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Schools are overloaded with health promotion programs that, altogether, focus on a broad array of behavioral domains, including substance abuse, sexuality and nutrition. Although the specific content of programs varies according to the domain focus, programs usually address similar concepts: knowledge, attitudinal beliefs, social influences and skills. This apparent conceptual overlap between behaviors and programs provides opportunities for a transfer-oriented approach which will stimulate students to apply the knowledge and skills they have learned in one domain (e.g. skills for resisting tobacco use) to other domains (e.g. alcohol, sex). A requirement for such an approach is that behaviors share at least some determinants. This review addresses this issue by examining similarities between domain-specific determinants of smoking, drinking, safe sex and healthy nutrition among adolescents. Recent empirical studies and reviews were examined. The results show that the following determinants are relevant to all four behaviors: beliefs about immediate gratification and social advantages, peer norms, peer and parental modeling and refusal self-efficacy. Several other determinants have been found to relate to at least two behaviors, e.g. health risk beliefs and parental norms. These results can be used for the development of a transfer-oriented school health promotion curriculum. © The Author 2008. Published by Oxford University Press. All rights reserved.

Background: The insertion of fixed orthodontic appliances increases the risk of dental caries, particularly in adolescents. Caries can be prevented through good oral health behavior. To support adolescents with fixed orthodontic appliances and for promoting oral health behavior, we developed a theory- and evidence-based mHealth program, the WhiteTeeth app. Objective: The objective of our paper was to describe the systematic development and content of the WhiteTeeth app. Methods: For systematic development of the program, we used the intervention mapping (IM) approach. In this paper, we present the results of applying the first 5 steps of IM to the design of an mHealth program: (1) identifying target behaviors and determinants through problem analysis, including a literature search, a survey study, and semistructured interviews, to explore adolescent oral health behavior during orthodontic therapy; (2) defining program outcomes and objectives; (3) selecting theoretical methods and translating them into practical strategies for the program design; (4) producing the program, including a pilot test with 28 adolescents testing the acceptability and usability of the WhiteTeeth app; and (5) planning implementation and adoption. Results: On the basis of our literature search, we identified fluoride use and control of dental plaque levels (eg, tooth brushing and proxy brush usage) as target behaviors for preventing caries. Next, we identified important and changeable determinants of oral health behavior that fitted the theoretical concepts of the Health Action Process Approach (HAPA) theory. The HAPA theory, the self-regulation theory, and the results of the semistructured interviews were used to define the program objectives, that is, the performance and change objectives. After defining the objectives, we identified multiple behavior change techniques that could be used to achieve these objectives, such as providing oral health information and feedback, prompting self-monitoring, coaching of set actions and coping plans, and sending reminders. We translated these methods into practical strategies, such as videos and a brushing timer. Next, we combined these strategies into a single program resulting in the WhiteTeeth app (which is available on both iTunes and Google Play stores as “Witgebit”). Adolescents with fixed orthodontic appliances and dental professionals were included in the development process to increase the success of implementation. The pilot test revealed that the app users appreciated and liked the app. The WhiteTeeth app can be integrated into current orthodontic care. Conclusions: IM allowed us to identify multiple techniques that have been shown to be the most effective in initiating behavior change, but have not yet been incorporated into existing orthodontic apps. The WhiteTeeth app contains all these techniques, which makes it a unique and promising home-based app for promoting oral health in adolescents with fixed orthodontic appliances.

Er is nagegaan of een 1 jaar durende lunchwandelcampagne werknemers in sedentaire beroepen kan stimuleren om meer te bewegen. Hierbij is gekeken naar het effect van de campagne op het aantal werknemers dat wandelt tijdens de lunch, de frequentie van het lunchwandelen, het percentage werknemers dat voldoet aan de Nederlandse Norm Gezond Bewegen (NNGB) en de invloed van de bedrijfsomgevind op het lunchwandelgedrag.

Objective: To study the association between commuter cycling and all-cause sickness absence, and the possible dose-response relationship between absenteeism and the distance, frequency and speed of commuter cycling. Method: Cross-sectional data about cycling in 1236 Dutch employees were collected using a self-report questionnaire. Company absenteeism records were checked over a one-year period (May 2007-April 2008). Propensity scores were used to make groups comparable and to adjust for confounders. Zero-inflated Poisson models were used to assess differences in absenteeism between cyclists and non-cyclists. Results: The mean total duration of absenteeism over the study year was more than 1. day shorter in cyclists than in non-cyclists. This can be explained by the higher proportion of people with no absenteeism in the cycling group. A dose-response relationship was observed between the speed and distance of cycling and absenteeism. Compared to people who cycle a short distance (≤ 5. km) three times a week, people who cycle more often and longer distances are absent for fewer days on average. Conclusion: Cycling to work is associated with less sickness absence. The more often people cycle to work and the longer the distance travelled, the less they report sick. © 2010 Elsevier Inc.

Ultrasound screening for developmental dysplasia of the hip (DDH) is an innovation in preventive child health care in the Netherlands. Parental participation in the screening will be essential for the success of implementation of the screening. The aim of the current study was to investigate whether psychosocial factors (attitude, subjective norm, self-efficacy, perceived susceptibility, perceived severity, perceived effectiveness) predicted parental participation in the screening. A cross-sectional survey was conducted. Using a questionnaire, several background variables (organization, sociodemographic variables, and knowledge) and psychosocial variables were collected. Blockwise logistic regression was used to analyze the relations. A total of 703 questionnaires of participating parents (response 61.7%) and 393 questionnaires of nonparticipating parents were received (response 37.2%). When controlling for the background variables, attitude, subjective norm, self-efficacy, perceived susceptibility, and perceived effectiveness predicted parental participation in the screening (p < .05). Perceived severity of the dysplasia did not predict participation (p > .05). Psychosocial determinants influenced parental participation in the ultrasound screening for DDH. Emphasizing the positive aspects of the screening, highlighting the effectiveness, removing practical barriers, and being conscious of the influential role of child health care professionals on decision making are areas to focus on when organizing the ultrasound screening for DDH. Health care policy decision makers and child health care professionals should consider these determinants in order to stimulate parental participation. © 2013 American Psychological Association.

Hepatitis B virus (HBV) is an important health problem in the Turkish Dutch. Screening is necessary for detection and prevention of HBV. We aimed to identify social-cognitive and socio-cultural determinants of HBV-screening intention among Turkish Dutch. A cross-sectional survey was carried out amongst 335 Turkish Dutch, aged 16-40 years. Respondents showed favorable scores for the potential determinants of HBV-screening. Attitude, perceived behaviour control, social support and social norm, and the level of satisfaction with Dutch health care proved to be directly associated with screening intention. Relevant socio-cultural beliefs were shame, stigma, the association of screening with sexuality and family values. Persons with lower screening intentions had lower scores for attitude, perceived behaviour control, social support and subjective norms, but scored higher for feelings of shame and stigma regarding hepatitis B. This study shows how cultural values and social-cognitive factors are related to HBV-screening intention.

Background: Many online interventions designed to promote health behaviors combine multiple behavior change techniques (BCTs) and additional modes of delivery (MoD, e.g. text messages) to maximize effectiveness. Also, usability factors may influence effectiveness. This study aims to identify synergistic effects of BCTs, MoDs and usability factors. Methods: A re-analysis of data from Webb (2010) was performed. Eighty interventions ((g ) ¯ = 0.16) were included, targeting a variety of health behaviors. 26 BCTS and 11 MoDs were coded in the interventions, and a usability taxonomy was developed. Meta-CART (Classification and Regression Trees) analyses were performed using the BCTs and MoDs as predictors, and effect size as outcome. Findings: Meta-CART identified one synergistic effect: Interventions that included barrier identification/ problem solving and prompted participants to plan social support/ social change but did not provide normative information about the behavior of others had an average effect size of 0.25 (95%CI=0.08-0.42). No synergistic effects were found for MoDs, or MoDs combined with BCTs. Discussion: The present analyses provide guidance on developing effective online interventions for promoting health behavior change. Only one combination was effective, indicating most BCTs did not have synergistic effects above their univariate effect found by Webb et al.

This study reports entry correlates and motivations of older adults participating in organized exercise programs in the Netherlands, as determined in a descriptive explorative study (N = 2,350, response rate 86%). Participants were community-dwelling older adults (50+ years) who enrolled and started in 10 different exercise programs. Entiy features were analyzed for differences in age, sex, marital status, education, living situation, body-mass index, lifestyle, and health status. Motivations for entering an exercise program were detemiined using homogeneity analyses. More Exercise for Seniors (MBvO) attracted relatively older seniors, whereas organized sports mainly attracted younger ones. Walking, MBvO, and gymnastics attracted more women, whereas skating and table tennis were reported to attract more male participants. Badminton and cycling attracted relatively higher educated participants, whereas MBvO attracted relatively lower educated participants. Three distinct motivational constructs were found: relax and enjoy, care and cure, and competition. Public health and recruitment implications of these findings are discussed. © 2008 Human Kinetics, Inc.

Vergeleken met mannelijke verzekeringsartsen beoordelen vrouwelijke verzekeringsartsen een specifieke client strenger en waren zij niet gevoelig voor de manier waarop een oordeel moest worden gegeven. Vrouwelijke verzekeringsartsen maken waarschijnlijk meer gebruik van nonverbale informatie.

Background. Most school health education programs focus on a single behavioral domain. Integrative programs that address multiple behaviors may be more efficient, but only if the elements of change are similar for these behaviors. The objective of this study was to examine which effective elements of school health education are similar across three particular behavioral domains. Methods. A systematic review of reviews of the effectiveness of school-based health promotion programs was conducted for the domains of substance abuse, sexual behavior, and nutrition. The literature search spanned the time period between 1995 and October 2006 and included three databases, websites of review centers and backward search. Fifty-five reviews and meta-analyses met predetermined relevance and publication criteria and were included. Data was extracted by one reviewer and checked by a second reviewer. A standardized data extraction form was used, with detailed attention to effective elements pertaining to program goals, development, content, methods, facilitator, components and intensity. Two assessors rated the quality of reviews as strong, moderate or weak. We included only strong and moderate reviews in two types of analysis: one based on interpretation of conflicting results, the other on a specific vote-counting rule. Results. Thirty six reviews were rated strong, 6 moderate, and 13 weak. A multitude of effective elements was identified in the included reviews and many elements were similar for two or more domains. In both types of analysis, five elements with evidence from strong reviews were found to be similar for all three domains: use of theory; addressing social influences, especially social norms; addressing cognitive-behavioral skills; training of facilitators; and multiple components. Two additional elements had positive results in all domains with the rule-based method of analysis, but had inconclusive results in at least one domain with the interpretion-based method of analysis: parent involvement and a larger number of sessions. Conclusion. Five effective elements of school health promotion were found to be similar across the three behavioral domains examined (substance abuse, sexual behavior, nutrition). An integrative program that addresses the three domains seems feasible. The five elements are primary candidates to include in programs targeting these behaviors. © 2009 Peters et al; licensee BioMed Central Ltd.

A previous study among Amsterdam 5-year-old children showed that on average, the older the child at the onset of toothbrushing and the less frequent the toothbrushing, the more life time caries experience it had. The aim of the present study was to assess correlates of these two caries risk factors, in four ethnic groups. A further aim was to evaluate the putative role of correlates as intervening variables between ethnicity and caries risk factors. Questionnaire data were available from the Amsterdam study, in which a stratified sample of 103 Turkish, 258 Moroccan, 59 Dutch and 56 Surinamese parents were interviewed at home in their mother tongue. Results showed 69 per cent of the Turkish, 45 per cent of the Moroccan, 17 per cent of the Dutch and 11 per cent of the Surinamese parents had commenced brushing their child's teeth only after its second birthday or even never at all. Moreover, many parents had not brushed their child's teeth every day. Almost all potential correlates in six domains, namely parental habits, attitudes, evaluative beliefs, behavioural beliefs, perceived role of the child and that of the partner, were found to be related crudely to the risk factors. Large differences in score patterns on the correlates were observed between ethnic groups. Multiple logistic regression analyses showed substantial parts of the differences in risk factor scores between the Turkish group and a combined Dutch and Surinamese reference group could be attributed to the intervening role of the correlates, as could only minor parts of the difference in risk factor scores between the Moroccan group and the reference group.

This investigation was first, to assess the oral health of 11-year-old children in four ethnic groups in Amsterdam; second, to assess their dental behaviour and third, to identify potential determinants of frequency of toothbrushing. Representative samples of 97 Surinamese, 209 Moroccan, 128 Turkish and 102 Dutch children were examined orally and asked to complete a questionnaire. Results showed that Turkish and Moroccan children had higher mean DMFT and DMFS scores than the Surinamese and the Dutch children. The mean plaque scores in the Turkish and Moroccan children were higher than those in the other two groups. Large differences in frequency of toothbrushing were found between the four ethnic groups, the Surinamese and Dutch children claimed to be the more regular brushers. Logistic regression analysis showed that the frequency of toothbrushing was related to the children's attitude towards toothbrushing and not to parental influence.

Background: Recent studies suggest that the basis for adverse pregnancy outcomes is often established early in pregnancy, during organogenesis. It is therefore important to take preventive action as early as possible, preferably before pregnancy. Because most adverse pregnancy outcomes occur in women who are unaware of being at risk, we conducted a randomized controlled trial, "Parents to Be." With this study, we sought to assess the extent to which women who have participated in preconception counseling (PCC) increase their knowledge on pregnancy-related risk factors and preventive measures and change their behavior before and during pregnancy and to provide an overview of adverse pregnancy outcomes among such women. Methods: Knowledge: Women aged 18-40 who attended PCC and women who received standard care were matched on previous pregnancy, time since last pregnancy, age, country of birth, and educational achievement. They were sent a questionnaire on knowledge about pregnancy-related risk factors and preventive measures. Behavior: Data on pregnancies and outcomes were collected. Two months after pregnancy, a questionnaire was sent regarding behavior before and during pregnancy. Results: Knowledge of women who received PCC (81.5%; n = 211) exceeded that of women who did not (76.9%; n = 422). Levels of knowledge in women who were not yet pregnant after PCC were comparable to those in women who became pregnant after PCC, indicating that, even before pregnancy, PCC increased knowledge in women contemplating pregnancy. After PCC, significantly more women started using folic acid before pregnancy (adjusted odds ratio [OR], 4.93; 95% confidence interval [CI], 2.81-8.66) and reduced alcohol use during the first 3 months of pregnancy (adjusted OR, 1.79; 95% CI, 1.08-2.97). Among the group receiving standard care, about 20% of all pregnancies ended in an adverse outcome; in the group with PCC this was 16% (OR, 0.77; 95% CI, 0.48-1.22). Conclusion: After PCC, women have more knowledge about essential items. Importantly, they gained this greater knowledge before pregnancy and more women changed their behavior to reduce adverse pregnancy outcomes. © 2008 Jacobs Institute of Women's Health.

Characterizing school health promotion is its category-by-category approach, in which each separate health-related behavior is addressed independently. Such an approach creates a risk that extra-curricular activities become overloaded, and that teaching staff are distracted by continuous innovations. Within the health promotion sector there are thus increasing calls for an integrative approach to health-related behaviors. However, a meaningful integrative approach to different lifestyles will be possible only if there is some clustering of individual health-related behaviors and if health-related behaviors have a minimum number of determinants in common. This systematic review aims to identify to what extent the four health-related behaviors smoking, alcohol abuse, safe sex and healthy nutrition cluster; and how their determinants are associated. Potentially modifiable determinants that offer clues for an integrative approach of school health-promotion programs are identified. Besides, the direction in which health educators should look for a more efficient instructional design is indicated. © 2006 Society for Prevention Research.

Objective: This study investigates the clustering of a broad range of health-compromising and delinquent behaviors. We examine whether these behaviors belong to a single but broad cluster, 'risk-taking behavior', and whether the nature and degree of clustering in adolescents differs from that in adults. Method: A representative sample (N = 4395) of the Dutch population aged 12 to 40 (overall response rate 67%), was asked about various health-compromising behaviors, such as alcohol consumption, smoking, illegal drug use, unsafe sexual behavior, physical inactivity, poor nutrition (such as skipping breakfast and not eating fruit and vegetables), poor sleep behavior, unlawful traffic behavior, and delinquent and aggressive behavior. Data were collected from fall 2005 to spring 2006 using internet questionnaires and face-to-face computer-assisted interviews. Results: No single broad cluster was found. Instead, there were several separate but interrelated clusters. The contents of these clusters differed between age groups. For young adolescents (12-15) two clusters were identified: Alcohol and Delinquency. For older adolescents (16-18) and adults (19-40) three clusters were identified: Alcohol, Delinquency and Health. Conclusion: The findings of this study support a more integrated approach to promoting healthier lifestyles, and suggest that the behavior targets of integrated prevention programs should be different for adolescents and adults. © 2009 Elsevier Inc. All rights reserved.

Objective: The aim of the study was to determine the pattern of health care utilization of people aged 55-74 years with arthritic pain in the knee or hip. Design: People with current pain were identified in a population- based study. A filter model was used to describe the pattern of health care utilization of people who presented as patients at different levels (GPs or specialist) of the health care system in the Netherlands. Setting: The study was carried out in the district of Ommoord in Rotterdam in an age- and gender-representative sample of 831 (response 83%; n = 691) people. Study participants: A group of 186 people with current pain was identified. They completed a questionnaire and were interviewed. Main outcome measures: Background variables, illness-related variables (including radiological osteoarthritis), and self-reported diagnoses were described and compared for attenders and non-attenders of GPs and specialists. A reference group of patients of GPs was used to determine the validity and generalizability of the findings. Results: Eighty-two per cent consulted a GP (passed filter 1). In 69% of the GP attenders, 'arthritis' was identified (passed filter 2), and 65% of them attended a specialist (passed filter 3). People who did not pass the various filters were different from those who did with respect to the body mass index (lower; OR 1.24), the chronicity of pain (less chronic pain; OR 4.9) and attendance of a physiotherapist (lower; OR 5.6). The chronicity of pain seems of more importance in determining the health care utilization pattern than the severity of pain, the level of disability or the presence of radiological osteoarthritis. We suggest that health promotion interventions could increase the self-management ability of patients and could lower costs.

Social support is important to achieve beneficial changes in risk factors for disease, such as overweight and obesity. This paper presents the theoretical and practical framework for social support, and the mechanisms by which social support affects body weight. The theoretical and practical framework is supported with a literature review addressing studies involving a social support intervention for weight loss and weight loss maintenance. A major aspect in social support research and practice is the distinction between structural and functional support. Structural support refers to the availability of potential support-givers, while functional support refers to the perception of support. Interventions often affect structural support, for example, through peer groups, yet functional support shows a stronger correlation with health. Although positive correlations between social support and health have been shown, social support may also counteract health behaviour change. Most interventions discussed in this review showed positive health outcomes. Surprisingly, social support was clearly defined on a practical level in hardly any studies, and social support was assessed as an outcome variable in even fewer studies. Future social support intervention research would benefit from clear definitions of social support, a clear description of the intended mechanism of action and the actual intervention, and the inclusion of perceived social support as a study outcome. © 2005 Nature Publishing Group. All rights reserved.

This is the second in a series of three articles addressing the intersection of interests in behavioral genetics and behavioral medicine. In this article, we use risk factors for cardiovascular disease as a prototypical trait for which behavioral genetic approaches provide powerful tools for understanding how risk factors, behavior, and health outcomes are related. The approach synthesizes a number of methods and areas of interest in an attempt to arrive at a comprehensive, whole-organism understanding of health-related risk factors and their response to behavioral interventions.

Background. CenteringPregnancy (CP) is a multifaceted group based care-model integrated in routine prenatal care, combining health assessment, education, and support. CP has shown some positive results on perinatal outcomes. However, the effects are less obvious when limited to the results of randomized controlled trials: as there are few trials and there is a variation in reported outcomes. Furthermore, former research was mostly conducted in the United States of America and in specific (often high risk) populations. Our study aims to evaluate the effects of CP in the Netherlands in a general population of pregnant women (low and high risk). Furthermore we aim to explore the mechanisms leading to the eventual effects by measuring potential mediating factors. Design. We will perform a stepped wedge cluster randomized controlled trial, in a Western region in the Netherlands. Inclusion criteria are <24 weeks of gestation and able to communicate in Dutch (with assistance). Women in the control period will receive individual care, women in the intervention period (starting at the randomized time-point) will be offered the choice between individual care or CP. Primary outcomes are maternal and neonatal morbidity, retrieved from a national routine database. Secondary outcomes are health behavior, psychosocial outcomes, satisfaction, health care utilization and process outcomes, collected through self-administered questionnaires, group-evaluations and individual interviews. We will conduct intention-to-treat analyses. Also a per protocol analysis will be performed comparing the three subgroups: control group, CP-participants and non-CP-participants, using multilevel techniques to account for clustering effects. Discussion. This study contributes to the evidence regarding the effect of CP and gives a first indication of the effect and implementation of CP in both low and high-risk pregnancies in a high-income Western society other than the USA. Also, measuring factors that are hypothesized to mediate the effect of CP will enable to explain the mechanisms that lead to effects on maternal and neonatal outcomes. Trial registration. Dutch Trial Register, NTR4178, registered September 17th 2013.