Healthy diets positively associated with health-related quality of life in children and adolescents from low socioeconomic areas: Findings from the Greek Food Aid Program, DIATROFI

OBJECTIVES

To assess the relationship of diet with health-related quality of life (HRQoL) in vulnerable children and adolescents.

METHODS

Data included 6583 children and adolescents (aged 3-18 years old) from the Greek Food-Aid DIATROFI Program in the 2015 to 2016 and 2017 to 2018 school years. HRQoL was measured with the Pediatric Quality of Life Inventory questionnaire and diet with food frequency questionnaires. The healthy plant-based diet index (hPDI), animal score, and dietary patterns were investigated.

RESULTS

The hPDI and animal score were associated with good HRQoL (odds ratio [OR] [95% confidence interval], 10-unit increase: ORhPDI = 1.28 [1.05, 1.57], ORanimal = 1.51 [1.14, 2.00]) and physical (ORanimal = 1.62 [1.23, 2.13]), emotional (ORhPDI = 1.30 [1.07, 1.58], ORanimal = 1.41 [1.08, 1.85]) and school function (ORhPDI = 1.32 [1.09, 1.59], ORanimal = 1.46 [1.12, 1.89]). Dietary patterns of fruits, raw vegetables, and cheese were associated with good HRQoL (OR of 1-unit increase: 1.22 [1.13, 1.32]), and physical OR = 1.18 [1.09, 1.27]) and emotional function (OR = 1.09 [1.02, 1.18]). Starchy foods and sweetened beverages were associated with poor HRQoL (OR = 0.75 [0.63, 0.90]), and emotional (OR = 0.80 [0.68, 0.95]) and school function (OR = 0.72 [0.61, 0.85]).

CONCLUSION

Healthy diets and dietary patterns were positively associated with the HRQoL of vulnerable children and adolescents, which may offer opportunities for prevention.

A capital-based approach to understand health inequalities: empirical explorations

Background

The persistence of health inequalities may not be merely driven by education and income, but also by other economic and non-economic factors. In this study we investigated how the association between single-dimensional health and socioeconomic status (SES) changes when including health-related person capital, economic capital, social capital, cultural capital and non-health related person capital.

Methods

The present study proposes a capital-based approach to understand health inequalities. It presumes intertwined relationships between a wide notion of health (‘health-related person capital’) and embodied resources (‘non-health related person capital’) on the one hand, and non-person capital, i.e. economic, social, and cultural resources on the other. We used cross-sectional data on 152,592 participants from the Dutch Lifelines cohort study. Correlations between capital constructs were estimated using partial least squares structural equation modelling.

Results

The correlation between health-related person capital and SES (r = 0.15) was higher than the correlations between single-dimensional health (physical and mental health) and SES (r = 0.12, r = 0.04, respectively). Non-person capital, combining economic, social and cultural capital, showed a correlation of 0.34 with health-related person capital. This was higher than the correlation between health-related person capital and economic capital alone (r = 0.19). Lastly, the correlation between health-related person capital and non-person capital increased when non-health (personality and attractiveness) and health related person capital were combined into person capital construct (from r = 0.34 to r = 0.49).

Conclusions

This exploratory observational study shows the empirical interconnectedness of various types of resources. Our findings corroborate the idea of considering health as a multidimensional concept, and to extend conventional SES indicators to a broader measurement of economic and non-economic resources.

Key messages

Socioeconomic Inequalities in pediatric Metabolic Syndrome: mediation by parental health literacy

Background

Parental health literacy may explain the relationship between parental socioeconomic status (SES) and pediatric metabolic syndrome (MetS). For this reason, we assessed to what extent parental health literacy mediates the relationships between parental SES and pediatric MetS.

Methods

We used data from the prospective multigenerational Dutch Lifelines Cohort Study. Our sample consisted of 6,683 children with an average follow-up of 36.2 months (SD 9.3) and a mean baseline age of 12.8 years (SD 2.6). We used natural effects models to assess the natural direct, natural indirect, and total effects of parental SES on MetS.

Results

On average, an additional four years of parental education, e.g. university instead of secondary school, would lead to cMetS scores that were 0.499 (95% confidence interval (CI) 0.364; 0.635) units lower, which is a small effect (d 0.18). If parental income and occupational level were one standard deviation higher, on average cMetS scores were 0.136 (95%CI 0.052; 0.219) and 0.196 (95%CI 0.108; 0.284) units lower, respectively; these are both small effects (d 0.05 and 0.07, respectively). Parental health literacy partially mediated these pathways; it accounted for 6.7% (education), 11.8% (income), and 8.3% (occupation) of the total effect of parental SES on pediatric MetS.

Conclusions

Socioeconomic differences in pediatric MetS are relatively small, the largest being by parental education. Improving parental health literacy may reduce these inequalities. Further research is needed into the mediating role of parental health literacy on other socioeconomic health inequalities in children.

Key messages

• Parental socioeconomic status (SES) has a small inverse relationship with pediatric metabolic syndrome (MetS), which is partially mediated by parental health literacy.

• Targeting parental health literacy may reduce inequalities in pediatric MetS. It may also influence other pediatric socioeconomic health inequalities, but further research is needed.

Educational inequalities in major depressive disorder over the adult life course: a microsimulation

Background

Educational inequalities in major depressive disorder (MDD) pose a major challenge. Tackling this issue requires evidence on the long-term impact of intervening on modifiable factors, e.g. behavioural and psychosocial factors. Therefore, we aim to simulate the development of educational inequalities in MDD across the life course, and to assess the impact of intervening on the modifiable factors that contribute to these inequalities.

Methods

We used data from the prospective Dutch Lifelines Cohort Study to estimate the required input for a continuous-time microsimulation. The microsimulation allowed us to estimate the development of educational inequalities in MDD with a synthetic cohort of 500,000 individuals followed from ages 18 to 65, and to assess the potential benefit of intervening on quality of social contacts, health literacy, and smoking.

Results

On average, an additional 19.1% of individuals with low education will ever experience MDD between ages 18 and 65 compared to those with high education (32.0% vs 12.9%, respectively). Additionally, individuals with low education generally will develop MDD 0.9 years earlier (35.6 years vs 36.5 years, respectively) and spend 1.2 years more with MDD (6.2 years vs 5 years, respectively), than individuals with high education. Improving the quality of social contacts in individuals with low education would have the largest impact; it would reduce the inequalities in the prevalence, onset, and duration of MDD by an average of 18.4%, 18.3%, and 28.6%, respectively.

Conclusions

Intervening on modifiable factors, especially quality of social contacts, in individuals with low education could help reduce the large estimated educational inequalities in MDD over the life course.

Key messages

• There are large educational inequalities in major depressive disorder (MDD) over the life course, especially with regard to the life course prevalence of MDD.

• Improving quality of social contacts, and to a lesser extent health literacy and smoking behaviours, amongst individuals with low education may help reduce the inequalities in MDD.

A multi-component health literacy intervention addressing needs of kidney patients and professionals

Background

Limited health literacy (LHL) is associated with faster kidney deterioration. To maintain kidney function, health care professionals (HCPs) promote self-management. However, in chronic kidney disease (CKD) care organizations, patients with LHL report multiple communication and self-management barriers. The need for health literacy responsive organizations, and multi-component interventions targeted at patients and HCPs, is recognized. We aimed to determine the objectives and strategies of such an intervention, and to co-create and evaluate it.

Methods

First, we performed a longitudinal qualitative study among CKD patients with LHL (n = 24) and HCPs (n = 37) from general practices and nephrology clinics to assess needs and barriers, and to identify promising intervention objectives. Second, we included patients (n = 19), HCPs (n = 15), educators (n = 3) and students (n = 4) in an Intervention Mapping (IM) process to co-create and evaluate the intervention.

Results

Grip on Your Kidneys (GoYK) addresses the competences of patients with LHL to self-manage CKD on the long-term, and the communication competences of patients and HCPs. Based upon patients’ preferences, GoYK encompasses a visually attractive website and brochures to optimize self-management and a card to contribute to consultations. With HCPs, we developed a training to optimize their competences to support patients with LHL. Evaluation revealed the intervention was useful, comprehensive and fitting needs.

Conclusions

Mapping the needs of CKD patients and HCPs, combined with a process of intervention co-creation, resulted in a multi-component, positively evaluated intervention. Implementation of this type of interventions in organizations is promising to improve care for patients with LHL. However, the effectiveness of these interventions requires further assessment.

Effectiveness of a health literacy intervention targeting kidney patients and professionals

Background

Chronic kidney disease (CKD) patients with limited health literacy (LHL) experience a faster kidney decline. To counteract this, we developed Grip on your Kidneys (GoyK). This intervention targets patients’ communication and self-management. It trains health care professionals (HCPs) competences to support patients with LHL. This study aims to test the effectiveness of GoyK on patients’ health and self-management, HCPs’ communication competences, and the quality of consultations.

Methods

A clustered and non-blinded quasi-experimental study was conducted, including 161 patients with mild to severe CKD and 48 HCPs from Dutch general practices and nephrology clinics. Patients (n = 77) and HCPs (n = 30) in the intervention group received GoyK. In the control group, patients (n = 76) had routine visits with HCPs (n = 19). Between March 2021 and June 2022, data were collected with questionnaires and from patient records at baseline (T0), 4 months (T1) and 9 months (T2). Primary outcomes were patients’ self-management and HCPs’ use of health literacy communication strategies.

Preliminary results

At T1, the intervention improved the days per week patients exercised (B = 1.00, 95% confidence interval, CI = 0.35-1.65, P = 0.003), and Likert-scale reported (1-4) fluid intake (B = 0.37, CI = 0.10-0.63, p = 0.006). The intervention had a positive effect on several outcomes related to how patients perceived the consultation quality, and improved the reported use of communication strategies by HCPs at T1 (B = 0.68, CI = 0.35-1.01, p = <0.001). We found no effects on other patient outcomes, like activation for self-management or salt intake.

Conclusions

Our health literacy intervention, targeting CKD patients with LHL and HCPs, improved lifestyle behaviors of patients and the quality of consultations. A further strengthening of other self-management behaviors and on HCPs’ competences is needed, also to reach sustainable effects in the care for patients with LHL.

Key messages

• A health literacy intervention, targeting patients and professionals simultaneously, improved the patients’ self-management and care consultations.

• Training of HCPs improved their competences to support patients with LHL, and care organizations and studies need to implement education on this topic.

Investigating the use of support in secondary school: the role of self-reliance and stigma towards help-seeking

Purpose: Adolescents are the least likely to seek help for their mental health problems. School may be an important route to improve early recognition of adolescents with mental health problems in need for support, but little is known about the barriers to school support.Materials and methods: Data were collected in a longitudinal cohort study of Dutch adolescents (age 12-16) in secondary school (n = 956). We assessed the relation between level of psychosocial problems at the beginning of the school year (T1) and the support used in school at the end of that school year (T2), whether the willingness to talk to others (measured at T1) mediates this relation, and whether stigma towards help-seeking (T1) moderates this mediation.Results: Adolescents with more psychosocial problems were more likely to use support in school and were less willing to talk to others about their problems, but the willingness to talk to others was not a mediator. Stigma moderated the relationship between psychosocial problems and willingness to talk to others.Conclusions: Most adolescents with psychosocial problems get support in Dutch secondary school regardless of their willingness to talk to others about their problems. However, perceiving stigma towards help-seeking makes it less likely for someone to talk about their problems.

Multimorbidity prevalence and patterns and their associations with health literacy among chronic kidney disease patients

Background

Health literacy is the ability to deal with information related to one’s health. Patients with low health literacy have poor disease-management skills for chronic diseases, such as chronic kidney disease (CKD). This could influence the number and combination of their diseases.

Methods

We included adult patients with CKD stages 1–5 from the Lifelines Study (n = 2,742). We assessed the association between low health literacy and the number and patterns of comorbidities, considering them globally and stratified by age and sex, using multinomial logistic regression and latent class analysis, respectively.

Results

Low health literacy was associated with a higher number of comorbidities in the crude models, and after adjustment for age, sex, eGFR, smoking, and BMI. In the crude model, the OR for low health literacy increased from 1.71 (1.25–2.33) for two comorbidities to 2.71 (2.00–3.68) for four comorbidities. In the fully-adjusted model, the associations remained significant with a maximum OR of 1.70 (1.16–2.49) for four comorbidities. The patterns of multimorbidity were similar for low and adequate health literacy, overall and by sex, bur tended to be different for patients older than 65. Older patients with low health literacy had higher comorbidity prevalence and a relatively greater share of cardiovascular, psychiatric, and central nervous system diseases.

Conclusions

Among CKD patients, low health literacy is associated with more multimorbidity. Health literacy is not associated with patterns of multimorbidity in younger patients, but a difference was observed in older ones. Improving low health literacy could be an intervention efficient also in decreasing multimorbidity in CKD patients.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40620-021-01229-1.

Spectacle wear and refractive errors in Dutch children

Background

Myopia is a refractive error that is increasing dramatically all over the world. Early onset is associated with a significant visual burden later in life, but little is known about refractive errors in preschool children. The aim of this study was to assess prevalence of spectacle wear, visual acuity and refractive errors in young Dutch children and to make global comparisons.

Methods

We analyzed data of three prospective population-based studies: 99,660 3- to 5-year-olds undergoing vision screening at preventive child healthcare organizations, 6,934 6-year-olds from the Generation R study, and 2,974 7-year-olds from the RAMSES study. Visual acuity was measured with Landolt-C or LEA charts, spectacle wear was assessed, and refractive errors at age 6 and 7 were measured with cycloplegic refraction. Spectacle wear was compared with international studies.

Results

The prevalence of spectacle wear was 1.5%, 2.3%, 6.6%, 8.2% and 11.8% at 36, 45, 60, 72 and 84 months, respectively, with no major sex differences. Among children with spectacle wear at 72 months (N = 583) and 84 months (N = 351) 29.8% and 34.6% had myopia respectively, of which 21.1% and 21.6% combined with astigmatism, 19.6% and 6.8% had hyperopia, 37.2% and 11.1% hyperopia and astigmatism, and 12.5% and 33.3% astigmatism only. The prevalence of spectacle wear globally varied between 1.5% to 21%.

Conclusions

Spectacle wear in these European children started early in preschool and increased to substantial figures at school age. Among children with spectacle wear, >30% were already myopic, illustrating the urgency to implement myopia prevention strategies in child health centers.

Key messages

Early onset myopia is a public health issue. Of the 6- to 7-year-olds with spectacles 30-34% were already myopic. Monitoring of refractive errors and preventive lifestyle interventions are warranted.

Multimorbidity patterns and its associations with health literacy in chronic kidney disease patients

Background

Health literacy is the ability to deal with information related to one's health. Patients with low health literacy have poor disease-management skills for chronic diseases, such as chronic kidney disease (CKD). This could influence the number and combination of their diseases.

Methods

We included adult patients with CKD stages 1-5 from the Lifelines Study (n = 2,742). We assessed the association between low health literacy and the number and patterns of comorbidities, overall and by age and sex, using multinomial logistic regression and latent class analysis, respectively.

Results

Low health literacy was associated with a higher number of comorbidities in the crude models, and after adjustment for age, sex, eGFR, smoking, and BMI. In the crude model, the OR for low health literacy increased from 1.71 (1.25 to 2.33) for two comorbidities to 2.71 (2.00 to 3.68) for four comorbidities. In the fully-adjusted model, the associations remained significant with a maximum OR of 1.70 (1.16 to 2.49) for four comorbidities. The patterns of multimorbidity were similar for low and adequate health literacy, overall and by sex, and slightly different for patients older than 65. Older patients with low health literacy had higher comorbidity prevalence and a relatively greater share of cardiovascular, psychiatric, and central nervous system diseases.

Conclusions

This study showed that CKD patients have a high prevalence of comorbidities. Patients with low health literacy are more likely to have a higher number of comorbidities than patients with adequate health literacy. Moreover, the multimorbidity patterns are similar for both groups of health literacy, differing slightly at older ages. This age difference suggests that the negative effects of low health literacy develop when aging. Therefore, low health literacy could be an intervention target to decrease multimorbidity along the life course of CKD patients.

Key messages

Among CKD patients, low health literacy is associated with more multimorbidity. Health literacy does not affect patterns of multimorbidity in younger patients, but it does slightly in older ones.

[COVID-19: recovering at home is not easy]

OBJECTIVE

To gain insight into 1) the symptoms and the disease process of healthcare professionals (HCPs) who tested positive for COVID-19 and were not hospitalized because of mild symptoms, 2) the impact on their psychological well-being and 3) the experiences with (after) care and infection prevention measures.

DESIGN

Explorative mixed-methods study.

METHOD

The municipal public health services of Groningen and Fryslân invited all HCPs aged above 18 years who tested positive for COVID-19 between March 18th and April 3rd 2020 to fill out an online questionnaire (n = 109), on average one month after diagnosis. 18 HCPs participated in telephone interviews.

RESULTS

Almost all HCPs mentioned fatigue as a long-term symptom, less frequently mentioned were, among other things, feeling physically weak and having a cold. Nearly half of them did not have a fever, two-thirds experienced stress. HCPs with comorbidity had more symptoms. The interviews showed that stress in particular occurred in families with children and because of uncertainty about the duration of infectiousness, with lack of good (after)care. Respondents experienced many negative reactions of people in their environment that felt stigmatizing. The isolation at home was considered bearable.

CONCLUSION

A COVID-19 infection has a significant impact on physical and mental health, even in HCPs with mild symptoms. Persistent fatigue in particular hinders patients' functioning. The absence of fever in almost half of the respondents is remarkable, as well as the negative impact on psychological well-being. HCPs are also dissatisfied with after-care. Infection prevention measures were relatively well-adhered too.

Pediatric metabolic syndrome definitions impact prevalence and socioeconomic gradients

Background

The choice of pediatric metabolic syndrome (MetS) definition influences prevalence estimates, but further implications, especially on the association with socioeconomic status (SES), are not well-known. This hampers a synthesis of the evidence to help guide the relevant stakeholders. For this reason, we aim to assess the impact of alternative definitions on the prevalence of MetS, the children that are identified, and the association between SES and MetS.

Methods

Data were used from the Lifelines Cohort Study, a prospective multigenerational cohort in the Netherlands. At baseline 9,754 children participated, of which 5,085 (52.1%) were included in the longitudinal analyses. We computed the prevalence of MetS according to five published definitions and measured the observed positive agreement between pairs of definitions, indicating the proportion of agreement across the average number of MetS cases. Logistic regression was used to assess the association between SES and MetS. All models were adjusted for age and sex; the longitudinal models were also adjusted for baseline MetS status.

Results

The prevalence rates of MetS varied between definitions (0.7-3.0% at baseline), but positive agreement between MetS definitions was generally fair to good ranging from 0.34 (95% confidence interval (CI) 0.28; 0.41) to 0.66 (95%CI 0.58; 0.75) at baseline. At both assessments, we found an inverse association between baseline SES and MetS, which ranged from 0.81 (95%CI 0.70; 0.93) to 0.92 (95%CI 0.86; 0.98) per definition in the longitudinal analyses with a mean follow-up (SD) of 3.0 (0.75) years.

Conclusions

Alternative definitions of MetS lead to differing prevalence estimates, and they agreed on 50% of the average number of cases of MetS. The alternative definitions also lead to similar socioeconomic gradients; regardless of which definition was used we concluded low SES was a risk factor for developing MetS.

Key messages

Evidence regarding different definitions of metabolic syndrome in children can be combined because the agreement among definitions is generally fair to good. As low socioeconomic status is a consistent risk factor for developing metabolic syndrome, preventive interventions should preferentially target children from low socioeconomic backgrounds.

Resident co-created urban redesign to improve health in post-war neighbourhoods: an exploration

Urban interventions in the built environment can improve the health of residents by impacting daily living patterns and lifestyles. Co-creation of these interventions with residents enhances their effectiveness. This pilot study investigates how the co-creation process can be developed, with elderly as a target group. The setting of the pilot is the area around a shopping centre in a post-war neighbourhood.

Residents were recruited via the neighbourhood council and existing networks, via student-recruiters and via door-to-door flyers. They were asked to participate in the evaluation of proposed interventions, which aimed to increase physical activity. Virtual reality (VR) techniques were used as a tool to communicate current and redesigned environments. We organised three meetings for residents, where VR was used to: 1) collect data on current urban issues, 2) evaluate the different redesigns of the project location, and 3) present a final redesign. During meeting 1 and 2, VR was supported by questionnaires to collect data.

We recruited 31 residents with an average age of 65, mostly through the neighbourhood council and existing networks. Recruitment with flyers resulted in only 1 participant (<1% response). The data collected from the combination of VR and questionnaires showed that participants were likely to walk more often in the redesigned interventions. Moreover, participants indicated that the differences between current and redesigned environments were very clear (score 4.8 out of 5) and that they could imagine very well what the designs would look like in real-life (score 4.6/5). The VR-experience was scored an 8/10 and 28 participants were willing to participate in future activities.

Recruiting residents through existing networks, including the neighbourhood council, was most effective. VR technology is a very useful tool to communicate urban interventions and the residents were very capable of evaluating them while providing valuable input for the redesigns.

Key messages

Co-creating urban redesigns with residents to improve health is feasible, and virtual reality is of great added value as a co-creation supporting and communication tool. Urban interventions impact daily living patterns and lifestyles of residents and thereby public health.

[Responsible use of screens: recommendations to limit myopia in children and young people]

The excessive use of screens is a contemporary problem that can have a number of effects on health. It is of particular influence on the onset and exacerbation of myopia, and for these reasons a group of professionals decided to draw up recommendations on a more sensible use of screens. The group comprised an ophthalmologist-epidemiologist, an orthoptist, paediatric and adolescent physicians, a youth health care nurse, an orthopaedic surgeon, a movement therapist-epidemiologist, health scientists and psychologists. They recommend that on history-taking, standard questions concerning screen use and its associated problems should be asked. The parents can then be given targeted lifestyle advice for the child, i.e. after 20-30 minutes continuous screen use there should be a change of activity, and that the child should spend 2 hours a day outdoors. These recommendations will promote the health of children's eyes as well as their general development.

The role of functional health literacy in long-term treatment outcomes in psychosocial care for adolescents

Although among adolescents with psychosocial problems low health literacy may increase the risk of poor treatment outcomes, the contributing mechanisms within treatment remain unclear. A better understanding of these mechanisms could contribute to improved treatment processes and outcomes. This study aims to examine the relationship between functional health literacy, treatment processes (treatment adherence, learning processes), and treatment outcome (level of psychosocial problems) in adolescents in psychosocial care. We used data from a prospective cohort study among adolescents aged 12-18 (N = 390), collected in four successive measurements: at entry into care, and 3, 12, and 24 months thereafter. We used a mixed effect model to investigate the association between level of functional health literacy (adequate vs. inadequate) and treatment processes (treatment adherence, learning processes) and treatment outcome (level of psychosocial problems). Between adolescents with adequate and inadequate functional health literacy, we found no differences or change over time in adherence or learning processes. The level of psychosocial problems significantly declined over time (β = - 1.70, 95% CI [- 2.72, - 0.69], p = .001) to a similar degree in both groups, though, in all measurements, the level was consistently higher for adolescents with inadequate health literacy. We conclude that health literacy levels did not affect change in treatment processes nor in outcomes of psychosocial treatment. However, the consistently higher level of psychosocial problems among adolescents with inadequate health literacy suggests an unaddressed need in psychosocial care.

Developmental Pathways from Genetic, Prenatal, Parenting and Emotional/Behavioral Risk to Cortisol Reactivity and Adolescent Substance Use: A TRAILS Study

Cortisol reactivity is a frequently studied biomarker of substance use, though infrequently examined in adolescence. However, past research provides evidence that multiple developmental influences, including genetics and both prenatal and postnatal environmental influences, contribute both to cortisol reactivity and adolescent substance use. The aim of this study was to assess the impact of these earlier developmental influences on cortisol reactivity to a social stress challenge and adolescent substance use (smoking, alcohol, and marijuana use frequency assessed at age 16 years), using data from the TRacking Adolescents' Individual Lives Survey (TRAILS; N= 2230 adolescents, 51% female). Developmental pathways included polygenic risk, prenatal stress, warm parenting (age 11), and internalizing and externalizing problems (intercepts and change from 11-16 years). Cortisol reactivity was associated with smoking but not alcohol or marijuana use. Externalizing problems were the stronger predictor of adolescent substance use, but internalizing problems also had an important role. Prenatal stress and middle childhood parenting operated via middle childhood externalizing problems, and parenting also operated via trajectories of growth of externalizing problems in predicting adolescent substance use outcomes. Further, there were protective effects of internalizing problems for alcohol and marijuana use in the context of a more comprehensive model. These developmental influences did not attenuate the association of cortisol reactivity and smoking. These findings suggest a need to understand the broader developmental context regarding the impact of internalizing pathways to substance use, and that it is unlikely that cortisol reactivity and smoking are associated solely because of common developmental influences.

[More attention for prevention, primary health care and public health; en route to research that makes you better]

An effective approach to health problems and a sustainable health care system requires more attention to prevention, primary health care and public health in research. For this to be achieved, university medical centres (UMCs) should strengthen the academic basis of prevention and primary care, as the Dutch Health Council recommended in its report 'Research that matters'. We are now three years on and the NFU, the association of the UMCs, recently published its plan 'Research and innovation with and for the healthy region'. This is a step in the right direction, but we are not there yet.

Effectiveness of the Children of Divorce Intervention Program in the Netherlands

Background

Many children experience parental separation and divorce. This experience is likely to negatively affect their wellbeing, conduct, psychological adjustment and social relations. Prevention of these problems thus has major priority but effective intervention programmes are still rare. This study therefore aimed to assess the effects of a 12-session preventive group intervention “Dappere Dinos™” for 6 to 8 year old children.

Methods

We performed a quasi-experimental study (registered as NTR 6788) on 105 children participating in the intervention group, 37 children with separated parents not participating (’divorce controls’) and 138 children from intact families (’intact controls’). Outcomes regarded children’s positive functioning (Parent Evaluation Form; Pedro-Carroll & Cowen, 1989), emotional and behavioral problems (Strengths and Difficulties Questionnaire; Goodman, 1997), and wellbeing (Cantril ladder, Cantril, 1965).

Results

Analyses showed that children’s positive functioning after participating in Dappere Dino’s increased according to mothers (MΔpre-post(SD) = 0.26 (0.32); p < .001). Also, children’s overall emotional and behavioral problems decreased after participation (MΔpre-post_mother(SD) = -2.02 (4.55); p < .01; MΔpre-post_trainer(SD) = -1.07 (4.34); p < .05; MΔpre-post_teacher(SD) = -1.64 (3.54); p < .01). Children’s wellbeing increased after participation (MΔpre-post_mother(SD) = 0.77 (1.02); p < .001; MΔpre-post_trainer(SD) = 0.69 (0.94); p < .001), or stayed the same (MΔpre-post_teacher(SD) = 0.19 (1.03); p = n.s.). No such changes were found in the two comparison groups.

Conclusions

After parental divorce, a 12-session preventive group intervention Dappere Dino’s™ for 6- to 8-year-olds can be efficacious in promoting children’s emotional well-being and positive functioning, and reducing their emotional and behavioral problems.

Key messages

Given the high prevalence of divorce and the potential risk for child well-being and functioning, prevention of problems for these children and helping them adapt to the divorce are major priorities. After parental divorce, preventive group support can be efficacious in promoting children’s emotional well-being and positive functioning, and reducing their emotional and behavioral problems.

Organization and content of primary care for adolescents – comparison of actual and desired situation

To successfully navigate increasing autonomy, independence and health behaviors in adolescence, accessible adolescent health care services (AHS) are essential. AHS comprise all services in primary care that are aimed at the specific needs of adolescents and can be provided in various settings such as public services, private services, schools and hospitals. In the MOCHA project (Models of Child Health Appraised) we assessed the structure and content of AHS in 30 European countries against the standards in the field of adolescent health services: accessibility, staff attitude, communication, staff competency and skills, confidential and continuous care, age appropriate environment, involvement in health care, equity and respect and a strong link with the community. The results revealed that although half of the 30 countries did adopt adolescent-specific policies, many countries did not meet the current standards of quality health care for adolescents. For example, the ability to provide emergency mental health care is limited. In addition, one third of the countries do not have a formal policy which guarantees the confidentiality of a consult and the possibility to consult a physician without parents knowing. Finally, around half of the countries do not have specialized centers in adolescent health care in order to tackle comprehensive health issues. Access to adolescent health care services needs to be improved for vulnerable adolescents such as migrant adolescents. Schools, ambulatory settings and hospitals should offer accessible, comprehensive health care and a culturally appropriate approach, particularly given the number of migrant adolescents living in EU and EEA countries. Finally, the health care systems should improve their communication strategies, to assist young people in understanding their rights and responsibility in the domain of health, and how and where to access to adequate care.

Beyond not bad or just okay: social predictors of young adults' wellbeing and functioning (a TRAILS study)

BACKGROUND

Various childhood social experiences have been reported to predict adult outcomes. However, it is unclear how different social contexts may influence each other's effects in the long run. This study examined the joint contribution of adolescent family and peer experiences to young adult wellbeing and functioning.

METHODS

Participants came from the TRacking Adolescents' Individual Lives Survey (TRAILS) study (n = 2230). We measured family and peer relations at ages 11 and 16 (i.e. family functioning, perceived parenting, peer status, peer relationship quality), and functioning as the combination of subjective wellbeing, physical and mental health, and socio-academic functioning at age 22. Using structural equation modelling, overall functioning was indicated by two latent variables for positive and negative functioning. Positive, negative and overall functioning at young adulthood were regressed on adolescent family experiences, peer experiences and interactions between the two.

RESULTS

Family experiences during early and mid-adolescence were most predictive for later functioning; peer experiences did not independently predict functioning. Interactions between family and peer experiences showed that both protective and risk factors can have context-dependent effects, being exacerbated or overshadowed by negative experiences or buffered by positive experiences in other contexts. Overall the effect sizes were modest at best.

CONCLUSIONS

Adolescent family relations as well as the interplay with peer experiences predict young adult functioning. This emphasizes the importance of considering the relative effects of one context in relation to the other.

Functional outcomes of child and adolescent mental disorders. Current disorder most important but psychiatric history matters as well

BACKGROUND

Various sources indicate that mental disorders are the leading contributor to the burden of disease among youth. An important determinant of functioning is current mental health status. This study investigated whether psychiatric history has additional predictive power when predicting individual differences in functional outcomes.

METHOD

We used data from the Dutch TRAILS study in which 1778 youths were followed from pre-adolescence into young adulthood (retention 80%). Of those, 1584 youths were successfully interviewed, at age 19, using the World Health Organization Composite International Diagnostic Interview (CIDI 3.0) to assess current and past CIDI-DSM-IV mental disorders. Four outcome domains were assessed at the same time: economic (e.g. academic achievement, social benefits, financial difficulties), social (early motherhood, interpersonal conflicts, antisocial behavior), psychological (e.g. suicidality, subjective well-being, loneliness), and health behavior (e.g. smoking, problematic alcohol, cannabis use).

RESULTS

Out of the 19 outcomes, 14 were predicted by both current and past disorders, three only by past disorders (receiving social benefits, psychiatric hospitalization, adolescent motherhood), and two only by current disorder (absenteeism, obesity). Which type of disorders was most important depended on the outcome. Adjusted for current disorder, past internalizing disorders predicted in particular psychological outcomes while externalizing disorders predicted in particular health behavior outcomes. Economic and social outcomes were predicted by a history of co-morbidity of internalizing and externalizing disorder. The risk of problematic cannabis use and alcohol consumption dropped with a history of internalizing disorder.

CONCLUSION

To understand current functioning, it is necessary to examine both current and past psychiatric status.

[Pain reduction during vaccination of young children]

- Children have the right to pain mitigation during vaccination.- There are several simple, non-costly and safe interventions to effectively reduce pain during vaccination.- To improve the Dutch vaccination praxis, it is essential to train professionals in the use of these interventions.- Using the vaccination technique described in the guideline of the Dutch National Immunisation Programme results in pain reduction.- As a pain-reducing intervention at every vaccination procedure, the healthcare professional can give the child and parents a feeling of being in control by explaining about the vaccination procedure, pain and pain reduction and by vaccinating in calm, low-stimulus surroundings.- Other effective interventions include distracting the child, having it sit in the lap of a parent, giving it something to suck on, feeding it or having it drink a sugary solution, and using a topical anaesthetic cream. The healthcare professional should implement these interventions in consultation with, and attuned to, both the child and its parents.

[Embrace, integrated primary care for older adults]

OBJECTIVE

To examine the impact of Embrace (Dutch: SamenOud), a new primary care model for community-living people aged over 75 years on perceived quality of care.

DESIGN

Randomized controlled trial in 15 general practices in the East Groningen region of the Netherlands.

METHOD

In the period January 2012-March 2013, 1456 general practice patients aged 75 years and older were stratified on the basis of self-reporting into 3 risk profiles: 'robust', 'frail' and 'complex care needs', and then randomized to the intervention or the control arm. Intervention consisted of care and support from an elderly-care team consisting of a specialist in Gerontology, a district nurse, and a social worker. Intensity and duration of the care and support were dependent on risk profile. The primary outcome measure was quality of care as reported by participants; the secondary outcome measure was the extent of implementation as reported by the caregivers.

RESULTS

The level of perceived quality of care after 12 months was slightly higher in the intervention arm than in the control arm, but the effect size was quite small. The difference was significant in elderly people with the risk profiles 'frail' and 'complex care needs'; robust elderly people did not experience a significant difference. The caregivers reported increased implementation of integrated care (effect size 0.71, that means average).

CONCLUSION

Embrace slightly improved the perceived quality of care, particularly for elderly people with complex care needs for whom case management was organised. Caregivers judged implementation of integrated care to be greatly improved, though there was still room for further improvement. Further research should be carried out into the effectiveness of integrated primary care for the elderly on health, service-use and healthcare costs.

Mental health in Dutch adolescents: a TRAILS report on prevalence, severity, age of onset, continuity and co-morbidity of DSM disorders

BACKGROUND

With psychopathology rising during adolescence and evidence suggesting that adult mental health burden is often due to disorders beginning in youth, it is important to investigate the epidemiology of adolescent mental disorders.

METHOD

We analysed data gathered at ages 11 (baseline) and 19 years from the population-based Dutch TRacking Adolescents' Individual Lives Survey (TRAILS) study. At baseline we administered the Achenbach measures (Child Behavior Checklist, Youth Self-Report) and at age 19 years the World Health Organization's Composite International Diagnostic Interview version 3.0 (CIDI 3.0) to 1584 youths.

RESULTS

Lifetime, 12-month and 30-day prevalences of any CIDI-DSM-IV disorder were 45, 31 and 15%, respectively. Half were severe. Anxiety disorders were the most common but the least severe whereas mood and behaviour disorders were less prevalent but more severe. Disorders persisted, mostly by recurrence in mood disorders and chronicity in anxiety disorders. Median onset age varied substantially across disorders. Having one disorder increased subjects' risk of developing another disorder. We found substantial homotypic and heterotypic continuity. Baseline problems predicted the development of diagnosable disorders in adolescence. Non-intact families and low maternal education predicted externalizing disorders. Most morbidity concentrated in 5-10% of the sample, experiencing 34-55% of all severe lifetime disorders.

CONCLUSIONS

At late adolescence, 22% of youths have experienced a severe episode and 23% only mild episodes. This psychopathology is rather persistent, mostly due to recurrence, showing both monotypic and heterotypic continuity, with family context affecting particularly externalizing disorders. High problem levels at age 11 years are modest precursors of incident adolescent disorders. The burden of mental illness concentrates in 5-10% of the adolescent population.

[Embrace, a model for integrated elderly care]

Ongoing growth in health care expenditures and changing patterns in the demand for health care challenge societies worldwide. The Chronic Care Model (CCM), combined with classification for care needs based on Kaiser Permanente (KP) Triangle, may offer a suitable framework for change. The aim of the present study is to investigate the effectiveness of Embrace, a population-based model for integrated elderly care, regarding patient outcomes, service use, costs, and quality of care.

METHODS

The CCM and the KP Triangle were translated to the Dutch setting and adapted to the full elderly population living in the community. A randomized controlled trial with balanced allocation was designed to test the effectiveness of Embrace. Eligible elderly persons are 75 years and older and enrolled with one of the participating general practitioner practices. Based on scores on the INTERMED-Elderly Self-Assessment and Groningen Frailty Indicator, participants will be stratified into one of three strata: (A) robust; (B) frail; and (C) complex care needs. Next, participants will be randomized per stratum to Embrace or care as usual. Embrace encompasses an Elderly Care Team per general practitioner practice, an Electronic Elderly Record System, decision support instruments, and a self-management support and prevention program - combined with care and support intensity levels increasing from stratum A to stratum C. Primary outcome variables are patient outcomes, service use, costs, and quality of care. Data will be collected at baseline, twelve months after starting date, and during the intervention period.

DISCUSSION

This study could provide evidence for the effectiveness of Embrace.