Jeanine Ahishakiye - Understanding the psychological and social environmental determinants driving young infant feeding practices among Rwandan households: a salutogenic approach
Although adequate nutrition and good health are children’s rights, they are often violated, especially in developing countries where undernutrition is one of the leading causes of mortality among children under the age of five. The problem is more pertinent in Sub-Saharan Africa (SSA), that still suffers from the highest under-five mortality rates in the world. Rwanda does not escape from this sad trend because despite continuous policy efforts, chronic malnutrition (stunting) among under-five remains a key public health concern. The 2014/15 Rwanda Demographic and Health Survey (RDHS) shows that 38% of under-five years old children were stunted in 2015. Hence, the Government of Rwanda has implemented numerous strategies to tackle the problem of chronic malnutrition. However, to date, much of our understanding on child chronic (mal)nutrition has been primarily based on research conducted on the nutritional physiological determinants of stunting such as the timing, composition and frequency of infant and young child feeding (IYCF). This view, however, has lacked a holistic orientation, ignoring the contextual and social determinants of IYCF practices. Moreover, the approach to tackle chronic malnutrition has been predominantly disease and risk-oriented, looking at the factors underlying stunting (pathogenic orientation).
From this perspective, IYCF practices have been researched in relation to their contribution to stunting and the determinants of inadequate IYCF practices. Very little is known on factors contributing to good nutritional status, with a particular focus on factors facilitating mothers’ appropriate IYCF in the context of their everyday lives.
Aim and research questions
The overall aim of this thesis is to identify factors that enable healthy IYCF practices in Rwandan households in order to contribute to the development of solution-oriented strategies for reducing child malnutrition. Guided by the salutogenic model of health, which searches for answers to the question what creates health rather than what causes disease, this thesis addressed three specific research questions that are:
1. What are the perceived challenges towards infant and young child feeding practices and the responses applied to overcome these challenges?
2. What factors impede or facilitate recommended infant feeding practices during the first 12 months of a child’s life?
3. How do life course learning experiences play a role in shaping infant and young child feeding practices during the first year of child’s life?
To address the above-mentioned research questions, the study adopted both crosssectional and longitudinal designs. The study was carried out in the catchment areas of Rutobwe and Buramba health centres located in a rural part of the district of Muhanga, in the southern province of Rwanda.
Socially vulnerable youth in high-income countries are youths that face stressors in their everyday life, including income poverty, poor family management, low housing quality, and peers being involved in problem behaviour. Policymakers, researchers, and field workers increasingly recognise sport as a means to promote positive development in socially vulnerable youth, but socially vulnerable youth participate less frequently in sports than their average peers.
Intersectoral action (i.e., collaborative efforts involving organisations from two or more sectors) between youth-care organisations and community sports clubs is advocated as an effective approach to reach socially vulnerable youth and include them in sport. Youth-care organisations in the Netherlands provide services to socially vulnerable youths and their families. Community sports clubs, usually run by unpaid volunteers, are the main provider of sports in the Netherlands. Intersectoral action between youth-care organisations and community sports clubs encompasses bringing sports clubs as settings for positive youth development to the attention of youth-care professionals, connecting youth-care professionals and sports clubs, integrating sport in the support that youth-care professionals deliver to their clients, and developing and implementing sports programmes serving socially vulnerable youth.
Intersectoral action between youth-care organisations and community sports clubs is not easy however, as these sectors are very dissimilar. Examples of differences between them include different opening hours, different goals, and different organisational structures based on unpaid volunteers and informal relationships in sports clubs versus paid professionals and mainly formalised procedures in youth-care organisations.
Study aim and research question
Despite the advocacy for intersectoral action between youth-care organisations and community sports clubs, little is known about how these organisations can best collaborate. Therefore, the aim of this thesis is to provide insights into the organisational context of the inclusion of socially vulnerable youth in sport by exploring elements of successful intersectoral action between youth-care organisations and voluntary sports clubs and how these elements are interrelated.
The following three research questions are formulated.
Research Question 1. What is the evidence on life-skill development in sports programmes serving socially vulnerable youth from both quantitative and qualitative studies?
Research Question 2. Which aspects of intersectoral action between youth-care organisations and voluntary sport clubs make these collaborations successful?
Research Question 3. What mechanisms underlie the process of how intersectoral action between youth organisations and sports clubs evolves and becomes embedded in local social policies?
An iterative mixed-methods research approach was adopted to address the aim of this thesis. This means that the studies conducted are set up in multiple rounds and that the findings of each study form the basis for the successive studies. Eventually, this thesis was composed of five studies. One systematic literature review addressing Research Question 1, three studies addressing Research Question 2, and a single case study addressing Research Question 3. The three studies conducted to answer Research Question 2 addressed different sub-questions. Two of these three studies were qualitative studies based on interviews and focus groups, and the other was a cross-sectional quantitative study.
Chapter 2 presents the findings from the systematic literature review conducted to describe what was known about life-skill development in sports programmes serving socially vulnerable youth, and, insofar as these were investigated in the included studies, the conditions conducive to life-skill development in these sports programmes. The studies included in the review are very diverse in terms of setting, study design, research method, and reported life skills. Each included study reported that at least one life skill improved in the youths who participated in the studied sports programme. Improvements in cognitive and social life skills were more frequently reported than improvements in emotional life skills. In some of the included studies, researchers cast doubts on whether the life skills developed in the sports programme were transferred to other societal domains, such as school and work environments. Regarding the conducive conditions, the findings indicate that a positive youth–coach relationship, sports coaches who encourage youths to deal with the challenges that arise in the sports activity, activities that improve a sense of belonging to the sports programme, and the inclusion of a life-skills education element are conducive to life-skill development.
In Chapter 3, the elements of successful intersectoral action between youth-care organisations and sports clubs were explored through open interviews with youth-care professionals and sports club volunteers. The findings demonstrated that the following elements were perceived as important for the extent to which the intersectoral action is successful: a societal and political context that provides funding for sports club membership fees for socially vulnerable youth, positive attitudes of youth-care professionals and sports club volunteers towards the intersectoral action, the confidence (i.e., self-efficacy) of the youth-care professionals and sports club volunteers that they are able to include the youths in sports clubs, visibility of the intersectoral action through a signed agreement, and the participation of a paid professional who (a) connects youth-care professionals and sports club volunteers and (b) supports sports clubs in building the conditions conducive to life-skill development.
Based on 23 semi-structured interviews, Chapter 4 provides more insights into (a) the performance indicators for intersectoral action and (b) facilitators of, and barriers to, successful intersectoral action, according to the participants in intersectoral action between youth-care and sports. The findings demonstrate that intersectoral action is perceived as successful when it leads to more socially vulnerable youths participating in sport, life-skill development in these youths through sport, and sustainable intersectoral action. Furthermore, this study indicates that the following elements facilitate or hinder successful intersectoral action: existing and good relationships (or lack thereof), a boundary spanner (or lack thereof), the attitudes of youth-care professionals towards the intersectoral action, the knowledge and competences of the participants, the policies and ambitions of the participating organisations, and some elements external to the intersectoral action, such as local and national governmental policies.
Chapter 5 describes the findings from a cross-sectional quantitative study among participants in coalitions between social-care professionals and sports club representatives. The aim of this study was to discern which elements of intersectoral action may be most important for its success. The bivariate results show that all nine elements (two institutional, two personal, and five organisational) in a proposed conceptual model are related to three indicators of successful intersectoral action (i.e., partnership synergy, partnership sustainability, and community outcomes). However, the indicators for successful intersectoral action were best predicted by organisational elements. Synergy was best predicted by communication structure and building on capacities, sustainability was best predicted by visibility, and community outcomes were best predicted by visibility and task management.
The study presented in Chapter 6, which was a single case study based on content analysis of policy documents and in-depth interviews, unravelled how intersectoral action between youth-care organisations and community sports clubs evolved in a large city in the Netherlands and became embedded in this city’s social policy. The findings demonstrate that the intersectoral action was initiated in small-scale sports projects developed by sports club volunteers, youth-care professionals, and other social professionals active at the most basic level of their organisations (i.e., grassroots). Individuals and organisations involved in these small-scale projects adopted several activities over time that led to more legitimacy and support for the intersectoral action from the wider societal and political context, and eventually to its embedding in local policy. These activities were: (a) framing the intersectoral action as a means to achieve wider social goals, (b) making the results of the intersectoral action visible for the wider societal and political context by presenting research findings, (c) building connections between multiple small-scale projects involving intersectoral action between youth-care organisations and sports clubs, and (d) connecting policymakers and other influential actors from the different sectors.
The first conclusion from this thesis is that sports clubs are settings where socially vulnerable youth can develop in a positive way, particularly when attention is paid to conditions conducive to life-skill development (Research Question 1). Second, the thesis revealed that four institutional elements, four personal elements, and five organisational elements are important for the extent to which intersectoral action between youth-care organisations and community sports clubs is successful. The institutional elements are: the societal and political context in which the intersectoral action operates, the policies of the organisations participating, the working processes in the organisations, and the organisational capacity of the organisations. The personal elements are the attitudes and beliefs of the individuals participating, the knowledge and competences of these individuals, the type of relationships between them, and the degree to which youth-care professionals and sports club representatives believe that they can make a difference in the intersectoral action (i.e., self-efficacy). The organisational elements are a communication structure based on face-to-face contact and flexibility on both sides regarding working hours; task management, building on the capacities of the individuals and organisations participating, which means that each participant contributes to the intersectoral action by using her or his specific resources in terms of competences, expertise, and networks; visibility of the intersectoral action and its results; and boundary spanning leadership, which encompasses building and maintaining connections between youth-care professionals and sports club volunteers (Research Question 2). Of these organisational elements, visibility and boundary spanning leadership proved most important for the evolution of the intersectoral action and its embedding in local policy (Research Question 3).
A closer look at the findings provides us with five more in-depth insights regarding the role of personal, institutional, and organisational elements in successful intersectoral action, and the interplay between these elements.
First, it emerged that building on capacities may be helpful in building the conditions conducive to life-skill development at sports clubs. This means that the sports coaches should remain focused on organising the sports activities and not on delivering care, and it is the youth-care professionals’ responsibility to provide sports coaches with support in building the conducive conditions.
Second, the finding that organisational elements are conditional for successful intersectoral action has at least two implications. Financiers and managers of intersectoral action between youth-care organisations and community sports clubs should invest in these elements. Furthermore, financiers of intersectoral action may benefit from employing one or maybe two leaders of the intersectoral action, who are responsible for (a) task management and (b) spanning boundaries at different levels between the participants from the different sectors.
Third, it was revealed that successful intersectoral action requires boundary spanners at two levels: (a) boundary spanners who manage the intersectoral action between the youth-care professionals and sports club volunteers at the operational level and (b) boundary spanners who build connections between the sectors at the political, policy, and managerial levels. The boundary spanners who manage the intersectoral action between the youth-care professionals and the sports club volunteers can connect these two actors and facilitate information exchange between them. To gain support for the intersectoral action from the different sectors, boundary spanners require knowledge of the different rules, thoughts, beliefs, languages, trends, and working procedures in the different sectors.
Fourth, it emerged that the societal and political context in which an intersectoral action operates is not necessarily a stable context, but rather a context that individuals and organisations can influence to gain support for the intersectoral action in terms of financial and human resources. Organisations or individuals that want to gain support for the intersectoral action are recommended to (a) make the intersectoral action at the operational level visible to local policymakers and (b) connect with boundary spanners acting at the managerial, policy, and political levels. Effective ways to make the intersectoral action visible include framing it as a means to address urgent social issues and presenting findings from research on the intersectoral action. Boundary spanners can be effective in obtaining support if they have knowledge of the paradigms, rules, working process, and policies of the different sectors, and if they possess the capacity to identify opportunities for gaining support for the intersectoral action at the operational level.
Fifth, the findings indicate that trust may be the glue for successful intersectoral action between youth-care organisations and sports clubs. To build trust, managers in intersectoral action between youth-care organisations and community sports clubs may benefit from (a) building on the capacities of the different participants, (b) making the intersectoral action and its results visible, and (c) task management activities, such as facilitating face-to-face contact, creating a flexible communication structure, and making formal or informal agreements about the roles and responsibilities of the participating organisations and individuals.
To stimulate physical activity (PA), the Dutch Ministery of Health, Welfare and Sports introduced Care Sport Connectors (CSCs) in 2012. This function is 40% funded by the state, with the remaining 60% funded by the municipality or other local organisations. CSCs are employed specifically to connect the primary care sector and the PA sector in order to guide primary care patients towards local sport facilities. The defined outcome of CSCs is an increased number of residents participating in local PA facilities and being physically active in their neighbourhood. This new CSC function is challenging because previous studies have shown that differences between the primary care and the PA sector can hinder their mutual collaboration. A broker, like the CSC, seems promising for improving intersectoral collaboration. However, to our knowledge the work, significance and challenges of brokers has not been studied often. Most studies focus on a brokers’ position and its impact on a network performance measured with quantitative outcome measures. The case of the CSC enables us to explore the broker role in connecting the primary care and the PA sector in order to stimulate PA. This insight is necessary firstly because the CSC function is new and unique and therefore the latest Dutch policy and its accountability need to be evaluated. Secondly, because intersectoral collaboration between the primary care and the PA sector is challenging, insight in CSCs’ role and impact seem to be relevant to further improve this connection. Thirdly, because the role and impact of a broker in establishing intersectoral collaboration is not studied often and therefore an insight helped us to advance health promotion theory and practice. The case of the CSC enables us to explore the role and impact of a broker on stimulating intersectoral collaboration. To explore CSCs’ role and impact in connecting the primary care and the PA sector four research questions were studied in different chapters: 1. What are the processes that contribute to the connection between primary care, and PA sector? 2. What are the conditions at national and local level that facilitate or hinder CSCs in connecting the primary care and the PA sector 3. Which impacts are mediated by CSCs and what are the perceived societal benefits for the municipality, neighbourhood, and local residents? 4. What lessons can be learned to advance health promotion theory and practice?
This thesis employed a multiple case study design in which 15 CSCs of nine municipalities spread over the Netherlands were followed in their work from 2014 to the end of 2016. In line with a multiple case-study design, perspectives of different stakeholders (policymakers, professionals, CSCs) in the connection between both sectors on different levels (policy, and community level) were taken into account in which different data collection methods were used (literature review, interview, focus group, document analysis, and questionnaires). Including different perspectives and using a mixed methods approach enabled us to provide a comprehensive insight in the connection between both sectors established by CSCs. In addition, cross-case synthesis helped us to draw general conclusions concerning the connection between the primary care and the PA sector when different cases share some similarities. As CSCs have the task to connect the primary care and the PA sector, and to stimulate PA among the target group, another study – not part of this thesis - is carried out as well, which aims to explore CSCs’ impact on promoting PA among the target group.
This thesis aimed to explore CSCs’ role and impact in connecting the primary care and the PA sector. The results of this thesis contribute to three important insights. First, the structure of the connection between the primary care and the PA sector established by CSCs can be characterised as a chain approach. Secondly, barriers related to the sectors are currently hindering this connection. Thirdly, an integral approach to structurally embed CSCs seems to be an important condition to facilitate the connection between the both sectors. The results all together showed that the CSC function seemed to be promising in connecting the primary care and the PA sector. However, to make a success of the connection between both sectors changes at both the policy as community level are needed. For example local policy should adopt a more integral approach, and a health-promotion mind set should be promoted among primary care professionals. Further research should focus on CSCs’ impact on stimulate PA among primary care patients, and the development of CSC’ role and the connection between both sectors in course of time.
Sabina Super - S(up)port your future! : A salutogenic perspective on youth development through sport
Sport is often recognised as an avenue for the positive development of young people, because sports participation has been positively linked to improvements in physical, cognitive, social, and emotional health. In line with these findings, policymakers and health professionals in the Netherlands, and elsewhere in the world, encourage socially vulnerable youth to participate in sport. Socially vulnerable youth are characterised as having an accumulated number of negative experiences with the societal institutions in their lives, leading to distorted relationships with those institutions and, eventually, to feelings of isolation and low self-esteem. As socially vulnerable youth participate less in sport than their non-vulnerable peers, encouraging them to participate in sport may support these youths in leading a healthy and productive life. However, to date, our understanding of the role of sport in positive youth development has been primarily based on research conducted in non-vulnerable populations, and very little research has been conducted among socially vulnerable youth. Moreover, we know very little about how sport can potentially support these youths in their personal development and under which conditions sport can do so.
The overall aim of this thesis is to unravel the value of sports participation for socially vulnerable youth. Given the salutogenic focus of this thesis, the first research objective is to provide insights into the mechanisms underlying sense of coherence so that these may underpin health promotion activities that aim to strengthen sense of coherence. Secondly, given the limited amount of research conducted on the value of sports participation for socially vulnerable youth, this current study aims to unravel whether this youth group may benefit from playing a sport at a local sports club (objective 2). As previous studies have shown that the social conditions in the sports setting are very important for achieving positive youth developmental outcomes, this study also aims to investigate how community sports coaches can create optimal social conditions for life skill development and transferability (objective 3). And fourth, this study aims to understand how socially vulnerable youth experience their participation in sport and the value they derive from sports participation (objective 4).
This study adopted a mixed-methods design, with one theoretical article, one systematic review, one quantitative study, and three qualitative studies. For the systematic review, 18 studies were identified – in seven electronic databases – that reported on life skill development in sports programmes serving socially vulnerable youth. For the quantitative study, two identical questionnaires were administered at a six-month interval among 187 socially vulnerable youth, measuring youth developmental outcomes and sports participation rates. Semistructured interviews were conducted with 15 community sports coaches to examine how they create optimal social conditions for life skill development and transferability. Open interviews were conducted with 22 socially vulnerable youths to explore their sports experiences, and life-course interviews were conducted with 10 adults who had been socially vulnerable in their childhood to reflect on the value of sport in their lives. The results from these studies provide a complete and comprehensive picture of the value of sport in a socially vulnerable childhood.
In Chapter 10, the integrated findings demonstrate the complex relation between sports participation and youth development. Current studies in the field have provided inconclusive evidence regarding the life skill development of socially vulnerable youth in sports programmes. Several positive relations were found between sports participation and youth developmental outcomes in this thesis, but these findings provide no evidence of a causal relationship. Furthermore, it was found that sports participation can play several roles in a socially vulnerable childhood that go beyond providing a setting in which youths can develop new skills, competencies, and behaviours. The roles of sport could be defined more broadly and include the importance of the sports setting in offering a safe haven for youths and providing them with a purpose in life. Policymakers and health professionals that aim to increase youths’ sports participation rates to achieve positive youth development have to recognise the various ways in which sport could contribute to youth development and organise sports activities in such a way that they can contribute to these various roles. The integrated findings also show that sports participation is related not only to positive youth development, but also to negative sports experiences that can diminish youth development and even increase vulnerability. Negative sports experiences were reported when the sports setting reflected the same struggles for youths as they encountered in everyday life. When there was an imbalance between the challenges in the sports setting and the resources that youths felt were available to deal with these stressors, feelings of failure and rejection could harm the youths. The sports coach was identified as a key player in tipping the balance towards positive sports experiences by creating a positive and motivational sports climate. However, supporting socially vulnerable youth in their personal development requires a strong commitment from youth professionals, policymakers, sports clubs, and sports coaches, but the collaboration between these actors is not always easy to organise. As an example, many sports coaches in the Netherlands, and elsewhere, are volunteers who do not receive formal coaching training; this makes it very difficult for them to create optimal social conditions that are conducive to youth development. Hence, health professionals and policymakers have to remain critical towards to use of sport as a means to achieve positive youth development, given the considerations stipulated in this thesis The integrated findings from this thesis show that finding meaningfulness in sport is an important factor in the positive development of socially vulnerable youth. For socially vulnerable youth, being engaged in positive challenges in the sports setting was an important motivator for them to take on new challenges in the sports setting; this in turn improved the visibility of their skills and increased their confidence in their sport. Also, the sports coaches focused on creating a meaningful sports activity by establishing an environment in which socially vulnerable youth could feel normal, accepted, and supported. This means that, when the sports setting becomes yet another setting in which youths feel they have to develop skills, learn, and do well, this may militate against the positive influence of sports participation by taking away its core value as an enjoyable leisure-time activity. Medicalising sport can be beneficial for a specific group of young people who are in need of alternative forms of therapy or youth care programmes, but for others it can take away the power that sport has for them. Hence, policymakers and health professionals have to offer a wide variety of sports activities to socially vulnerable youth from which they can choose an activity that best matches their developmental status and personal interests.
Poverty-related diseases (PRDs) assume poverty as a determinant in catching disease and an obstacle for cure and recovery. In Cameroon, over 48% of the population lives below the poverty line. This dissertation starts from the premise that the relation between poverty and disease is mediated by a person’s capacity to cope with the challenges posed by the natural and social environment. The central problem addressed is that in (inter)national health promotion, disease eradication is overemphasized whereas strengthening the capacity of people to cope with harsh conditions is disregarded. Research efforts show a similar division in emphasis, resulting in a limited understanding of the way people deal with health challenges in conditions of poverty. This dissertation is based on the salutogenic model of health that emphasizes the combined effects of (natural) disease conditions, mental conditions and social factors as determinants of health. This implies an emphasis on health as a positive strategy to deal with stressors and also an emphasis on the agency of people to respond to challenges that hamper their health and wellbeing.
The study is carried out among two different groups of people in Cameroon. These are workers including dependents of workers of the Cameroon Development Corporation (CDC) and students from the universities of Buea and Yaoundé. The overall aim of this dissertation is to understand how conditions of poverty impact the health of people and how they manage these challenges. Specifically, the study aims to unravel the interlink-ages between poverty and health by creating a deeper understanding of the social and material dynamics which enable people’s capacity to preserve health, anticipate health risks, and mitigate or recover from stressors such as PRDs. The main research question addressed is: What factors underlie the maintenance of good health and overcoming stressors in the face of PRDs in Cameroon?
Different research methods were used to collect data. Interviews were carried out with respondents from both groups addressing PRDs, other stressors and coping strategies. General surveys were carried out to identify perceptions as well as health behaviour patterns across the two groups. Standardized surveys were carried out to measure individual factors such as sense of coherence, resilience, self-efficacy, subjective well-being and self-rated health.
Results presented in different empirical chapters of the thesis each respond to a specific research question. In Chapters 2 and 3 are presented surveys with 272 students and 237 camp-dwellers respectively. Perceptions, attributed causes of, and responses towards PRDs are explored as well as motivations for given responses to health challenges. In chapter 4, a qualitative study with 21 camp-dwellers and 21 students is presented in which the dynamics of health-seeking behavior is highlighted. In this chapter also, factors which are influential in seeking formal healthcare are indicated. Chapter 5 elaborates on what people experience as stressors and the mechanisms they put in place to cope with the stressors. In this chapter, not only is the diversity of stressors outlined for both groups, but also presented are the Abstract different identified coping mechanisms put in place by respondents. Chapter 6 which is the last empirical chapter presents coping with PRDs through an analysis of individual, demographic and environmental factors.
Based on the studies carried out, this thesis concludes that the two groups investigated are very aware of what PRDs are and can differentiate them from common diseases. Major PRDs listed by the two groups of respondents were malaria, cholera and diarrhoea. This classification is different from what is considered major PRDs by (inter)national health bodies such as the World Health Organization and the Ministry of Public Health in Cameroon. Also, organizations such as CDC and Universities, offer limited contributions towards better health for camp-dwellers and students respectively. This is experienced relative to the living conditions, quality of the healthcare system and poor work or study conditions. That notwithstanding, people play an active role in maintaining their health through diverse coping mechanisms. Coping was most strongly related to enabling individual factors such as sense of coherence and subjective health, perceptions of effective strategies to respond to diseases as well as social factors such as the meaningful activities in the social groups to which they belong. The results presented in this thesis are intended to contribute to sustainable and effective response strategies towards PRDs.
Esther van Hoek - Young Children and Obesity: Development and Evaluation of Family-oriented Treatment.
The prevalence of childhood obesity has increased rapidly during the last decades. Childhood obesity is a multisystem disease with serious consequences such as hypertension, dyslipidemia, chronic inflammation, endothelial dysfunction and hyperinsulinemia. In addition, obese children have a decreased health-related quality of life (HRQoL). The age interval of 3 to 7 years is a critical growth period. Fast increase of weight in this period is associated with obesity later in life. Furthermore, starting treatment at younger age is associated with a larger reduction in overweight. At the start of this project in 2009, there was no evaluated treatment program available for young obese children (defined as 3 to 8 years). The risk of cardiovascular diseases and type 2 diabetes (i.e. cardiometabolic risk)can be assessed by measuring conventional risk factors (for example blood pressure). Other markers, such as pro-inflammatory markers, are part of the cardiometabolic risk profile. Epicardial adipose tissue is a metabolically active cardiac fat depot. In obese adults, the epicardial adipose tissue thickness (EATT) is increased, this is correlated to atherosclerosis. It is unknown whether young overweight children have already increased EATT.
The aim of this thesis is to develop, implement and evaluate a treatment program for obese young children. Furthermore, it aims to assess whether EATT is increased in obese young children and is correlated with the cardiometabolic risk profile, and with treatment.
The treatment program for obese young children is developed based on a review of the clinical guidelines, a literature review (including a systematic review with meta-analysis and an extended literature review) and target group interviews. The findings were integrated with professional judgement. To evaluate the resulting program called AanTafel!, a pilot study was performed (n=7 children), including a process evaluation based on parental interviews and questionnaires with the therapists. The effectiveness of AanTafel! was evaluated with a pre-post-test design including 40 children with a median BMI z-score of 3.4 (standard deviation 1.0) in secondary care. The BMI-z-score was the main outcome measure. Secondary outcome measures were components of the metabolic syndrome, markers of cardiometabolic risk, and HRQoL. Outcome measures were assessed at baseline and at the end of treatment (1 year). The BMI z-score was also evaluated 3 years after baseline in the first 23 children who finished treatment. EATT was measured by echocardiography in 25 obese, 8 overweight, and 15 normal weight young children. In the obese and overweight children the EATT, as well as cardiometabolic risk factors, and the markers adiponectin and high sensitive CRP (hsCRP) were measured at baseline and after treatment.
Meta-analysis showed that multicomponent treatment programs of moderate or high intensity (> 26 hours) were the most effective and resulted in a decrease of BMI z-score of 0.5. During the development of the treatment program, the gaps in evidence in clinical guidelines for childhood obesity treatment were overcome by insights from an additional literature review, target group interviews and professional judgement. The resulting treatment program AanTafel! has the following key characteristics: multicomponent, multidisciplinary, family-based with focus on parents, age-specific, tailored to individual children and families, a duration of one year and a combination of individual and group sessions and a web-based learning module. The pilot study showed that to improve parental involvement, peer support, family tailoring, and highly participative elements (such as self-monitoring) are important. The treatment program AanTafel! resulted in a change of mean BMI z-score of -0.5 directly after finishing treatment. This clinical relevant result persisted 2 years after baseline. Furthermore, a significant increase in HDL cholesterol and a reduction in the number of components of metabolic syndrome were found. Regarding markers of cardiometabolic risk, an overall significant decrease was seen in IL18, e-selectin, and sICAM. The HRQoL showed a non-significant improvement in most domains, with a clinically relevant improvement in the physical summary score. EATT was higher in overweight and obese young children compared to their normal weight peers. EATT was inversely correlated with adiponectin, but correlations with other cardiometabolic risk factors were not statistically significant. EATT did not change during treatment (n=17).
During the development process of an obesity treatment program, it was important to add the views of the target group and therapists to the evidence from clinical guidelines and literature review. The resulting treatment program AanTafel! is effective with a clinically relevant decrease of BMI z-score, an improvement of cardiometabolic risk profile, and a clinically relevant increase in the physical summary score of HRQoL. EATT is increased in obese young children; this is inversely correlated with adiponectin.
Marion Herens - Promoting physical activity in socially vulnerable groups : a mixed method evaluation in multiple community-based physical activity programs.
In the Netherlands, inequalities in physical activity behaviour go hand in hand with socioeconomic inequalities in health. To stimulate physical activity behaviour and promote physical activity effectively and equitably, participatory community-based physical activity interventions seem promising. The Dutch government’s policy is to support community-based sport and physical activity schemes at municipal level, on the assumption that participation in these programs supports the development of social capital, the quality of life in acommunity, and health and wellbeing. Although many strategies have been developed to increase physical activity levels in general and in socially vulnerable groups in particular, most evaluations show only small to moderate effects. To date, the evidence base rests mainly on correlational, cross-sectional studies at participant level, lacking insight into causal relationships and interaction patterns between factors influencing physical activity. In addition, in line with Dutch health promotion policy, there is a general demand for community-based health-enhancing physical activity (CBHEPA) programs to be evaluated for impacts and (cost) effectiveness.
The aim of this thesis is to report on the design and implementation of an evaluation approach, assessing the effectiveness of CBHEPA programs at different impact levels (individual, group, and program), and the mechanisms involved. This study aims to contribute to the evidence base of programs targeting socially vulnerable groups, by applying systematically a multilevel and realist perspective in order to generate recommendations about how to evaluate physical activity promotion interventions targeting socioeconomic inequalities in health and physical activity.
The study was built on a mixed methods design, combining quantitative techniques and qualitative approaches, to monitor 268 participants in 19 groups in seven ongoing CBHEPA programs between 2012 and 2015. We collected data at multiple levels. At individual level, a sequential cohort design was used to acquire quantitative longitudinal data on developments in physical activity behaviour and health-related indicators, and to assess participants’ willingness to pay for sport and physical activity. At group and program level, interviews and focus group qualitative techniques of measurement were used. Thus, we were able to link outcomes at multiple impact levels from different datasets over a period of time, adding contextual and time-related value to our findings. The different kinds of evidence pulled from all cases contributed to the robustness of the mixed methods approach and to the generalisability of the findings
This thesis presents the theoretical orientations for the development of a context sensitive monitoring and evaluation approach in order to measure the effectiveness of CBHEPA programs. It also presents an evaluation design, grounded in an ecological perspective on human health, enabling the identification of underlying mechanisms at multiple levels which explain what works and why in community-based physical activity programs. This thesis presents the empirical findings from multiple perspectives. CBHEPA programs reach socially vulnerable, but not necessarily inactive, groups in terms of socioeconomic and health-related quality of life outcomes. No increase in physical activity levels over time was observed. Over time, significant positive associations were found between leisure-time physical activity, and health-related quality of life, self efficacy, and enjoyment. Furthermore, participants’ willingness to pay (WTP) for sports and physical activity was explored– as also its associated predictors – in terms of money and time.From the literature, relevant predictors of WTP were identified, relating to personal, socioeconomic, health-related, and sports and physicalactivity-related predictors. At group level, participants’ appreciation of the group-based principles for action was explored, addressing active participation, enjoyment, and fostering group processes. A multilevel framework was used to explore the issue of physical activity maintenance in the case of women of non-Western origin. At group level, mutual support, security, sharing stories, and trust wereimportant factors. At program level program, quality, staff responsiveness, continuity, and accessibility were important factors.From a local stakeholders’ perspective, key combinations of contextual factors and mechanisms triggering outcomes of interest were explored. Outcomes of interest related to community outreach, program sustainability, intersectoral collaboration, and enhancing participants’ active lifestyles.
This thesis describes how CBHEPA programs, if supported intheir performance and sustainability, succeed in generating physical activity maintenance in socially vulnerable groups. Two parallel tracks of value co-creation were identified, reflecting value-in-social-context shaped by social forces and reproduced in social structures through interaction and dialogue: the institutional track and the exercise group track. The exercise trainer is usually the only linchpin responsible for connecting these parallel tracks. Strong evidence was found on how contextual dynamics shape local CBHEPA initiatives and on the need for responsiveness and adaptive mechanisms in the institutional track as well as in the exercise group track, in order to realise sustained CBHEPA programs. People from socially vulnerable groups participate in CBHEPA programs primarily for fun, and most of them are willing to pay a modest contribution. Evidence was found of the necessity for a shift in perspective on how CBHEPA programs operate: from an intervention to a service logic or transactional paradigm, in which participants are seen as co-creators of value from a consumer perspective, putting emphasis on the need to develop so-called consumer–supplier relationships through interaction and dialogue. With reference to the Dutch recognition system, put in place to promote quality assurance of lifestyle interventions by encouraging scientific substantiation of intervention effectiveness and feasibility, this research challenges the assumptions underlying the intervention concept as such. Future research on physical activity behaviour and maintenance should focus not only on how individuals act, but also on how individuals, groups, and environments interact.
The biomedical model of health studies disease origins and causes. When applied to nutrition research, the underlying assumption is that healthful eating supports physical health and prevents disease. This view tends to ignore the social-contextual dimension of eating. The biomedical model has led to an advancement of knowledge regarding nutritional risk factors. This research brought forth new knowledge of factors that enable healthful eating in the context of everyday life through cross-sectional survey research and interviews with Dutch adults. We found that healthful eating results from: 1) balance and stability (giving meaning to eating as an integral part of life, comprehending its importance to oneself, and having competencies to manage its organization in everyday life); 2) sense of agency (feeling in control of one’s eating and life in general); and 3) sensitivity to the dynamics of everyday life (confidence that one can deal with and navigate through everyday challenging situations).
The overall aim of this thesis is to contribute to a better understanding of healthful eating in the context of everyday life. The salutogenic framework acted as the theoretical underpinning. Instead of only looking at factors that determine unhealthful eating, this research puts new focus on identifying factors that enable healthful eating. The following objectives have been formulated: 1) To map factors underlying the development of SOC. 2) To study which of these factors are predictors for healthful eating. 3) To unravel how people develop healthful eating practices in everyday life. 4) To integrate this understanding and provide building blocks for nutrition promotion.
This research employed a mixed research design, using both quantitative and qualitative methods. This was carried out through cross-sectional survey research and in-depth semi-structured interviews. The reason for employing a mixed research design is that it increases methodological pluralism, which enhances the richness, diversity, and depth of findings as compared to mono-methodological research. This is particularly useful in social science research because the study of social phenomenon tends to be nothing but linear and simplistic in nature.
Our study brings forth new and significant findings since it is the first to identify a number of individual, social- and physical-environmental levelfactors that relate to SOC. The relationship between a limited number of factors including socio-demographic characteristics and living and working conditions and SOC had been explored in previous research. However it was not known whether other factors also underlie SOC. Specifically, SOC was positively correlated to individual, social- and physical-environmental characteristics including satisfaction with weight, neighborhood collective efficacy, age, and income level and negatively related to doctor-oriented MHLC. Furthermore, SOCwas positively correlated to a number of individual, social- andphysical-environmental characteristics with a specific food or eating-related component including situational self-efficacy for healthy eating and perceived neighborhood affordability, accessibility and availability of healthy foods and inversely correlated to social discouragement for healthy eating.
This research carried out four studies. Based on the findings from these studies, we conclude that healthful eating results from exposure to individual- and context-bound factors during childhood and adulthood and involves specific mental and social capacities relevant to cope with everyday life situations and challenges.
Annemarie Wagemakers - Community health promotion. Facilitating and evaluating coordinated action to create supportive social environments.
Community programs to promote health have been launched all over the world and fit well with Dutch policy that emphasizes the participation of all citizens in all facets of society. However, researchers, practitioners, and policy makers report uncertainty about how to implement and evaluate health promotion programs. In particular, the social environment of health is still overlooked and underexposed due to a lack of consensus on concepts relating to the social environment of health, a lack of information on interventions that bring about social change, and a lack of feasible methods and tools. Consequently, the effectiveness of health promotion may not be evaluated under all relevant headings.
The aim of the studies reported in this thesis was to gain the required knowledge to contribute to the development of methods, tools, and theory to facilitate and evaluate community health promotion. Case studies have been selected that are guided by action research or in which action research was part of the research activities. Methods, tools, and theory have been developed, piloted, and evaluated simultaneously and iteratively in the Eindhoven program Working on Healthy Neighborhoods and the Healthy Lifestyles program in Amsterdam. Based on these case studies and the experiences in other Dutch community health programs, factors that are important in community health promotion were identified and a framework to facilitate and evaluate the social environment of health was developed. Based on the factors and the framework a Checklist for Coordinated Action was developed and assessed for usability in six different partnerships: a national program, an academic collaborative and four local partnerships.
In the Eindhoven program the participatory action research facilitated the restart and continuation of the program, the achievement of intersectoral collaboration, the initiation of community participation, and other accompanying research. In the Amsterdam program, participatory approaches facilitated the participation of 15% of the target population at the desired level in the different phases of the program. The factors important in community health promotion are representation of relevant societal sectors, discussing aims, objectives, roles and responsibilities, communication infrastructure, visibility and management. These factors helped to develop a framework and guidelines which offer operational variables of participation and collaboration and thereby provide common ground for researchers and practitioners. The developed Checklist for Coordinated Action facilitates and evaluates partnerships that differ in context and level, phase of the program and topics addressed.
The thesis has revealed that action research methods and tools are valuable because they fit community health promotion, they generate actionable knowledge for relevant stakeholders, and they are essential and complementary in capturing and assessing the full effects of a community health promotion intervention. Scientific quality is assured by the use of different verification techniques and scientific criteria. Participation is of cardinal value as it contributes to health and serves multiple purposes in health promotion programs. Systematic learning processes can make participation manageable, and research activities are a proper way to facilitate those learning processes. Nonetheless, the potential of participation has not yet been harnessed. Participation thrives in principle-based programs: programs that are characterized by the co-generation of knowledge by involved stakeholders in a flexible and tailored way. To further develop and harvest the full benefit of participation and principle-based programs, researchers are challenged to broaden their research paradigm, practitioners are challenged to foster and coordinate principle-based programs, participation and learning processes and policymakers are challenged to stimulate and support science and practice. By participating and collaborating supportive social environments for health can be created.
Jenneken Naaldenberg - Healthy aging in complex environments. Exploring the benefits of systems thinking for health promotion practice.
Many different stakeholders and contextual factors influence the success or failure of health promotion activities. Conventional approaches and evaluation designs underlying health promotion interventions, often explicitly take contextual variables out of consideration by controlling them. In doing so, relevant information about why a project was successful or failed to reach success remains invisible and ‘black boxed’. Next to this, in health promotion practice, control over contextual variables often is not possible.
Given the complexity of health promotion practice, research approaches often do not fit the realities of practice. As a result, health promotion activities are not always experienced as meaningful by all stakeholders involved. This thesis aims to appreciate the complex environment in which health promotion takes place by applying a systems thinking perspective to healthy aging in order to contribute to more robust strategies and interventions to support the aging population.
Systems thinking aims to include a diversity of viewpoints on an issue. Therefore, to be able to answer the research questions, multiple methods were required. A combination of literature review, semi-structured and open interviews, interactive workshops, case study and survey research was used. Different sources for data collection included the aging population, local and national stakeholders, and AGORA project members.
Part I of this thesis concludes that a systems thinking approach strengthens health promotion by 1) including diverse stakeholder perspectives, 2) explicitly addressing contextual factors, and 3) co-creating solutions with all involved. Following this conclusion, Part II addressed the application of systems thinking at the local level by investigating different stakeholders perspectives on healthy aging. Results show how there is a discrepancy between the way aging individuals experience healthy aging as an integral part of everyday life and the way services and interventions are presented with a focus on isolated health themes. Local healthy aging strategies can benefit by taking into account an assets based approach that better matches aging persons’ perspectives. Next to this, collaboration between local stakeholders can be facilitated when shared issues are made visible and contextual preconditions are taken into account. Since the operationalization of systems thinking in health promotion can benefit from learning experiences with application in practice, findings from Part II were discussed in interactive presentations and workshop formats within participating municipalities. This resulted in the co-creation of a model to facilitate collaboration and the co-creation of an intervention through application of this model. The salutogenic concept Sense of Coherence was identified as a promising concept to operationalize systems approaches in health promotion practice. It was therefore expected that quantitative measurement of SOC could provide useful information for both the development and evaluation of health promotion. The OLQ-13 scale to measure Sense of Coherence was therefore investigated for its psychometric properties. Results indicate difficulties with the use of this scale in aging populations. Deleting two items from the original 13 items, improved the functioning of OLQ.
The importance of the fact that health issues and possible intervention strategies are perceived differently by involved actors was argued within this thesis. Research is one amongst many stakeholders and a systems thinking approach implies linking all kinds of actors in order to enable co-creation of projects. Consequently, the definition of health risks, health determinants, and possible intervention effects have to be verified in both scientific research and everyday practice. Strategies to improve health are context sensitive, and consequently, certain strategies may not work in some settings whereas they function perfectly well in others. Measurement of successes of interventions should therefore use multi-method evaluations combining the use of quantitative and qualitative approaches to gain insight in the ‘black box’ of why an intervention failed or was successful. If not, alternatives are overlooked and at the same time successes may go unnoticed.
Jeanette Lezwijn - Towards salutogenic health promotion. Organizing healthy ageing programs at the local level.
The increase in the ageing population in the Netherlands is having an impact on national as well as on local level. As people are now living longer, the importance of preventing unnecessary disability, maintaining physical functioning and preventing complications from chronic diseases and adding life to years rather than years to live has become increasingly important. Local governments therefore face challenges to improve healthy ageing for their ageing population.
In municipalities all kind of facilities and activities to improve healthy ageing are already developed. However the reach of these facilities and activities is often low. Especially among the more vulnerable older people. More insights and new methods are therefore needed to reach these older people or to develop facilities and activities that better fit the wishes and desires of older people themselves. This study aims to contribute to the knowledge base of health promotion professionals about how to develop, implement and evaluate local healthy ageing programs.
Since in this study, the researcher is at the same time a health promotion professional developing, implementing and evaluating a healthy ageing program in three municipalities in the eastern part of the Netherlands, mainly an action research approach is used. Thereby, action research fits well within the complex setting of a municipality. It aims to analyse the situation and its problems, to find solutions to address the problems, and to look for opportunities to put these solutions into practice. In this thesis multiple methods, such as interviews and participant observation, and different sources of data, such as the ageing population, local organizations and policymakers, were used.
Because intersectoral collaboration and participation of the community, which are essential for developing a new healthy ageing program (coordinated action for health), were not selfgenerating processes, the HP 2.0 framework is developed. The framework is based on the principles of health promotion and on salutogenesis and exist out of the concepts ‘sense of coherence (SOC)’, ‘resources for health’ and ‘health’. When ‘resources for health’ are adapted to the SOC, older people are more likely to identify those resources and make use of it. The HP 2.0 framework is developed to contribute to the discussion concerning the content of a health promotion program. Other issues contributing to coordinated action for health are prerequisites such as time and money. Thereby, in each municipality the extent to which coordinated action is built and sustained was different, which influenced the processes in the municipalities when developing a healthy ageing program. Four different planning approaches were identified, namely the classical, evolutionary, processual and the systemic approach to planning. In the process of achieving and sustaining coordinated action for health, both context-free – such as epidemiological data and scientific literature – and context-sensitive evidence – stemming from interviews with older people, organizations and local policymakers – were combined. This resulted in a new healthy ageing program, called Neighbors Connected.
Three conclusions can be drawn from this study. The first conclusion is that the HP 2.0 framework contributed to the development, implementation and evaluation of healthy ageing strategies. The framework visualizes the salutogenic relationship between resources for health and SOC, which is not made explicit elsewhere. This means that although a health promotion program in itself has the potential to contribute to health, the framework adds that a program also needs to be perceived as comprehensible, manageable and meaningful. The second conclusion is that coordinated action starts from the moment stakeholders meet and share ideas, and thus before the actual health promotion programs starts. Such a preliminary phase influences local planning processes to develop and implement health promotion programs in the municipality, since in this phase relevant stakeholders have to be found and discussions with stakeholders have to take place about aims and objectives. Therefore, this preliminary phase should be part of the evaluation of the health promotion program as well, next to the evaluation of the impact of the program on (determinants of) health. The third conclusion is that within this study the HP 2.0 framework and the achieved coordinated action for health made it possible to combine different forms of evidence. Combining different forms of evidence, context-free and context-sensitive, contributed to the sharing of knowledge, to the co-creation of a salutogenic health promotion program and to more sustainable changes.Click here to download this thesis from Wageningen UR Library