Area-based interventions to ameliorate deprived Dutch neighborhoods in practice: does the Dutch District Approach address the social determinants of health to such an extent that future health impacts may be expected?

Neighborhood Deprivation and Rurality Associated With Patient-Reported Outcomes and Survival in Men With Prostate Cancer in NRG Oncology RTOG 0415

PURPOSE

Rurality and neighborhood deprivation can contribute to poor patient-reported outcomes, which have not been systematically evaluated in patients with specific cancers in national trials. Our objective was to examine the effect of rurality and neighborhood socioeconomic and environmental deprivation on patient-reported outcomes and survival in men with prostate cancer in NRG Oncology RTOG 0415.

METHODS AND MATERIALS

Data from men with prostate cancer in trial NRG Oncology RTOG 0415 were analyzed; 1,092 men were randomized to receive conventional radiation therapy or hypofractionated radiation therapy. Rurality was categorized as urban or rural. Neighborhood deprivation was assessed using the area deprivation index and air pollution indicators (nitrogen dioxide and particulate matter with a diameter less than 2.5 micrometers) via patient ZIP codes. Expanded Prostate Cancer Index Composite measured cancer-specific quality of life. The Hopkins symptom checklist measured anxiety and depression. EuroQoL-5 Dimension assessed general health.

RESULTS

We analyzed 751 patients in trial NRG Oncology RTOG 0415. At baseline, patients from the most deprived neighborhoods had worse bowel (P = .011), worse sexual (P = .042), and worse hormonal (P = .015) scores; patients from the most deprived areas had worse self-care (P = .04) and more pain (P = .047); and patients from rural areas had worse urinary (P = .03) and sexual (P = .003) scores versus patients from urban areas. Longitudinal analyses showed that the 25% most deprived areas (P = .004) and rural areas (P = .002) were associated with worse EuroQoL-5 Dimension visual analog scale score. Patients from urban areas (hazard ratio, 1.81; P = .033) and the 75% less-deprived neighborhoods (hazard ratio, 0.68; P = .053) showed relative decrease in risk of recurrence or death (disease-free survival).

CONCLUSIONS

Patients with prostate cancer from the most deprived neighborhoods and rural areas had low quality of life at baseline, poor general health longitudinally, and worse disease-free survival. Interventions should screen populations from deprived neighborhoods and rural areas to improve patient access to supportive care services.

Do inhabitants profit from integrating a public health focus in urban renewal programmes? A Dutch case study

Background

Urban renewal traditionally involves policy sectors such as housing, transport, and employment, which potentially can enhance the health of residents living in deprived areas. Additional involvement of the public health sector might increase the health impact of these urban renewal activities. This study evaluates the health impact of an additional focus on health, under the heading of Healthy District Experiments (HDE), within districts where an urban renewal programme was carried out.

Methods

We evaluated changes in health outcomes before the start of the HDE and after implementation, and compared these changes with health changes in control areas, e.g. districts from the urban renewal programme where no additional HDE was implemented. Additionally, we gathered information on the content of the experiments to determine what types of activities have been implemented.

Results

The additional activities from the HDE were mostly aimed at strengthening the health care in the districts and at promoting physical activity. When we compared the prevalence in general health, mental health, overweight, obesity, smoking, and physical activity during the study period between the HDE districts and control districts, we found no significant differences in the rate of change. The study is limited by a small sample size and the cross-sectional nature of the data. These and other limitations are discussed.

Conclusion

We found no evidence for a beneficial health impact of the activities that were initiated with a specific focus on health, within a Dutch urban renewal programme. Specific attention for network management and the integration of such activities in the wider programme, as well as an allocated budget might be needed in order to sort a health impact.

The Use of the Bolk Model for Positive Health and Living Environment in the Development of an Integrated Health Promotion Approach: A Case Study in a Socioeconomically Deprived Neighborhood in The Netherlands

Background. Despite considerable efforts, health disparities between people with high and low socioeconomic status (SES) have not changed over the past decades in The Netherlands. To create a culture of health and an environment in which all people can flourish, a shift in focus is needed from disease management towards health promotion. The Bolk model for Positive Health and Living Environment was used as a tool to guide this shift. This study aimed to describe how this model was used and perceived by stakeholders in a case study on an integrated health promotion approach for residents with low SES. Methods. An instrumental case study was undertaken in Venserpolder, a neighborhood in Amsterdam South East of approximately 8500 residents. A participatory action approach was used that allowed continuous interaction between the residents, health care professionals, researchers, and other stakeholders. The Bolk model is a tool, based on the conceptual framework of positive health, that was developed to guide health promotion practice. Its use in the case study was evaluated by means of semistructured interviews with stakeholders, using qualitative directed content analyses. Results. The Bolk model was found to be a useful tool to identify and map the needs and strengths of residents with low SES. The model facilitated the development and implementation of eight health promotion pilots by transforming the needs and strengths of residents into concrete actions carried out by responsible actors in the neighborhood. Although the Bolk model seemed to be accepted by all stakeholders, the shift towards positive health thinking appeared to be more embodied by local professionals than by residents. Adjustments were proposed to enhance the applicability of the model in a multicultural setting, to increase its cultural sensitivity and to use language more familiar to residents. Conclusions. The Bolk model for positive health and living environment seems to be promising in the guidance of health promotion practices in Amsterdam South East. Further research and development are needed to improve its cultural sensitivity and to investigate its applicability in a broader range of public health settings.

Regeneration of deprived neighbourhoods and indicators of functioning in older adults: A quasi-experimental evaluation of the Dutch District Approach

This study examines the impact of the Dutch District Approach, a major urban regeneration programme that was started in 2008 in the Netherlands, on social, physical and mental functioning of older adults. Data from 1092 participants (58-93 years at baseline) across two waves (2005/06 and 2011/12) of the Longitudinal Aging Study Amsterdam were linked to detailed data on exposure to the programme. Using a difference-in-difference approach, we assessed differences from pre-intervention to the intervention period between the target and control districts in loneliness, social engagement, social isolation, physical activity, and anxiety and depressive symptoms. Regardless of programme intensity, the results indicate that the Dutch District Approach did not benefit or harm these aspects of functioning in older adults.

A toolkit with nine district types to support municipalities in taking an integrated approach to prevention

Background

Not only do people differ in their health, so do districts within municipalities. For example, city centres have different characteristics and health issues than villages or post-war neighbourhoods. This is why the Dutch National Institute for Public Health and the Environment has developed a toolkit, 'Prevention in the district', based on nine different types of district.

Methods

The aim of the toolkit is to help municipalities implement an integrated approach to prevention by providing tailored, practical information. We therefore looked at the best way to improve the connection between the available knowledge and local needs. Based on data analysis, expert opinion and working sessions with professionals and local policymakers, we developed a toolkit with three related tools.

Results

The following tools were developed: 1) nine district types with their prominent characteristics and 14 themes for prevention (ranging from loneliness to overweight); 2) a data guide containing a set of indicators to assess the district health profile; 3) a prevention guide containing a mix of evidence-based interventions for the 14 themes. The tools are presented in a toolkit (a clickable PDF) to emphasise the fact that they form a coherent whole. The link between data and interventions is considered to be particularly innovative.

Conclusion

The three tools support the improvement of the health and well-being of residents in a district. The first indications are that the toolkit empowers municipalities and lets them work towards an integrated approach. An integrated approach in both district health profiles and district plans could also serve as an example for other countries.

New physical activity spaces in deprived neighborhoods: Does it change outdoor play and sedentary behavior? A natural experiment

BACKGROUND

We used the introduction of dedicated physical activity (PA) spaces in Rotterdam, the Netherlands, to study the impact of reducing distance to dedicated PA spaces on outdoor play and sedentary behavior, and to evaluate if these effects were similar between population subgroups.

METHODS

We included 1841 Dutch children from the Generation R Study who participated at two subsequent measurement waves when the children were, on average, 6.0 and 9.7 years old. None of these children lived within 600 m of a dedicated PA space at baseline, and during follow-up 171 children became exposed to 13 new PA spaces within 600 m from home. Individual-level fixed-effects models were used to evaluate changes in distances (determined by Geographical Information Systems (GIS)) from home to the nearest new dedicated PA space, to parent-reported outdoor play and sedentary behavior.

RESULTS

The introduction of a dedicated PA space within 600 m from home, and the reduction of the distance per 100 m, did not affect outdoor play or sedentary behaviors. At p < 0.1, significant interaction terms were found between the introduction of the PA spaces and indicators of family socioeconomic position. Although not statistically significant, stratified analyses showed a consistent pattern, suggesting that reducing the distance to the nearest PA space increased outdoor play for children from parents with lower levels of education. However, they also showed a non-significant increase in sedentary behaviors for children from families with net household income below average Dutch income, and for children from a non-Dutch ethnicity.

CONCLUSIONS

Introducing dedicated PA spaces may be a promising approach to increase outdoor play for children from more socioeconomically disadvantaged families, but larger studies are needed to contribute to the evidence.

Does selective migration bias the health impact assessment of urban regeneration programmes in cross-sectional studies? Findings from a Dutch case study

We examined if the assessment of the health impact of a national Dutch regeneration programme depends on using either a repeated cross-sectional or longitudinal study design. This is important as only the latter design can incorporate migration patterns. For both designs, we compared trends in medication use between target and control districts. We found differences in medication use trends to be modest under the longitudinal design, and not demonstrable under the repeated cross-sectional design. The observed differences were hardly influenced by migration patterns. We conclude that in the Netherlands migration patterns had little effect on the health impact assessment of this national urban regeneration programme, so either the cross-sectional or longitudinal evaluation study design will do.

The effects of changes to the built environment on the mental health and well-being of adults: Systematic review

There is increasing interest in the influence of place on health, and the need to distinguish between environmental and individual level factors. For environmental-level factors, current evidence tends to show associations through cross-sectional and uncontrolled longitudinal analyses rather than through more robust study designs that can provide stronger causal evidence. We restricted this systematic review to randomised (or cluster) randomised controlled trials and controlled before-and-after studies of changes to the built environment. Date of search was December 2016. We identified 14 studies. No evidence was found of an effect on mental health from 'urban regeneration' and 'improving green infrastructure' studies. Beneficial effects on quality-of-life outcomes from 'improving green infrastructure' were found in two studies. One 'improving green infrastructure' study reported an improvement in social isolation. Risk-of-bias assessment indicated robust data from only four studies. Overall, evidence for the impact of built environment interventions on mental health and quality-of-life is weak. Future research requires more robust study designs and interdisciplinary research involving public health, planning and urban design experts.

What works to promote walking at the population level? A systematic review

OBJECTIVE

Interventions to promote walking have focused on individual or group-based approaches, often via the randomised controlled trial design. Walking can also be promoted using population health approaches. We systematically reviewed the effectiveness of population approaches to promote walking among individuals and populations.

DESIGN

A systematic review.

DATA SOURCES

10 electronic databases searched from January 1990 to March 2017.

ELIGIBILITY CRITERIA

Eligibility criteria include pre-experimental and postexperimental studies of the effects of population interventions to change walking, and the effects must have been compared with a 'no intervention', or comparison group/area/population, or variation in exposure; duration of ≥12 months of follow up; participants in free-living populations; and English-language articles.

RESULTS

12 studies were identified from mostly urban high-income countries (one focusing on using tax, incentivising the loss of parking spaces; and one using policy only, permitting off-leash dogs in city parks). Five studies used mass media with either environment (n=2) or community (n=3) approaches. Four studies used environmental changes that were combined with policies. One study had scaled up school-based approaches to promote safe routes to schools. We found mass media, community initiatives and environmental change approaches increased walking (range from 9 to 75 min/week).

An intervention strategy for improving residential environment and positive mental health among public housing tenants: rationale, design and methods of Flash on my neighborhood!

BACKGROUND

In Canada, public housing programs are an important part of governmental strategies to fight poverty and public exclusion. The Flash on my neighborhood! project is a four-year multiphase community-based participatory action research strategy currently implemented in six public housing developments (n = 1009 households) across the province of Québec, Canada. The goal is to reduce the mental health disparities faced by these public housing tenants compared to the general population, while identifying which environmental and policy changes are needed to turn public housing settings into healthier environments.

METHODS

The protocol involves three successive, interconnected phases: 1) Strengths and needs assessment, including community outreach and recruitment of tenants to collaborate as peer researchers, an exploratory qualitative component (photovoice), a systematic neighborhood observation, and a household survey; 2) Action plan development, including a community forum and interactive capacity-building and discussion sessions; 3) Action plan implementation and monitoring. The entire intervention is evaluated using a mixed-method design, framed within a multiple case study perspective. Throughout the project and particularly in the evaluation phase, data will be collected to record a) contextual factors (tenants' previous experience of participation, history of public housing development, etc.); b) activities that took place and elements from the action plan that were implemented; and c) short- and medium-term outcomes (objective and perceived improvements in the quality of the residential setting, both physically and in terms of mental health and social capital).

DISCUSSION

The study will provide unprecedented evidence-based information on the key ingredients of a collective intervention process associated with the increased collective empowerment and positive mental health of public housing tenants.

Local professionals' perceptions of health assets in a low-SES Dutch neighbourhood: a qualitative study

Background

Asset-based approaches have become popular in public health. As yet it is not known to what extent health and welfare professionals are able to identify and mobilise individual and community health assets. Therefore, the aim of this study was to understand professional’s perceptions of health and health assets.

Methods

In a low-SES neighbourhood, 21 health and welfare professionals were interviewed about their definition of health and their perceptions of the residents’ health status, assets available in the neighbourhood’s environment, and the way residents use these assets. A Nominal Group Technique (NGT) session was conducted for member check. Verbatim transcripts of the semi-structured interviews were coded and analysed using Atlas.ti.

Results

The professionals used a broad health concept, emphasizing the social dimension of health as most important. They discussed the poor health of residents, mentioning multiple health problems and unmet health needs. They provided many examples of behaviour that they considered unhealthy, in particular unhealthy diet and lack of exercise. Professionals considered the green physical environment, as well as health and social services, including their own services, as important health enhancing factors, whereas social and economic factors were considered as major barriers for good health. Poor housing and litter in public space were considered as barriers as well. According to the professionals, residents underutilized neighbourhood health assets. They emphasised the impact of poverty on the residents and their health. Moreover, they felt that residents were lacking individual capabilities to lead a healthy life. Although committed to the wellbeing of the residents, some professionals seemed almost discouraged by the (perceived) situation. They looked for practical solutions by developing group-based approaches and supporting residents’ self-organisation.

Conclusions

Our study shows, firstly, that professionals in the priority district Slotermeer rated the health of the residents as poor and their health behaviour as inadequate. They considered poverty and lack of education as important causes of this situation. Secondly, the professionals tended to talk about barriers in the neighbourhood rather than about neighbourhood health assets. As such, it seems challenging to implement asset-based approaches. However, the professionals, based on their own experiences, did perceive the development of collective approaches as a promising direction for future community health development.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4555-6) contains supplementary material, which is available to authorized users.

The impact of urban regeneration programmes on health and health-related behaviour: Evaluation of the Dutch District Approach 6.5 years from the start

BACKGROUND

Large-scale regeneration programmes to improve the personal conditions and living circumstances in deprived areas may affect health and the lifestyle of the residents. Previous evaluations concluded that a large-scale urban regeneration programme in the Netherlands had some positive effects within 3.5 years. The aim of the current study was to evaluate the effects at the longer run.

METHODS

With a quasi-experimental research design we assessed changes in the prevalence of general health, mental health, physical activity, overweight, obesity, and smoking between the pre-intervention (2003-04 -mid 2008) and intervention period (mid 2008-2013-14) in 40 deprived target districts and comparably deprived control districts. We used the Difference-in-Difference (DiD) to assess programme impact. Additionally, we stratified analyses by sex and by the intensity of the regeneration programme.

RESULTS

Changes in health and health related behaviours from pre-intervention to the intervention period were about equally large in the target districts as in control districts. DiD impact estimates were inconsistent and not statistically significant. Sex differences in DiD estimates were not consistent or significant. Furthermore, DiD impact estimates were not consistently larger in target districts with more intensive intervention programmes.

CONCLUSION

We found no evidence that this Dutch urban regeneration programme had an impact in the longer run on self-reported health and related behaviour at the area level.

Is it better to invest in place or people to maximize population health? Evaluation of the general health impact of urban regeneration in Dutch deprived neighbourhoods

AIM

To study the general health impact of urban regeneration programmes in deprived Dutch districts. We compared initiatives that focused on the improvement of place with initiatives that mainly invested in people.

METHOD

A quasi-experimental design compared the trend in good perceived general health in the target districts with comparison districts. Generalized general mixed models assessed the rate of change in prevalence of good health per half year during a prolonged period before and after the start of the interventions.

RESULTS

Neither the target districts that invested mainly in place nor the ones with interventions focused on people showed trends in general health different than comparison districts (p>0.05). However, only districts with interventions focused on place showed no deterioration in general health during the intervention period. The trend change in these districts differed significantly from the change in the districts that invested mainly in people (p<0.05).

CONCLUSION

Urban regeneration programmes that focus on place may be effective in promoting general health.

Proportionate universalism in practice? A quasi-experimental study (GoWell) of a UK neighbourhood renewal programme's impact on health inequalities

Recommendations to reduce health inequalities frequently emphasise improvements to socio-environmental determinants of health. Proponents of 'proportionate universalism' argue that such improvements should be allocated proportionally to population need. We tested whether city-wide investment in urban renewal in Glasgow (UK) was allocated to 'need' and whether this reduced health inequalities. We identified a longitudinal cohort (n = 1006) through data linkage across surveys conducted in 2006 and 2011 in 14 differentially disadvantaged neighbourhoods. Each neighbourhood received renewal investment during that time, allocated on the basis of housing need. We grouped neighbourhoods into those receiving 'higher', 'medium' or 'lower' levels of investment. We compared residents' self-reported physical and mental health between these three groups over time using the SF-12 version 2 instrument. Multiple linear regression adjusted for baseline gender, age, education, household structure, housing tenure, building type, country of birth and clustering. Areas receiving higher investment tended to be most disadvantaged in terms of baseline health, income deprivation and markers of social disadvantage. After five years, mean mental health scores improved in 'higher investment' areas relative to 'lower investment' areas (b = 4.26; 95% CI = 0.29, 8.22; P = 0.036). Similarly, mean physical health scores declined less in high investment compared to low investment areas (b = 3.86; 95% CI = 1.96, 5.76; P < 0.001). Relative improvements for medium investment (compared to lower investment) areas were not statistically significant. Findings suggest that investment in housing-led renewal was allocated according to population need and this led to modest reductions in area-based inequalities in health after five years. Study limitations include a risk of selection bias. This study demonstrates how non-health interventions can, and we believe should, be evaluated to better understand if and how health inequalities can be reduced through strategies of allocating investment in social determinants of health according to need.

How can collaboration be strengthened between public health and primary care? A Dutch multiple case study in seven neighbourhoods

Background

Although public health and primary care share the goal of promoting the health and wellbeing of the public, the two health sectors find it difficult to develop mutually integrated plans and to collaborate with each other. The aim of this multiple case study was to compare seven neighbourhoods in which a stepwise approach based on two central tools (district health profile and policy dialogue) was used to develop integrated district plans and promote collaboration.

Methods

The stepwise approach involved the following steps: 1 Getting to know the neighbourhood, 2 Assembling the workgroup, 3 Analysing the neighbourhood, 4 Developing a district health profile, 5 Preparing policy dialogue, 6 Holding local dialogues, 7 Embedding integrated district plans and collaboration. To supervise this process, a core team was assembled for each neighbourhood, consisting of people drawn from both public health and primary care. Both the use of the two tools and the collaboration were studied by means of documentary analysis, interviews, questionnaires and observations.

Results

The seven neighbourhoods differed in the way the two tools of the stepwise approach were used: general versus focused profiles, the actors involved, the aims of the dialogue or the intensity of the steps. There were also similarities: profile indicators (e.g., population prognosis, vulnerability) and dialogue themes (e.g., obesity, social cohesion). The local actors experienced that the combination of both tools facilitates the process of bringing public health and primary care closer together, and that it is essential to invest sufficiently in the integration of profile data and in involving appropriate actors in the dialogue (e.g., GPs, residents). Collaboration was perceived as positive (e.g., feels involved, focus on consensus), but a starting process. Local actors also believe that the stepwise approach supported the process.

Conclusion

A stepwise approach involving the combined use of district health profiles and policy dialogues promotes the integrated planning of health activities and facilitates collaboration between public health and primary care at the local level. Local differences may arise in the intensity and form of the various steps, but because they are practical and clearly defined, they remain transferrable to other neighbourhoods.

Are area-based initiatives able to improve area safety in deprived areas? A quasi-experimental evaluation of the Dutch District Approach

Background

Numerous area-based initiatives have been implemented in deprived areas across Western-Europe with the aim to improve the socio-economic and environmental conditions in these areas. Only few of these initiatives have been scientifically evaluated for their impact on key social determinants of health, like perceived area safety. Therefore, this study aimed to assess the impact of a Dutch area-based initiative called the District Approach on trends in perceived area safety and underlying problems in deprived target districts.

Methods

A quasi-experimental design was used. Repeated cross-sectional data on perceived area safety and underlying problems were obtained from the National Safety Monitor (2005–2008) and its successor the Integrated Safety Monitor (2008–2011). Study population consisted of 133,522 Dutch adults, including 3,595 adults from target districts. Multilevel logistic regression analyses were performed to assess trends in self-reported general safety, physical order, social order, and non-victimization before and after the start of the District Approach mid-2008. Trends in target districts were compared with trends in various control groups.

Results

Residents of target districts felt less safe, perceived less physical and social order, and were victimized more often than adults elsewhere in the Netherlands. For non-victimization, target districts showed a somewhat more positive change in trend after the start of the District Approach than the rest of the Netherlands or other deprived districts. Differences were only statistically significant in women, older adults, and lower educated adults. For general safety, physical order, and social order, there were no differences in trend change between target districts and control groups.

Conclusions

Results suggest that the District Approach has been unable to improve perceptions of area safety and disorder in deprived areas, but that it did result in declining victimization rates.

Socioeconomic inequalities in smoking in The Netherlands before and during the Global Financial Crisis: a repeated cross-sectional study

Background

The Global Financial Crisis (GFC) increased levels of financial strain, especially in those of low socioeconomic status (SES). Financial strain can affect smoking behaviour.

This study examines socioeconomic inequalities in current smoking and smoking cessation in The Netherlands before and during the Global Financial Crisis (GFC).

Methods

Participants were 66,960 Dutch adults (≥18 years) who took part in the annual national Health Survey (2004–2011). Period was dichotomised: ‘pre-’ and ‘during-GFC’. SES measures used were income, education and neighbourhood deprivation. Outcomes were current smoking rates (smokers/total population) and smoking cessation ratios (former smokers/ever smokers). Multilevel logistic regression models controlled for individual characteristics and tested for interaction between period and SES.

Results

In both periods, high SES respondents (in all indicators) had lower current smoking levels and higher cessation ratios than those of middle or low SES. Inequalities in current smoking increased significantly in poorly educated adults of 45–64 years of age (Odds Ratio (OR) low educational level compared with high: 2.00[1.79-2.23] compared to pre-GFC 1.67[1.50-1.86], p for interaction = 0.02). Smoking cessation inequalities by income in 18–30 year olds increased with borderline significance during the GFC (OR low income compared to high income: 0.73[0.58-0.91]) compared to pre-GFC (OR: 0.98[0.80-1.20]), p for interaction = 0.051).

Conclusions

Overall, socioeconomic inequalities in current smoking and smoking cessation were unchanged during the GFC. However, current smoking inequalities by education, and smoking cessation inequalities by income, increased in specific age groups. Increased financial strain caused by the crisis may disproportionately affect smoking behaviour in some disadvantaged groups.