific effects of PA interventions has not yet been sufficiently exploited. The aim of this study was to set out a novel equity-specific re-analysis strategy tried out in an international interdisciplinary collaboration.

METHODS

The re-analysis strategy comprised harmonizing choice and definition of outcomes, exposures, socio-demographic indicators, and statistical analysis strategies across studies, as well as synthesizing results. It was applied in a collaboration of a convenience sample of eight European PA intervention studies in adults aged ≥45 years. Weekly minutes of moderate-to-vigorous PA was harmonized as outcome. Any versus no intervention was harmonized as exposure. Gender, education, income, area deprivation, and marital status were harmonized as socio-demographic indicators. Interactions between the intervention and socio-demographic indicators on moderate-to-vigorous PA were analyzed using multivariable linear regression and random-effects meta-analysis.

RESULTS

The collaborative experience shows that the novel re-analysis strategy can be applied to investigate equity-specific effects of existing PA interventions. Across our convenience sample of studies, no consistent pattern of equity-specific intervention effects was found. Pooled estimates suggested that intervention effects did not differ by gender, education, income, area deprivation, and marital status.

CONCLUSIONS

To exploit the potential for equity-specific effect analysis, we encourage future studies to apply the strategy to representative samples of existing study data. Ensuring sufficient representation of 'hard to reach' groups such as the most disadvantaged in study samples is of particular importance. This will help to extend the limited evidence required for the design and prioritization of future interventions that are most likely to reduce health inequalities.

The effectiveness of workplace health promotion programs on self-perceived health of employees with a low socioeconomic position: An individual participant data meta-analysis

The aim of the current study was to evaluate whether workplace health promotion programs improve self-perceived health of employees with a low socioeconomic position (SEP), and whether differential effects exist between individuals with a low SEP for gender, marital status or age. Individual participant data from six Dutch intervention studies aiming at promoting healthy behavior and preventing obesity in the work setting, with a total of 1906 participants, were used. The overall intervention effect and interaction effects for gender, marital status and age were evaluated using two-stage meta-analyses with linear mixed regression models. In the first stage effect sizes of each study were estimated, which were pooled in the second stage. Compared to control conditions, workplace health promotion programs did not show an overall improvement in self-perceived health of employees with a low SEP (β0.03 (95%CI: −0.03 to 0.09)). Effects did not differ across gender, marital status and age. Future research could be focused on the determinants of self-perceived health next to health behavior to improve the health of employees with a low SEP.

Lifetime cost-effectiveness and equity impacts of the Healthy Primary School of the Future initiative

BACKGROUND

This study estimated the lifetime cost-effectiveness and equity impacts associated with two lifestyle interventions in the Dutch primary school setting (targeting 4-12 year olds).

METHODS

The Healthy Primary School of the Future (HPSF; a healthy school lunch and structured physical activity) and the Physical Activity School (PAS; structured physical activity) were compared to the regular Dutch curriculum (N = 1676). An adolescence model, calculating weight development, and the RIVM Chronic Disease Model, calculating overweight-related chronic diseases, were linked to estimate the lifetime impact on chronic diseases, quality adjusted life years (QALYs), healthcare, and productivity costs. Cost-effectiveness was expressed as the additional costs/QALY gained and we used €20,000 as threshold. Scenario analyses accounted for alternative effect maintenance scenarios and equity analyses examined cost-effectiveness in different socioeconomic status (SES) groups.

RESULTS

HPSF resulted in a lifetime costs of €773 (societal perspective) and a lifetime QALY gain of 0.039 per child versus control schools. HPSF led to lower costs and more QALYs as compared to PAS. From a societal perspective, HPSF had a cost/QALY gained of €19,734 versus control schools, 50% probability of being cost-effective, and beneficial equity impact (0.02 QALYs gained/child for low versus high SES). The cost-effectiveness threshold was surpassed when intervention effects decayed over time.

CONCLUSIONS

HPSF may be a cost-effective and equitable strategy for combatting the lifetime burden of unhealthy lifestyles. The win-win situation will, however, only be realised if the intervention effect is sustained into adulthood for all SES groups.

TRIAL REGISTRATION

Clinicaltrials.gov ( NCT02800616 ). Registered 15 June 2016 - Retrospectively registered.

Socio-economic inequalities in the effectiveness of workplace health promotion programmes on body mass index: An individual participant data meta-analysis

This individual participant data meta-analysis assessed the effectiveness of workplace health promotion programmes on body mass index (BMI) across socio-economic groups and whether study and intervention characteristics explained inequalities in effectiveness. Studies were eligible if they assessed the effect of a workplace health promotion programme on BMI in the Netherlands, included workers of at least two different socio-economic positions (SEPs) and had a study design with premeasurement and postmeasurement and control condition. Data of 13 studies presenting 16 interventions (5183 participants) were harmonized. In a two-stage meta-analysis, the interaction between intervention and SEP on BMI was tested with linear mixed models for each study. Subsequently, the interaction terms were pooled. The influence of study and intervention characteristics on the effectiveness of workplace health promotion programmes was evaluated using meta-regression analyses. Compared with control conditions, workplace health promotion programmes overall showed a statistically non-significant 0.12 kg/m2 (95% CI: -0.01, 0.25) decrease in BMI, which did not differ across SEP. Interventions evaluated within randomized controlled trials, agentic interventions, those that focused on high-risk groups, included a counselling component, consisted of more than five sessions, or were offered at the individual level did statistically significantly reduce BMI. No evidence was found for intervention-generated SEP inequalities.

Socioeconomic inequalities in effectiveness of and compliance to workplace health promotion programs: an individual participant data (IPD) meta-analysis

BACKGROUND

This individual patient data (IPD) meta-analysis aimed to investigate socioeconomic inequalities in effectiveness on healthy behavior of, and compliance to, workplace health promotion programs.

METHODS

Dutch (randomized) controlled trials were identified and original IPD were retrieved and harmonized. A two-stage meta-analysis was conducted where linear mixed models were performed per study (stage 1), after which individual study effects were pooled (stage 2). All models were adjusted for baseline values of the outcomes, age and gender. Intervention effects were assessed on physical activity, diet, alcohol use, and smoking. Also, we assessed whether effects differed between participants with low and high program compliance and. All analyses were stratified by socioeconomic position.

RESULTS

Data from 15 studies (n = 8709) were harmonized. Except for fruit intake (beta: 0·12 [95% CI 0·08 0·15]), no effects were found on health behaviors, nor did these effects differ across socioeconomic groups. Only participants with high compliance showed significant improvements in vigorous and moderate-to-vigorous physical activity, and in more fruit and less snack intake. There were no differences in compliance across socioeconomic groups.

CONCLUSIONS

Workplace health promotion programs were in general not effective. Neither effectiveness nor compliance differed across socioeconomic groups (operationalized by educational level). Even though stronger effects on health behavior were found for participations with high compliance, effects remained small. The results of the current study emphasize the need for new directions in health promotion programs to improve healthy behavior among workers, in particular for those in lower socioeconomic position.

Adapting Citizen Science to Improve Health in an Occupational Setting: Preliminary Results of a Qualitative Study

Health interventions often do not reach blue-collar workers. Citizen science engages target groups in the design and execution of health interventions, but has not yet been applied in an occupational setting. This preliminary study determines barriers and facilitators and feasible elements for citizen science to improve the health of blue-collar workers. The study was conducted in a terminal and construction company by performing semi-structured interviews and focus groups with employees, company management and experts. Interviews and focus groups were analyzed using thematic content analysis and the elements were pilot tested. Workers considered work pressure, work location and several personal factors as barriers for citizen science at the worksite, and (lack of) social support and (negative) social culture both as barriers and facilitators. Citizen science to improve health at the worksite may include three elements: (1) knowledge and skills, (2) social support and social culture, and (3) awareness about lifestyle behaviors. Strategies to implement these elements may be company specific. This study provides relevant indications on feasible elements and strategies for citizen science to improve health at the worksite. Further studies on the feasibility of citizen science in other settings, including a larger and more heterogeneous sample of blue-collar workers, are necessary.

Estimating Reductions in Ethnic Inequalities in Child Adiposity from Hypothetical Diet, Screen Time, and Sports Participation Interventions

BACKGROUND

Childhood obesity is a global epidemic, and its prevalence differs by ethnicity. The objective of this study was to estimate the change in ethnic inequalities in child adiposity at age 10 resulting from interventions on diet at age 8 and screen time and sports participation at age 9.

METHODS

We conducted a population-based cohort study, the Generation R Study, from 9,749 births in Rotterdam (2002-2006), of which 9,506 children remained in the analysis. We measured ethnicity, diet, screen time, and sports participation through questionnaires; we measured weight, body mass index (BMI), fat mass index, and fat-free mass index directly. We used sequential G-estimation to estimate the reduction in inequality that would result from the interventions.

RESULTS

We observed that sociodemographic characteristics, diet, screen time, sports participation, and all adiposity measurements were more favorable in children from Western versus non-Western ethnic backgrounds: weight = -1.2 kg (95% confidence interval [CI] = -1.7, -0.8), BMI = -1.0 kg/m (CI = -1.2, -0.9), and fat mass index = -0.8 kg/m (CI = -0.9, -0.7). We estimated that extreme intervention (maximum diet score of 10, no screen time, and >4 hours/week of sports) reduced ethnic inequalities by 21% (CI = 8%, 35%) for weight, 9% (CI = 4%, 14%) for BMI, and 9% (CI = 6%, 13%) for fat mass index. A diet score ≥5 points, screen time ≤2 hours/day, and sports participation >2 hours/week reduced ethnic inequalities by 17% (CI = 6%, 28%) for weight, 7% (CI = 3%, 11%) for BMI, and 7% (CI = 4%, 10%) for fat mass index.

CONCLUSIONS

Our results are consistent with the hypothesis that interventions integrating diet, screen time, and sports participation have a moderate impact on reducing ethnic inequalities in child adiposity.

Successfully Recruiting Adults with a Low Socioeconomic Position into Community-Based Lifestyle Programs: A Qualitative Study on Expert Opinions

We explored experts’ perceived challenges and success factors in the recruitment of adults with a low socioeconomic position (SEP) for participation in community-based lifestyle modification programs. We conducted semi-structured interviews with 11 experienced project coordinators, based on a topic list that included experiences with recruitment, perceived barriers and success factors, and general views on recruitment strategies. Results revealed challenges related to the context of the program (e.g., limited program resources), psychosocial barriers of the participants (e.g., mistrust or skepticism), practical barriers (e.g., low literacy or having other priorities), and reasons to decline participation (e.g., lack of interest or motivation). Success factors were related to securing beneficial contextual and program-related factors (e.g., multi-layered recruitment strategy), establishing contact with the target group (e.g., via existing networks, community key-members), methods to increase engagement (e.g., personal approach and involvement of the target group in the program process) and making participation easier (e.g., providing transport), and providing various types of incentives. Concluding, the group of participants with low SEP covers a wide spectrum of individuals. Therefore, multiple recruitment strategies at multiple layers should be employed, and tailored. The lessons learned of those with hands-on experiences will help to enhance recruitment in future programs.

Are workplace health promotion programmes effective for all socioeconomic groups? A systematic review

Decreasing socioeconomic health inequalities is considered an important policy priority in many countries. Workplace health promotion programmes (WHPPs) have shown modest improvements in health behaviour. This systematic review aims to determine the presence and magnitude of socioeconomic differences in effectiveness and the influence of programme characteristics on differential effectiveness of WHPPs. Three electronic databases were searched for systematic reviews published from 2013 onwards and for original studies published from 2015 onwards. We synthesised the reported socioeconomic differences in effectiveness of WHPPs on health behaviours, and calculated effectiveness ratios by dividing the programme effects in the lowest socioeconomic group by the programme effects in the highest socioeconomic group. Thirteen studies with 75 comparisons provided information on the effectiveness of WHPPs across socioeconomic groups. Ten studies with 54 comparisons reported equal effectiveness and one study with 3 comparisons reported higher effectiveness for lower socioeconomic groups. Quantitative information on programme effects was available for six studies with 18 comparisons, of which 13 comparisons showed equal effectiveness and 5 comparisons showed significantly higher effect sizes among workers in low socioeconomic position. The differential effectiveness of WHPPs did not vary across programme characteristics. In this study no indications are found that WHPPs increase socioeconomic inequalities in health behaviour. The limited quantitative information available suggests that WHPPs may contribute to reducing socioeconomic inequalities. Better insight is needed on socioeconomic differences in effectiveness of WHPPs to develop strategies to decrease socioeconomic inequalities in health in the workforce.

Responsive evaluation of stakeholder dialogue as a worksite health promotion intervention to contribute to the reduction of SEP related health inequalities: a study protocol

BACKGROUND

Large health inequalities exist in the Netherlands among individuals with a high compared to a low socioeconomic position. Worksite health promotion interventions are considered promising to reduce these inequalities, however, current interventions seem not to have the desired effects. This study proposes 'moral case deliberation', a form of stakeholder dialogue on moral dilemmas, as an integrated and inclusive intervention for worksite health promotion. This intervention takes into account three factors that are considered possible underlying causes of low effectiveness of current interventions, namely the lack of deliberate attention to: 1) the diverging values and interests of stakeholders in worksite health promotion, 2) the ethical issues of worksite health promotion, and 3) the connection with the lived experience (lifeworld) of lower SEP employees. Moral case deliberation will help to gain insight in the conflicting values in worksite health promotion, which contributes to the development of a vision for worksite health promotion that is supported by all parties.

METHODS

The intervention will be evaluated through Responsive Evaluation, a form of participatory research. Key to Responsive Evaluation is that stakeholders are consulted to determine relevant changes as a result of the intervention. The intervention will be evaluated yearly at both fixed moments (baseline and annual evaluation(s)) and continuously. Mixed methods will be used, including interviews, participatory observations, analyses of HRM-data and short questionnaires. In addition, the intervention will be evaluated economically, on both monetary and non-monetary outcomes.

DISCUSSION

This protocol proposes an innovative intervention and a novel participatory evaluation in the context of worksite health promotion. The study aims to gain understanding in how dialogue on moral dilemmas on health and health promotion can contribute to heightened personal and mutual understanding among stakeholders and practice improvements in the work context. By evaluating the intervention in more than one setting, findings of this study will provide knowledge about how MCD can be adapted to specific work settings and what changes it may lead to in these settings.

TRIAL REGISTRATION

Netherlands Trial Register (NRT): NL8051. Registration date: 28/09/2019, retrospectively registered. https://www.trialregister.nl/.

Equity-Specific Effects of Interventions to Promote Physical Activity among Middle-Aged and Older Adults: Development of a Collaborative Equity-Specific Re-Analysis Strategy

Reducing social inequalities in physical activity (PA) has become a priority for public health. However, evidence concerning the impact of interventions on inequalities in PA is scarce. This study aims to develop and test the application of a strategy for re-analyzing equity-specific effects of existing PA intervention studies in middle-aged and older adults, as part of an international interdisciplinary collaboration. This article aims to describe (1) the establishment and characteristics of the collaboration; and (2) the jointly developed equity-specific re-analysis strategy as a first result of the collaboration. To develop the strategy, a collaboration based on a convenience sample of eight published studies of individual-level PA interventions among the general population of adults aged ≥45 years was initiated (UK, n = 3; The Netherlands, n = 3; Belgium, n = 1; Germany, n = 1). Researchers from these studies participated in a workshop and subsequent e-mail correspondence. The developed strategy will be used to investigate social inequalities in intervention adherence, dropout, and efficacy. This will allow for a comprehensive assessment of social inequalities within intervention benefits. The application of the strategy within and beyond the collaboration will help to extend the limited evidence regarding the effects of interventions on social inequalities in PA among middle-aged and older adults.

Longitudinal analysis of health disparities in childhood

OBJECTIVE

Combatting disparities in health outcomes among children is a major public health concern. This study focuses on two questions: (1) To what extent does socioeconomic status (SES) contribute to disparities in health outcomes? and (2) To what extent can social inequalities in health outcomes be explained by differences in children's health behaviours?

DESIGN

This study included 2-year follow-up data of 1259 children (4-12 years of age) who participated in the 'Healthy Primary School of the Future' project (ClinicalTrials.gov NCT02800616). SES was measured by maternal and paternal education and household income (adjusted for family size). Health outcomes were body mass index (BMI) z-score, health resource use, school absenteeism, health-related quality of life and psychosocial health, measured over 2 years of follow-up (2015-2017). Health behaviours included physical activity, and consumption of fruits, vegetables and sweetened beverages. Associations between SES and baseline health behaviours were examined, and mixed models for repeated measures were used to assess associations between SES and health outcomes over 2 years of follow-up.

RESULTS

A high socioeconomic background was significantly associated with better health outcomes (all outcomes). For example, children with a low SES had higher BMI z-scores (beta coefficient: 0.42, 95% CI 0.22 to 0.62) and higher consumption healthcare costs (ratio of mean costs: 2.21, 95% CI 1.57 to 3.10). Effects of SES changed very little after controlling for health behaviours.

DISCUSSION

Our findings strongly suggest that socioeconomic background has a pervasive impact on disparities in child health, but gives little support to the idea that social inequalities in child health can be tackled by means of lifestyle interventions.

Socioeconomic inequalities in reach, compliance and effectiveness of lifestyle interventions among workers: protocol for an individual participant data meta-analysis and equity-specific reanalysis

INTRODUCTION

Obesity and unhealthy behaviour are more prevalent among workers with a low compared with a high socioeconomic position (SEP), and thus contribute to socioeconomic health inequalities. The occupational setting is considered an important setting to address unhealthy behaviours due to the possibility to efficiently reach a large group of adults through worksite health promotion. This paper describes the rationale and design for an individual participant data (IPD) meta-analysis and a socioeconomic equity-specific reanalysis aiming to: (1) investigate socioeconomic differences in the effectiveness of interventions aimed at promoting healthy behaviour and preventing obesity, (2) examine socioeconomic differences in reach and compliance and (3) to investigate underlying factors affecting possible socioeconomic differences.

METHODS AND ANALYSIS

A systematic search was conducted in electronic databases including Embase, Medline Ovid, Web of Science, Cochrane Central and Google Scholar as well as in grey literature and trial registries. Two researchers have independently selected a total of 34 relevant studies (from 88 articles). Responsible researchers of these eligible studies were asked to provide their study data and an assessment of the methodological criteria was done. The data of the intervention studies will be pooled for the IPD meta-analysis, whereas the socioeconomic equity-specific reanalysis will focus on each study separately, stratified for SEP. Both methods will be conducted to investigate socioeconomic differences in effectiveness, reach and compliance (research aims 1 and 2). For research aim 3, different factors, such as population characteristics, organisational work environment and intervention characteristics, will be investigated as possible moderators in the associations between SEP and effectiveness, reach and compliance.

ETHICS AND DISSEMINATION

The Medical Ethical Committee of Erasmus MC declared that the Medical Research Involving Human Subjects Act does not apply to the meta-analyses. The findings will be disseminated through peer-reviewed publications and (inter)national conference presentations.

TRIAL REGISTRATION NUMBER

CRD42018099878.

Examining subgroup effects by socioeconomic status of public health interventions targeting multiple risk behaviour in adolescence

BACKGROUND

Multiple risk behaviour (MRB) refers to two or more risk behaviours such as smoking, drinking alcohol, poor diet and unsafe sex. Such behaviours are known to co-occur in adolescence. It is unknown whether MRB interventions are equally effective for young people of low and high socioeconomic status (SES). There is a need to examine these effects to determine whether MRB interventions have the potential to narrow or widen inequalities.

METHODS

Two Cochrane systematic reviews that examined interventions to reduce adolescent MRB were screened to identify universal interventions that reported SES. Study authors were contacted, and outcome data stratified by SES and intervention status were requested. Risk behaviour outcomes alcohol use, smoking, drug use, unsafe sex, overweight/obesity, sedentarism, peer violence and dating violence were examined in random effects meta-analyses and subgroup analyses conducted to explore differences between high SES and low SES adolescents.

RESULTS

Of 49 studies reporting universal interventions, only 16 also reported having measured SES. Of these 16 studies, four study authors provided data sufficient for subgroup analysis. There was no evidence of subgroup differences for any of the outcomes. For alcohol use, the direction of effect was the same for both the high SES group (RR 1.26, 95% CI: 0.96, 1.65, p = 0.09) and low SES group (RR 1.14, 95% CI: 0.98, 1.32, p = 0.08). The direction of effect was different for smoking behaviour in favour of the low SES group (RR 0.83, 95% CI: 0.66, 1.03, p = 0.09) versus the high SES group (RR 1.16, 95% CI: 0.82, 1.63, p = 0.39). For drug use, the direction of effect was the same for both the high SES group (RR 1.29, 95% CI: 0.97, 1.73, p = 0.08) and the low SES group (RR 1.28, 95% CI: 0.84, 1.96, p = 0.25).

CONCLUSIONS

The majority of studies identified did not report having measured SES. There was no evidence of subgroup difference for all outcomes analysed among the four included studies. There is a need for routine reporting of demographic information within studies so that stronger evidence of effect by SES can be demonstrated and that interventions can be evaluated for their impact on health inequalities.

A review of the impact of physical activity mass media campaigns on low compared to high socioeconomic groups

Physical inactivity is a major contributor to non-communicable disease and people of low socioeconomic status (SES) are more likely to be insufficiently active. Physical activity mass media campaigns aim to increase physical activity participation, but little is known about their impact on low SES groups. We reviewed the published literature from 1990 to June 2016 to identify reports of physical activity mass media campaigns. We documented evaluation/study design, target population, campaign outcomes assessed, SES measures used and analysed the results of the SES comparisons. A total of 23 papers were reviewed, reporting on 17 physical activity campaigns and 12 campaigns compared SES differences for 85 outcomes: 45 comparisons showed no difference between lowest and highest SES groups, 20 showed a better outcome for the lowest SES group and 20 showed a worse outcome. Some campaigns found inconsistent results, but seven found only equal and/or better results for low SES groups. Post-campaign physical activity behaviour most commonly showed no SES differences, but no other patterns were seen. Our review found that physical activity mass media campaigns have mostly equitable or better impacts for low SES groups, but to reduce inequalities these campaigns need to be maximally effective for low SES populations.

Interventions to improve physical activity among socioeconomically disadvantaged groups: an umbrella review

Background

People from socioeconomically disadvantaged population groups are less likely to be physically active and more likely to experience adverse health outcomes than those who are less disadvantaged. In this umbrella review we examined across all age groups, (1) the effectiveness of interventions to improve physical activity among socioeconomically disadvantaged groups, (2) the characteristics of effective interventions, and (3) directions for future research.

Methods

PubMed/MEDLINE and Scopus were searched up to May 2017 to identify systematic reviews reporting physical activity interventions in socioeconomically disadvantaged populations or sub-groups. Two authors independently conducted study screening and selection, data extraction (one author, with data checked by two others) and assessment of methodological quality using the ‘Assessment of Multiple Systematic Reviews’ scale. Results were synthesized narratively.

Results

Seventeen reviews met our inclusion criteria, with only 5 (30%) reviews being assessed as high quality. Seven (41%) reviews focused on obesity prevention and an additional four focused on multiple behavioural outcomes. For pre school children, parent-focused, group-based interventions were effective in improving physical activity. For children, school-based interventions and policies were effective; few studies focused on adolescents and those that did were generally not effective; for adults, there was mixed evidence of effectiveness but characteristics such as group-based interventions and those that focused on physical activity only were associated with effectiveness. Few studies focused on older adults. Across all ages, interventions that were more intensive tended to be more effective. Most studies reported short-term, rather than longer-term, outcomes and common methodological limitations included high probability of selection bias, low response rates, and high attrition.

Conclusions

Interventions can be successful at improving physical activity among children from socioeconomically disadvantaged groups, with evidence for other age groups weak or inconclusive. More high-quality studies in this population group are needed, which adopt strategies to increase recruitment rates and reduce attrition, report longer term outcomes, and provide adequate intervention details, to allow determination of the characteristics of effective interventions. We recommend that the benefits of physical activity be recognised more broadly than obesity prevention in future studies, as this may have implications for the design and appeal of interventions.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0676-2) contains supplementary material, which is available to authorized users.

Cultural primer for cardiometabolic health: health disparities, structural factors, community, pathways to improvement, and clinical applications

The quest to optimize cardiometabolic health has created great interest in nonmedical health variables in the population, community-based research and coordination, and addressing social, ethnic, and cultural barriers. All of these may be of equal or even greater importance than classical health care delivery in achieving individual well-being. One dominant issue is health disparity - causes, methods of reduction, and community versus other levels of solutions. This communication summarizes some major views regarding social structures, followed by amplification and synthesis of central ideas in the literature. The role of community involvement, tools, and partnerships is also presented in this Primer. Recent views of how these approaches could be incorporated into cardiometabolic initiatives and strategies follow, with implications for research. Two examples comparing selected aspects of community leverage and interventions in relation to individual approaches to health care equity are examined in depth: overall performance in reducing cardiovascular risk and mortality, and the recent National Diabetes Prevention Program, both touching upon healthy diets and adherence. Finally, the potential that precision medicine offers, and possible effects on disparities are also discussed.

Obesity Prevention: A Systematic Review of Setting-Based Interventions from Nordic Countries and the Netherlands

AIM

Effective evidence-based interventions have an important role in obesity prevention. Our aim was to present a qualitative synthesis of setting-based health promotion interventions on obesity, from Nordic countries and the Netherlands.

METHODS

A systematic review of the literature was completed for studies in the community, schools, and worksite, with BMI as an outcome. A descriptive analysis was completed for all full-text articles meeting the inclusion criteria.

RESULTS

Thirty-three articles were identified: 7 whole of community, 3 worksite, and 23 school-based interventions. The studies were largely quasiexperimental in design (21/33), with follow-up from 4 months to 8 years. The explicit use of theory was not featured in many of the studies (20/33). No consistent direction for BMI change could be identified in the whole of community interventions (2/7 positive, 2/7 negative, and 3/7 no effect) and no effect for worksite (3/3 no effect) or many of the school-based interventions (1/23 negative, 4/23 positive, 15/23 no effect, 1/23 BMI significant increase only for control group and 3/23 no data available).

CONCLUSIONS

There is a need to prioritise interventions with study designs of high quality, theory, and a participatory approach, for optimal implementation and evaluation of obesity prevention interventions.

Use of programme theory to understand the differential effects of interventions across socio-economic groups in systematic reviews-a systematic methodology review

BACKGROUND

Systematic review guidance recommends the use of programme theory to inform considerations of if and how healthcare interventions may work differently across socio-economic status (SES) groups. This study aimed to address the lack of detail on how reviewers operationalise this in practice.

METHODS

A methodological systematic review was undertaken to assess if, how and the extent to which systematic reviewers operationalise the guidance on the use of programme theory in considerations of socio-economic inequalities in health. Multiple databases were searched from January 2013 to May 2016. Studies were included if they were systematic reviews assessing the effectiveness of an intervention and included data on SES. Two reviewers independently screened all studies, undertook quality assessment and extracted data. A narrative approach to synthesis was adopted.

RESULTS

A total of 37 systematic reviews were included, 10 of which were explicit in the use of terminology for 'programme theory'. Twenty-nine studies used programme theory to inform both their a priori assumptions and explain their review findings. Of these, 22 incorporated considerations of both what and how interventions do/do not work in SES groups to both predict and explain their review findings. Thirteen studies acknowledged 24 unique theoretical references to support their assumptions of what or how interventions may have different effects in SES groups. Most reviewers used supplementary evidence to support their considerations of differential effectiveness. The majority of authors outlined a programme theory in the "Introduction" and "Discussion" sections of the review to inform their assumptions or provide explanations of what or how interventions may result in differential effects within or across SES groups. About a third of reviews used programme theory to inform the review analysis and/or synthesis. Few authors used programme theory to inform their inclusion criteria, data extraction or quality assessment. Twenty-one studies tested their a priori programme theory.

CONCLUSIONS

The use of programme theory to inform considerations of if, what and how interventions lead to differential effects on health in different SES groups in the systematic review process is not yet widely adopted, is used implicitly, is often fragmented and is not implemented in a systematic way.

Effectiveness of a Video-Versus Text-Based Computer-Tailored Intervention for Obesity Prevention after One Year: A Randomized Controlled Trial

Computer-tailored programs may help to prevent overweight and obesity, which are worldwide public health problems. This study investigated (1) the 12-month effectiveness of a video- and text-based computer-tailored intervention on energy intake, physical activity, and body mass index (BMI), and (2) the role of educational level in intervention effects. A randomized controlled trial in The Netherlands was conducted, in which adults were allocated to a video-based condition, text-based condition, or control condition, with baseline, 6 months, and 12 months follow-up. Outcome variables were self-reported BMI, physical activity, and energy intake. Mixed-effects modelling was used to investigate intervention effects and potential interaction effects. Compared to the control group, the video intervention group was effective regarding energy intake after 6 months (least squares means (LSM) difference = -205.40, p = 0.00) and 12 months (LSM difference = -128.14, p = 0.03). Only video intervention resulted in lower average daily energy intake after one year (d = 0.12). Educational role and BMI did not seem to interact with this effect. No intervention effects on BMI and physical activity were found. The video computer-tailored intervention was effective on energy intake after one year. This effect was not dependent on educational levels or BMI categories, suggesting that video tailoring can be effective for a broad range of risk groups and may be preferred over text tailoring.

A lifestyle intervention study targeting individuals with low socioeconomic status of different ethnic origins: important aspects for successful implementation

Background

Evaluation of the implementation process of trials is important, because the way a study is implemented modifies its outcomes. Furthermore, lessons learned during implementation can inform other researchers on factors that play a role when implementing interventions described in research. This study evaluates the implementation of the MetSLIM study, targeting individuals with low socioeconomic status of different ethnic origins. The MetSLIM study was set up to evaluate the effectiveness of a lifestyle programme on waist circumference and other cardio-metabolic risk factors. The objective of this evaluation was to identify components that were essential for the implementation of the MetSLIM study and to inform other researchers on methodological aspects when working with inadequately reached populations in health research.

Methods

In this evaluation study the experiences of health professionals, study assistants, a community worker and regional research coordinators involved in the MetSLIM study were explored using semi-structured interviews. Questionnaires were used to evaluate participants’ satisfaction with the lifestyle intervention.

Results

Our analyses show that a flexible recruitment protocol eventually leads to recruitment of sufficient participants; that trust in the recruiter is an important factor in the recruitment of individuals with low socioeconomic status of different ethnic origins; and that health professionals will unavoidably shape the form of intervention activities. Furthermore, our evaluation shows that daily practice and research mutually influence each other and that the results of an intervention are a product of this interaction.

Conclusions

Health promotion research would benefit from a perspective that sees intervention activities not as fixed entities but rather as social interaction that can take on numerous forms. Analysing and reporting the implementation process of studies, like in this evaluation, will allow readers to get a detailed view on the appropriateness of the (intended) study design and intervention for the targeted population. Evaluation studies that shed light on the reasons for adaptations, rather than describing them as deviation from the original plan, would point out methodological aspects important for a study’s replication. Furthermore, they would show how various factors can influence the implementation, and therewith initiate a learning cycle for the development of future intervention studies.

Trial registration

Netherlands Trial Register NTR3721 (since November 27, 2012).

Multibehavioural Interventions with a Focus on Specific Energy Balance-Related Behaviours Can Affect Diet Quality in Preschoolers from Six European Countries: The ToyBox-Study

The present study aimed to examine whether a multibehavioural intervention with a focus on specific energy balance-related behaviours can affect total diet quality and its four subcomponents in European preschoolers and to investigate if these intervention effects differed by socioeconomic status (SES). Parents/caregivers of 3.5 to 5.5 year-olds (n = 4968) recruited through kindergartens in six European countries within the ToyBox-study completed questionnaires on socio-demographics and a food frequency questionnaire on their preschoolers' diet. To assess intervention effects and differences by SES, multilevel repeated measures analyses were conducted. In contrast to no significant difference in total diet quality, in both the intervention and control group, the dietary quality and dietary equilibrium increased, with a larger increase in the intervention group (mean difference quality: +3.4%; mean difference equilibrium: +0.9%) compared to the control group (quality: +1.5%; equilibrium: +0.2%). SES was not a significant moderator for intervention effects on total diet quality, nor for the four subcomponents. This study indicates that multibehavioural interventions with a focus on specific energy balance-related behaviours in preschoolers not only affect those targeted behaviours, but can also have more generalized effects. The ToyBox-intervention effects were similar for both lower and high SES preschoolers.

Impact of universal interventions on social inequalities in physical activity among older adults: an equity-focused systematic review

Background

Physical activity is one of the most important contributors to healthy aging. Public health strategies aiming to promote physical activity among older adults are increasingly being implemented. However, little is known about their impact on social inequalities. Purpose of the study was to analyze whether and how studies of interventions consider effects on social inequalities in physical activity among older adults.

Methods

Nine electronic databases were searched to identify quantitative studies evaluating the effects of interventions on self-reported or objectively measured physical activity among the general population of older adults (≥50 years). English and German language peer-reviewed journal articles published between 2005 and 2015 were included. Using the PROGRESS-Plus framework, data on whether and how social factors were considered both for describing participants’ baseline characteristics and for measuring intervention effects were systematically extracted. Studies examining differential intervention effects by at least one PROGRESS-Plus factor were quality assessed. Results were presented in narrative synthesis.

Results

Fifty-nine studies were included. Beside age and sex, 44 studies used at least 1 further PROGRESS-Plus factor for the description of participants’ baseline characteristics. When measuring intervention effects, 22 studies considered PROGRESS-Plus factors as control variables. Eleven studies reported having analyzed potential effects on inequalities by testing interaction effects, stratifying effect analyses, or exploring associations between PROGRESS-Plus factors and increases in physical activity following an intervention. Effects were most often analyzed by gender/sex (n = 9) and age (n = 9), followed by education (n = 3), marital status (n = 2), and race/ethnicity (n = 2). Five studies pointed to gender/sex- or age-specific intervention effects, indicating that some interventions affect males and females, and younger and older individuals differently.

Conclusions

Many studies evaluating the effects of interventions on physical activity among older adults have not exploited the potential for assessing effects on social inequalities so far. There is an urgent need for systematic application of appropriate methodological approaches and transparent reporting of social inequalities-related findings which can provide important indications for the design of those interventions most likely to be effective across all social groups of older adults.

Trial registration

PROSPERO registration number: CRD42015025066

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-017-0472-4) contains supplementary material, which is available to authorized users.

Place, health, and community attachment: Is community capacity associated with self-rated health at the individual level?

Community-level interventions dominate contemporary public health responses to health inequalities as a lack of political will has discouraged action at a structural level. Health promoters commonly leverage community capacity to achieve programme goals, yet the health implications of low community capacity are unknown. In this study, we analyse perceptions of community capacity at the individual-level to explore how place-based understandings of identity and connectedness are associated with self-rated health. We examine associations between individual community capacity, self-rated health and income using a cross-sectional survey that was disseminated to 303 residents of four small (populations 1500–2000) New Zealand towns. Evidence indicating a relationship between individual community capacity and self-reported health was unconvincing once the effects of income were incorporated. That is, people who rated their community's capacity higher did not have better self-rated health. Much stronger evidence supported the relationship between income and both higher individual community capacity and higher self-rated health. We conclude that individual community capacity may mediate the positive association between income and health, however, overall we find no evidence suggesting that intervening to enhance individual community capacity is likely to improve health outcomes.

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People who rated their town's community capacity higher did not have better self-rated health.

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Higher individual community capacity was associated with greater income.

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Building individual community capacity seems unlikely to improve health outcomes.

Can policy ameliorate socioeconomic inequities in obesity and obesity-related behaviours? A systematic review of the impact of universal policies on adults and children

This systematic review examined the impact of universal policies on socioeconomic inequities in obesity, dietary and physical activity behaviours among adults and children. PRISMA-Equity guidelines were followed. Database searches spanned from 2004 to August 2015. Eligible studies assessed the impact of universal policies on anthropometric, dietary or physical activity-related outcomes in adults or children according to socioeconomic position. Thirty-six studies were included. Policies were classified as agentic, agento-structural or structural, and their impact on inequities was rated as positive, neutral, negative or mixed according to the dominant associations observed. Most policies had neutral impacts on obesity-related inequities regardless of whether they were agentic (60% neutral), agento-structural (68% neutral) or structural (67% neutral). The proportion of positive impacts was similar across policy types (10% agentic, 18% agento-structural and 11% structural), with some differences for negative impacts (30% agentic, 14% agento-structural and 22% structural). The majority of associations remained neutral when stratified by participant population, implementation level and socioeconomic position measures and by anthropometric and behavioural outcomes. Fiscal measures had consistently neutral or positive impacts on inequities. Findings suggest an important role for policy in addressing obesity in an equitable manner and strengthen the case for implementing a broad complement of policies spanning the agency-structure continuum.

Inequalities in energy-balance related behaviours and family environmental determinants in European children: changes and sustainability within the EPHE evaluation study

Background

Increasing social inequalities in health across Europe are widening the gap between low and high socio-economic groups, notably in the prevalence of obesity. Public health interventions may result in differential effects across population groups. Therefore, the EPHE (EPODE for the Promotion of Health Equity) project analysed the added value of community-based programmes, based on the EPODE (Ensemble Prévenons l’Obésité Des Enfants-Together Let’s Prevent Obesity) model, to reduce socio-economic inequalities in energy balance-related behaviours of children and their family-environmental related determinants in seven European communities. This study presents the changes between baseline and follow-up after the one-year interventions and their sustainability one year after.

Methods

This is a prospective study with a one school-year intervention, followed by one year of follow-up. In all, 1266 children (age 6-8 years) and their families from different socio-economic backgrounds were recruited at baseline. For 1062 children, information was available after one year (T₁) and for 921 children after two years (T₂). A self-reported questionnaire was completed by the parents to examine the children’s energy balance-related behaviours and family- environmental determinants. Socio-economic status was defined by the educational level of the mother. The Wilcoxon signed-rank test for paired data was used to test the differences between baseline and intermediate, and between intermediate and final, measurements for each of the socio-economic status groups.

Results

Post-intervention effects in energy-balance related behaviours showed the following improvements among the low socio-economic status groups: increased fruit consumption (Netherlands), decreased fruit juices amount consumed (Romania) and decreased TV time on weekdays (Belgium). Whereas in only the latter case the behavioural change was accompanied with an improvement in a family-environmental determinant (monitoring the time the child watches TV), other improvements in parental rules and practices related to soft drinks/fruit juices and TV exposure were observed. A few of those effects were sustainable, notably in the case of Belgium.

Conclusions

Inequalities in obesity-related behaviours could be potentially reduced when implementing community-based interventions, tailored to inequality gaps and using the EPODE methodology. Within-group changes varied widely, whereas monitoring of interventions and process evaluation are crucial to understand the observed results.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-016-0438-1) contains supplementary material, which is available to authorized users.

Exploring equity in primary-care-based physical activity interventions using PROGRESS-Plus: a systematic review and evidence synthesis

BACKGROUND

Little is known about equity effects in primary care based physical activity interventions. This review explored whether differences in intervention effects are evident across indicators of social disadvantage, specified under the acronym PROGRESS-Plus (place of residence, race/ethnicity, occupation, gender, religion, education, social capital, socioeconomic status, plus age, disability and sexual orientation).

METHODS

Six bibliographic databases were systematically searched for randomised controlled trials (RCTs) of physical activity interventions conducted in primary care. Harvest plots were used to synthesize findings from RCTs reporting subgroup or interaction analyses examining differences in intervention effects across levels of at least one PROGRESS-Plus factor.

RESULTS

The search yielded 9052 articles, from which 173 eligible RCTs were identified. Despite PROGRESS-Plus factors being commonly measured (N = 171 RCTs), differential effect analyses were infrequently reported (N = 24 RCTs). Where reported, results of equity analyses suggest no differences in effect across levels or categories of place of residence (N = 1RCT), race (N = 4 RCTs), education (N = 3 RCTs), socioeconomic status (N = 3 RCTs), age (N = 16 RCTs) or disability (N = 2 RCTs). Mixed findings were observed for gender (N = 22 RCTs), with some interventions showing greater effect in men than women and others vice versa. Three RCTs examined indicators of social capital, with larger post-intervention differences in physical activity levels between trial arms found in those with higher baseline social support for exercise in one trial only. No RCTs examined differential effects by participant occupation, religion or sexual orientation.

CONCLUSION

The majority of RCTs of physical activity interventions in primary care record sufficient information on PROGRESS-Plus factors to allow differential effects to be studied. However, very few actually report details of relevant analyses to determine which population subgroups may stand to benefit or be further disadvantaged by intervention efforts.

The impact of a tax on sugar-sweetened beverages according to socio-economic position: a systematic review of the evidence

Objective

A tax on sugar-sweetened beverages (SSB) has been proposed to address population weight gain but the effect across socio-economic position (SEP) is unclear. The current study aimed to clarify the differential impact(s) of SSB taxes on beverage purchases and consumption, weight outcomes and the amount paid in SSB taxes according to SEP.

Design

Databases (OVID and EMBASE) and grey literature were systematically searched in June 2015 to identify studies that examined effects of an SSB price increase on beverage purchases or consumption, weight outcomes or the amount paid in tax across SEP, within high-income countries.

Results

Of the eleven included articles, three study types were identified: (i) those that examined the association between variation in SSB taxes and SSB consumption and/or body weight (n 3); (ii) price elasticity estimation of SSB demand (n 1); and (iii) modelling of hypothetical SSB taxes by combining price elasticity estimates with population SEP-specific beverage consumption, energy intake or body weight (n 7). Few studies statistically tested differences in outcomes between SEP groups. Nevertheless, of the seven studies that reported on changes in weight outcomes for the total population following an increase in SSB price, all reported either similar reductions in weight across SEP groups or greater reductions for lower compared with higher SEP groups. All studies that examined the average household amount paid in tax (n 5) reported that an SSB tax would be regressive, but with small differences between higher- and lower-income households (0·10–1·0 % and 0·03 %–0·60 % of annual household income paid in SSB tax for low- and high-income households, respectively).

Conclusions

Based on the available evidence, a tax on SSB will deliver similar population weight benefits across socio-economic strata or greater benefits for lower SEP groups. An SSB tax is shown to be consistently financially regressive, but to a small degree.

The preventive treatment of recurrent stone-formation: how can we improve compliance in the treatment of patients with recurrent stone disease?

Whether prevention of Urolithiasis is worthwhile is the outcome of the balance between efficacy of prevention and costs and efforts related of respectively prevention and treatment of a new stone. Well controlled trials demonstrate that effective prevention of new stone formation is possible using medical treatment and lifestyle interventions. In long-term general practice the results obtained with preventive interventions is disappointing. Low and diminishing long-term compliance to the intervention is a major cause for this. Both the long-term aspect and the natural resistance to lifestyle changes contribute to this low compliance. From an analysis of the existing data on trials of preventive interventions and from experiences obtained in other patient groups where lifestyle changes are applied I will make the case that self-empowerment of the patient using m-health lifestyle coaching (a smart phone application) can considerably enhance the level of prevention that is obtained in general practice. In conclusion, I will describe what features will improve usage and efficacy of such an app.

Efficacy of a Behavioral Intervention for Pediatric Type 1 Diabetes Across Income

INTRODUCTION

Youth with Type 1 diabetes and lower family income typically have poorer glycemic control. This post hoc analysis examines whether a family-oriented behavioral intervention for this population is differentially effective across income levels.

METHODS

Families of youth aged 9-15 years with Type 1 diabetes (N=390; 49.2% female; age, 12.4 [1.7] years; hemoglobin A1c [HbA1c], 8.4 [1.2]; pump, 33.8%) at four U.S. pediatric endocrinology clinics participated in a 2-year RCT (data collected 2006-2011) of a clinic-integrated behavioral intervention designed to improve diabetes management by facilitating problem-solving skills, communication skills, and responsibility sharing. HbA1c was analyzed centrally. Family income was categorized as <$50,000 (low); $50,000 to <$100,000 (middle); and ≥$100,000 (high). Treatment effect was defined as the change in HbA1c from baseline to 2-year follow-up. A linear model tested the interaction of treatment effect with family income, controlling for race, insulin regimen, and site (analyzed in 2014).

RESULTS

Baseline HbA1c was significantly poorer (p=0.004) in the low-income group. There was a significant overall effect of treatment group on change in HbA1c from baseline to follow-up (p=0.04). The interaction term for treatment by income group was not significant (p=0.44). Within each income category, a smaller deterioration in glycemic control was observed for the treatment group relative to controls.

CONCLUSIONS

This clinic-integrated behavioral intervention was similarly effective in improving glycemic control among youth with Type 1 diabetes across income levels. This family-oriented problem-solving approach offers flexibility in addressing families' needs and may optimize impact on health outcomes across income groups.

Challenges of a healthy lifestyle for socially disadvantaged people of Dutch, Moroccan and Turkish origin in the Netherlands: a focus group study

Lifestyle interventions often fail to successfully reach individuals with lower socio-economic status (SES), possibly because of the individual behavioural orientation to health behaviour and because limited research has included the target groups' perspectives in the development of interventions. Certainly, in order to make lifestyle interventions more applicable, target groups' viewpoints should to be taken into account. In order to tailor an effective lifestyle intervention to groups with lower SES of different ethnic origins, 14 focus group interviews were conducted with Turkish, Moroccan and Dutch male and female groups. The target groups' responses highlight their viewpoint and their dilemmas with regard to physical activity behaviour and healthy eating. Exploration of the target groups' behaviour in terms of their own logic revealed three prominent themes. Firstly, some individuals find it difficult to maintain healthy eating habits and regular physical activities, as their concept of a healthy life comprises competing values and activities. Secondly, social norms and social practices of others influence health behaviour. Thirdly, respondents' answers reflect how they deal with the dilemma of competing values and norms. They use different ways of reasoning to make sense of their own (health) behaviour. Taken together, the results of this study suggest that considering physical activity and eating as collective social practices rather than as determinants of health will provide new opportunities to initiate healthy lifestyles and to make lifestyle interventions more applicable to target groups' realities.

Comparing a Video and Text Version of a Web-Based Computer-Tailored Intervention for Obesity Prevention: A Randomized Controlled Trial

Background

Web-based computer-tailored interventions often suffer from small effect sizes and high drop-out rates, particularly among people with a low level of education. Using videos as a delivery format can possibly improve the effects and attractiveness of these interventions

Objective

The main aim of this study was to examine the effects of a video and text version of a Web-based computer-tailored obesity prevention intervention on dietary intake, physical activity, and body mass index (BMI) among Dutch adults. A second study aim was to examine differences in appreciation between the video and text version. The final study aim was to examine possible differences in intervention effects and appreciation per educational level.

Methods

A three-armed randomized controlled trial was conducted with a baseline and 6 months follow-up measurement. The intervention consisted of six sessions, lasting about 15 minutes each. In the video version, the core tailored information was provided by means of videos. In the text version, the same tailored information was provided in text format. Outcome variables were self-reported and included BMI, physical activity, energy intake, and appreciation of the intervention. Multiple imputation was used to replace missing values. The effect analyses were carried out with multiple linear regression analyses and adjusted for confounders. The process evaluation data were analyzed with independent samples t tests.

Results

The baseline questionnaire was completed by 1419 participants and the 6 months follow-up measurement by 1015 participants (71.53%). No significant interaction effects of educational level were found on any of the outcome variables. Compared to the control condition, the video version resulted in lower BMI (B=-0.25, P=.049) and lower average daily energy intake from energy-dense food products (B=-175.58, P<.001), while the text version had an effect only on energy intake (B=-163.05, P=.001). No effects on physical activity were found. Moreover, the video version was rated significantly better than the text version on feelings of relatedness (P=.041), usefulness (P=.047), and grade given to the intervention (P=.018).

Conclusions

The video version of the Web-based computer-tailored obesity prevention intervention was the most effective intervention and most appreciated. Future research needs to examine if the effects are maintained in the long term and how the intervention can be optimized.

ClinicalTrial

Netherlands Trial Register: NTR3501; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3501 (Archived by WebCite at http://www.webcitation.org/6cBKIMaW1)

Use and Effectiveness of a Video- and Text-Driven Web-Based Computer-Tailored Intervention: Randomized Controlled Trial

Background

Many Web-based computer-tailored interventions are characterized by high dropout rates, which limit their potential impact.

Objective

This study had 4 aims: (1) examining if the use of a Web-based computer-tailored obesity prevention intervention can be increased by using videos as the delivery format, (2) examining if the delivery of intervention content via participants’ preferred delivery format can increase intervention use, (3) examining if intervention effects are moderated by intervention use and matching or mismatching intervention delivery format preference, (4) and identifying which sociodemographic factors and intervention appreciation variables predict intervention use.

Methods

Data were used from a randomized controlled study into the efficacy of a video and text version of a Web-based computer-tailored obesity prevention intervention consisting of a baseline measurement and a 6-month follow-up measurement. The intervention consisted of 6 weekly sessions and could be used for 3 months. ANCOVAs were conducted to assess differences in use between the video and text version and between participants allocated to a matching and mismatching intervention delivery format. Potential moderation by intervention use and matching/mismatching delivery format on self-reported body mass index (BMI), physical activity, and energy intake was examined using regression analyses with interaction terms. Finally, regression analysis was performed to assess determinants of intervention use.

Results

In total, 1419 participants completed the baseline questionnaire (follow-up response=71.53%, 1015/1419). Intervention use declined rapidly over time; the first 2 intervention sessions were completed by approximately half of the participants and only 10.9% (104/956) of the study population completed all 6 sessions of the intervention. There were no significant differences in use between the video and text version. Intervention use was significantly higher among participants who were allocated to an intervention condition that matched their preferred intervention delivery format. There were no significant interaction terms for any of the outcome variables; a match and more intervention use did not result in better intervention effects. Participants with a high BMI and participants who felt involved and supported by the intervention were more likely to use the intervention more often.

Conclusions

Video delivery of tailored feedback does not increase the use of Web-based computer-tailored interventions. However, intervention use can potentially be increased by delivering intervention content via participants’ preferred intervention delivery format and creating feelings of relatedness. Because more intervention use was not associated with better intervention outcomes, more research is needed to examine the optimum number of intervention sessions in terms of maximizing use and effects.

Trial Registration

Nederlands Trial Register: NTR3501; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3501 (Archived by WebCite at http://www.webcitation.org/6b2tsH8Pk)

Educational Inequalities in Exit from Paid Employment among Dutch Workers: The Influence of Health, Lifestyle and Work

Background

Individuals with lower socioeconomic status are at increased risk of involuntary exit from paid employment. To give sound advice for primary prevention in the workforce, insight is needed into the role of mediating factors between socioeconomic status and labour force participation. Therefore, it is aimed to investigate the influence of health status, lifestyle-related factors and work characteristics on educational differences in exit from paid employment.

Methods

14,708 Dutch employees participated in a ten-year follow-up study during 1999–2008. At baseline, education, self-perceived health, lifestyle (smoking, alcohol, sports, BMI) and psychosocial (demands, control, rewards) and physical work characteristics were measured by questionnaire. Employment status was ascertained monthly based on tax records. The relation between education, health, lifestyle, work-characteristics and exit from paid employment through disability benefits, unemployment, early retirement and economic inactivity was investigated by competing risks regression analyses. The mediating effects of these factors on educational differences in exit from paid employment were tested using a stepwise approach.

Results

Lower educated workers were more likely to exit paid employment through disability benefits (SHR:1.84), unemployment (SHR:1.74), and economic inactivity (SHR:1.53) but not due to early retirement (SHR:0.92). Poor or moderate health, an unhealthy lifestyle, and unfavourable work characteristics were associated with disability benefits and unemployment, and an unhealthy lifestyle with economic inactivity. Educational differences in disability benefits were explained for 40% by health, 31% by lifestyle, and 12% by work characteristics. For economic inactivity and unemployment, up to 14% and 21% of the educational differences could be explained, particularly by lifestyle-related factors.

Conclusions

There are educational differences in exit from paid employment, which are partly mediated by health, lifestyle and work characteristics, particularly for disability benefits. Health promotion and improving working conditions seem important measures to maintain a productive workforce, particularly among workers with a low education.