Country-level sociocultural context and socioeconomic inequalities in adolescent dietary behaviours: A multilevel analysis in 21 European countries

Studies to date have predominantly focused on countries' socioeconomic conditions (e.g., income inequality) to explain cross-national differences in socioeconomic inequalities in adolescent health (behaviours). However, the potential explanatory role of sociocultural contexts at country-level remains underexamined. This study examined whether the country-level sociocultural context and changes thereof were associated with adolescent socioeconomic inequalities in dietary behaviours. International comparative data of 344,352 adolescents living in 21 countries participating in 2002, 2006, 2010 and 2014 waves of the Health Behaviour in School-aged Children (HBSC) survey were combined with aggregated levels of openness-to-change from the European Social Survey (ESS). Four dietary behaviours (i.e., fruit, vegetable, sweets and soft drink consumption) and two measures of socioeconomic status (SES) on the individual level (i.e., family affluence scale [FAS] and occupational social class [OSC]) were studied. Multilevel logistic regression analyses returned contrasting results for the two SES measures used. In countries with higher levels of openness-to-change, smaller FAS inequalities in daily fruit, sweets and soft drink consumption were observed, but no such inequalities were found for vegetable consumption. Conversely, in these countries, larger OSC inequalities in soft drink consumption were found. Country-specific changes in openness-to-change over time were not associated with the magnitude of adolescent dietary inequalities. Findings underscore the importance of including country-level sociocultural contexts to improve the understanding of cross-national differences in socioeconomic inequalities in adolescents' diets. Future studies, spanning a longer timeframe, are required to examine whether such associations exist within countries over time since our timeframe might have been too small to capture these long-term trends.

Associations between the objective and perceived food environment and eating behavior in relation to socioeconomic status among adults in peri-urban settings: results from the CIVISANO study in Flanders, Belgium

Obesity, a significant public health concern, disproportionately affects people with lower socioeconomic status (SES). Food environments have been identified as part of the causal chain of this disparity. This study investigated variations in the food environment across groups with different SES profiles residing in peri-urban municipal settings. In addition, it examined the association of the perceived and objective food environments with eating behaviour and assessed if these associations were moderated by SES. Utilizing GIS and survey data (n = 497, aged 25-65), results showed differences in the objective and perceived food environments based on SES. Respondents with higher SES perceived their food environments as better but resided farther from all food outlets compared to respondents with lower SES. However, there was no difference in outlet density or mRFEI between SES groups. SES moderated associations between the objective and perceived food environments and most eating behavior outcomes except fast food consumption frequency. For fruits and vegetables, SES moderated the association between neighborhood availability and consumption frequency (β0.23,CI0.03;0.49). Stratified analysis revealed a positive association for both lower (β0.15, CI0.03;0.27) and higher (β0.37, CI 0.12;0.63) SES groups. For snack foods, SES moderated the association between healthy outlet density and consumption frequency (β-0.60, CI-0.94; -0.23), showing statistical significance only for respondents with higher SES (β0.36,CI 0.18;0.55). Similarly, for sugar-sweetened beverages, a statistically significant interaction was observed between unhealthy outlet density in the 1000m buffer and consumption frequency (β 0.06, CI 0.02; 0.11). However, this association was only statistically significant for respondents with higher SES (β-0.02,CI -0.05;-0.0002). These results emphasize the significance of SES as a crucial element in comprehending the connection between the food environment and eating behaviour. Indicating the need for policymakers to take SES into account when implementing food environment interventions, particularly when focusing on the neighborhood food environment without considering residents' SES and their perceptions.

A within-subject examination of grandparents' physical activity and sedentary behavior levels in the presence or absence of grandchild care provision

BACKGROUND

This study aimed to examine within-subject differences in levels of physical activity (PA) and sedentary behavior (SB) among Flemish grandparents aged 50 years and older during a day of providing versus not providing grandchild care. Additionally, grandparents' PA and SB levels of the specific caregiving moment within the included care day were also compared with those of the corresponding specific time frame on the matching non-care day.

METHODS

Data were obtained and pooled from three assessment time points of the Healthy Grandparenting Project. Objectively measured PA and SB levels were assessed through ActiGraphs wGT3x(+) worn during waking hours for seven consecutive days and expressed relative to the total wear time of the selected days or moments (i.e., percentage of time per day or per moment). Generalized linear mixed models were used to evaluate the within-subject differences in grandparents' light intensity PA (LIPA), moderate-to-vigorous intensity PA (MVPA) and SB levels between a care and non-care day as well as between the care and non-care moment of those respective days.

RESULTS

A total of 92 grandparents (64.6 ± 4.8 years, 67.4% women) were included in the analyses. During the care day and care moment, grandparents showed higher relative levels of LIPA (∆=4.0% and ∆=7.9%, respectively) and lower relative levels of SB (∆=3.7% and ∆=6.7%, respectively) as compared to their respective non-care day and non-care moment (all p < 0.001). While there was no significant difference in relative MVPA levels between a day of providing versus not providing grandchild care (∆=0.3%, p = 0.500), the grandparents showed significantly lower relative levels of MVPA during the specific care moment against the non-care moment (∆=1.3%, p = 0.029).

CONCLUSIONS

The higher percentage of time of LIPA and lower percentage of time spent on SB during a care day and care moment compared to a non-care day and non-care moment, highlight the positive impact of grandchild care provision on grandparents' activity levels, potentially improving other health-related outcomes. Furthermore, grandparents seem to compensate for their lower MVPA levels during the actual care moment since no differences in MVPA levels were found at day level when compared to a day without grandchild care.

TRIAL REGISTRATION

clinicaltrials.gov, Identifier: NTC04307589. Registered March 2020.

Associations of habitual sedentary time with executive functioning and short-term memory in 7th and 8th grade adolescents

BACKGROUND

While there is increasing evidence for negative physical health consequences of high volumes of sedentary time and prolonged sedentary time in adolescents, the association with cognition is less clear. This study investigated the association of volumes of habitual sedentary time and prolonged sedentary time with executive functions and short-term memory in adolescents.

METHODS

This study has a cross-sectional observational study design. Volumes of sedentary time and prolonged sedentary time (accumulated sedentary time spent in bouts of  ≥ 30 min) were measured using the Axivity AX3 accelerometer. Six cognitive functions (spatial and verbal short-term memory; and working memory, visuospatial working memory, response inhibition and planning as executive functions) were measured using six validated cognitive assessments. Data were analysed using generalised linear models.

RESULTS

Data of 119 adolescents were analysed (49% boys, 13.4 ± 0.6 year). No evidence for an association of volumes of sedentary time and prolonged sedentary time with spatial and verbal short-term memory, working memory, and visuospatial working memory was found. Volumes of sedentary time and prolonged sedentary time were significantly related to planning. One hour more sedentary time or prolonged sedentary time per day was associated with respectively on average 17.7% (95% C.I.: 3.5-29.7%) and 12.1% (95% C.I.: 3.9-19.6%) lower scores on the planning task.

CONCLUSIONS

No evidence was found for an association of volumes of habitual sedentary time and prolonged sedentary time with short-term memory and executive functions, except for planning. Furthermore, the context of sedentary activities could be an important confounder in the association of sedentary time and prolonged sedentary time with cognition among adolescents. Future research should therefore collect data on the context of sedentary activities.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov in January 2020 (NCT04327414; released on March 11, 2020).

Process evaluation of the Belgian one-month-without alcohol campaign 'Tournée Minérale': a mixed method approach

BACKGROUND

The Tournée Minérale campaign [TMC] is a mass media prevention campaign challenging Belgian adults to refrain from alcohol during one month. A process evaluation may help us better understand the effect of TMC and to formulate recommendations for future editions. The current study aimed to examine reach, experiences, perceived effectiveness and maintenance of TMC.

METHODS

A mixed method design was used to assess the process, using pre- and post-questionnaires (n = 49.022, 44.5 ± 13.1 years old, 37.0% men) and focus groups (n = 31, 47.3 ± 14.3 years old, 33.3% men).

RESULTS

Most campaign materials were considered useful and/or motivating. Facilitators for taking part in TMC were connectedness with other participants, stimulus control (e.g. removing alcohol at home) and a supportive social environment. Most difficulties were encountered with abstaining during social occasions as participants had to change a habit or find alternative non-alcoholic beverages. Participants reported both beneficial (e.g. sleeping better) and adverse effects (e.g. drinking more soft drinks).

CONCLUSIONS

Future editions of TMC should try to decrease perceived adverse effects (e.g. by providing attractive non-alcoholic beverages) and can benefit from having a forum where people can share experiences.

Psychosocial Determinants of Sleep Behavior and Healthy Sleep Among Adolescents: A Two-Wave Panel Study

To date, it remains unknown which psychosocial determinants identified by several leading behavior change theories are associated with different sleep parameters among adolescents. Therefore, this study investigates whether changes in knowledge about healthy sleep, attitude toward healthy sleep and going to bed on time, self-efficacy to engage in healthy sleep behavior, perceived parental and peer norms, perceived barriers (e.g., worrying, fear of missing out), and perceived support (e.g., bedtime rules, encouragement) related to healthy sleep are associated with changes in adolescents' sleep duration on school days and free days and sleep quality over a period of 1 year. Two-wave data of 1648 Flemish adolescents (mean age = 15.01, SD = 0.65, 46.3% female) were analyzed using linear models. Increased levels of parental social support, positive attitude towards and perceived advantages of healthy sleep, norm-knowledge, and perceived peer behavior were associated with sleep duration, with parental social support having the strongest association. Increased levels of perceived barriers were associated with decreased levels of sleep quality parameters, and increased levels of self-efficacy, positive attitude, and parental modeling were associated with improved sleep quality parameters, with perceived barriers having the strongest association. The current results indicate that behavior change theories are useful in the context of adolescent sleep behavior and suggest that perceived parental support (i.e., bedtime rules) and perceived barriers are most strongly associated with adolescents' sleep duration and/or quality.

Home-delivered meal boxes in a family setting: a qualitative study investigating reasons for use and perceived impact on meal practices

BACKGROUND

Cooking and consuming a homemade meal is associated with health benefits. Home-delivered meal boxes can support families in cooking this fresh meal. The current study aimed to gain a deeper understanding of the determinants of meal box use, and of the perceived impact on meal practices of parents with younger (i.e., aged 6-12 years) and older children (i.e., 13-18 years).

METHODS

Four focus groups were conducted (n = 19); two with parents of younger children, and two with parents of older children. A semi-structured interview guide was developed and interviews were recorded and transcribed. Reflexive thematic analysis was performed using NVivo 1.4.

RESULTS

Most parents mentioned practical reasons like saving time and money, as well as inspiration, as reasons to choose a home-delivered meal box. Also, tastiness and menu variation were often mentioned as determining factors by both parent groups. However, a few parents stated to stop using the meal boxes because of returning menus or too small portion sizes. Meal box providers were chosen based on the price, the freshness and the quality of the products. Moreover, positive effects on parents' perceived cooking skills and knowledge were reported. Also, some parents mentioned positively changed attitudes towards vegetarian dishes. Lastly, parents reported healthier eating due to more appropriate portion sizes and more vegetables. A prominent difference between parent groups was that older children played a role in continuing the use of meal boxes, and helped to prepare the meals (contrary to younger children).

CONCLUSIONS

Home-delivered meal boxes might be promising to enhance families' meal practices. This study could inform social marketeers and health promotors to adopt an optimal strategy to reach families.

Combining participatory action research with intervention mapping to develop and plan the implementation and evaluation of a healthy sleep intervention for adolescents

Background

Adolescents' sleep deteriorated over the last decades, urging the need to develop effective interventions. Using participatory action research (PAR) is a promising and unique approach to target adolescents' sleep. This study aims to describe the process and results of combining PAR and intervention mapping (IM) to guide future researchers on developing and planning of the implementation and evaluation of interventions promoting healthy sleep in adolescents.

Methods

In each of three intervention schools (two with general and technical education and one with technical and vocational education), an action team including adolescents (age 13- 15 years, n=max. 12) and a researcher was composed to develop and plan the intervention. During weekly sessions (n=ranging from 23 to 34 per school), the action team went through the six steps of IM. A short PAR was performed with parents (n=7) to develop parental intervention components.

Results

Combining PAR and IM resulted in interventions focusing on the importance of healthy sleep, regular sleep patterns and associated behaviors: screen behaviors, physical activity, dietary behavior and relaxation. Several differences in the participatory process (i.e. more guidance needed during brainstorms in the vocational/technical school) and developed intervention (i.e. less intrusive intervention components in the vocational/technical school) were observed between schools.

Conclusion

Combining PAR with IM resulted in more extensive interventions than other existing school-based sleep interventions. Future studies should investigate whether a participatory developed sleep intervention could be transferred to another setting using a shorter participatory process.

Determinants of caregiving grandparents' physical activity and sedentary behavior: a qualitative study using focus group discussions

BACKGROUND

Evidence on the factors influencing physical activity (PA) and sedentary behavior (SB) in middle-aged and older adults taking care of their grandchild(ren) is limited, even though this knowledge seems imperative when considering the unique relationship between grandparents and their grandchild(ren) as well as the rising popularity of intergenerational interventions targeting these energy-expenditure related behaviors. Therefore, this explorative qualitative study aimed to identify the determinants of PA and SB levels among Flemish caregiving grandparents in the presence of their grandchild(ren) aged between 0-5 years.

METHODS

Six online focus group discussions were conducted via Microsoft Teams, all of which were audio- and videotaped with permission granted by the participating grandparents. In total, nine caregiving grandfathers and 28 caregiving grandmothers (overall mean age = 60.9 ± 4.1y) participated in this study. An inductive content analysis approach was used to derive subcategories, categories and themes from the verbatim transcribed data using NVivo R1.

RESULTS

Caregiving grandparents' levels of PA and SB were both influenced by personal determinants (e.g., physical health, grandparental perceptions and responsibilities), interpersonal determinants (e.g., characteristics of the grandchild(ren), such as age-related physical/motor development and family interaction), and environmental determinants (e.g., weather and seasonal circumstances). PA levels of caregiving grandparents were further affected by additional personal determinants (e.g., age of the grandparent, planning and location) and interpersonal determinants (e.g., characteristics of the grandchild(ren), such as new experiences of the grandchild(ren)). Additionally, some personal determinants (e.g., perception of educational value) and interpersonal determinants (e.g., characteristics of the grandchild(ren), such as age-related cognitive development and health of the grandchild(ren)) were strictly mentioned to influence caregiving grandparents' SB.

CONCLUSIONS

Acknowledging the unique relationship between grandparents and their grandchild(ren), the current study identified specific factors determining grandparents' PA and SB levels during the provision of grandchild care. Besides, it turned out of importance to take the interplay between the different determinants into account. Especially, for those grandparents with older grandchild(ren), within the studied 0-5 years age range, more attention should be paid to grandchild characteristics as part of the interpersonal determinants when setting up interventions to improve levels of PA and SB in caregiving grandparents.

What does the general public know about palliative care? A population-based survey

OBJECTIVES

The need for public education on palliative care has been widely argued for. To develop effective educational strategies, a stronger evidence base is needed on what exactly is known and unknown about palliative care as well as what the differences are between subgroups.

METHODS

We conducted a cross-sectional population-based survey. Mail questionnaires were sent to a random sample of 4400 citizens (aged ≥16 years) within 4 municipalities in Flanders, Belgium. The Palliative Care Knowledge Scale (PaCKS) was used to measure knowledge. Associations between knowledge and sociodemographics and various experiential factors were tested, as well as the congruence between actual and self-perceived knowledge scores.

RESULTS

Response was obtained from 2008 (45.6%) citizens. The mean PaCKS score was 7.87 (SD 3.41; range 0-13) with the highest proportion (84.7%) correctly answering that palliative care is not specifically for older adults and the lowest (32.1%) correctly answering that improving the ability to participate in daily life is a palliative care goal. Being aged between 30 and 59, non-religious, more highly educated, having professional healthcare experience and knowing palliative care through personal experience were significantly associated with higher knowledge, while sex and informal caregiving experience were not. 52.4% self-perceived their knowledge as lower than it actually was.

CONCLUSIONS

While the general public seems to be familiar with some basic concepts of palliative care, several key aspects remain unknown. Educational strategies, with suggested potential for community-based and experience-based approaches, may need to focus specifically on these aspects and not just on the broader palliative care concept.

The role of the perceived environment for recreational walking among adults in socioeconomically disadvantaged situations: A study using walk-along interviews

Background

Persons in socioeconomically disadvantaged situations (PSEDS) are generally less likely to engage in recreational walking (RW) compared to higher socioeconomic groups and are often more dependent on their local environment. Studies on RW have primarily focused on the role of the built environment for the general adult population and the older population in urban areas. The aim of this study is to qualitatively identify the perceived environmental factors affecting RW among PSEDS in peri-urban areas.

Methods

In two peri-urban municipalities in Belgium, walk-along interviews were conducted until data saturation with a purposeful convenience sampling of 38 PSEDS (25-65y/o) to identify local environmental factors affecting RW. A subsample of 22 participants joined a focus group (n = 4) to categorize the identified factors into environmental types (physical, sociocultural, political, and economic) of the Analysis Grid for Environments Linked to Obesity (ANGELO) framework. The interviews were transcribed and analyzed thematically using Maxqda 2022.0.

Results

The information environment (dissemination, retrieving and understanding of information) was added to the ANGELO framework, highlighting the importance of digital literacy. Availability and accessibility of well-maintained walking surfaces, toilets, street lighting and seating options (physical environment), social support, dog-ownership, stigmatization, social isolation, and a sense of belonging (sociocultural environment) and indirect costs (economic environment) were identified as important environmental factors in RW among PSEDS. The identified political and economic factors are intertwined with the other environments.

Conclusions

Perceived environmental factors affect RW among PSEDS and peri-urban settings offer specific challenges. Local governments should incorporate citizen perception into decision-making processes to create supportive environments that have the potential to promote RW among PSEDS in a peri-urban setting.

Study design: The social wellbeing of newly-arrived adolescent migrants in reception education in Flanders (socNAMs)

AIMS

socNAMs provides a comprehensive and comparative dataset for researchers to identify how students' recent migration and their school setting relates to their social wellbeing, particularly regarding their feelings of loneliness. Results: This study design article delineates a quantitative cross-sectional research study (socNAMs) which successfully developed three questionnaires that were administered with unique and hard to reach populations, newly-arrived adolescent migrants (NAMs) and school staff offering reception education in Flanders, Belgium.

METHODS

At the individual level, socNAMs collected information on: (1) socio-demographic variables of NAMs; (2) migration and family context; (3) social relationships; (4) school experiences; (5) self-perceived wellbeing (physical and social); and (6) experiences with discrimination. The questionnaire developed for NAMs is available in 16 languages. To gain a further understanding of the impact of the school environment on NAMs, socNAMs collected contextual information primarily concerning school social capital by including data collected from teachers and reception-class coordinators. The final sample included 1379 NAMs, 50 teachers and 26 reception-class coordinators, from 35 schools offering reception education.

CONCLUSIONS

In this article, we present the rationale for this study, the methodology of sampling and recruitment, the development and content of the questionnaires, some preliminary descriptive results and the strengths and limitations of the study. Future empirical studies will address the research aims outlined in this protocol paper. In addition, we highlight the opportunities that the dataset provides for advancing research regarding the social wellbeing of NAMs in varying school and national contexts.

Experiences of Men With Prostate Cancer Participating in a Clinical Pathway With a Supervised Group-based Exercise Program to Combat Androgen Deprivation-Induced Side Effects: A Qualitative Focus Group Study

OBJECTIVES

A clinical pathway in daily practice improved implementation of evidence-based strategies for the management of androgen deprivation-induced side effects in men with prostate cancer. This study aimed to explore patients' expectations and reasons to start with the clinical pathway; explore patients' experiences and attitudes toward the pathway; and identify key pathway ingredients and examine patients' attitudes about a possible transition toward the home environment after a hospital-based pathway participation.

DATA SOURCES

Focus group interviews were conducted through purposeful sampling, consisting of former and current participants of the clinical pathway at Ghent University Hospital. Data was audiotaped and transcribed verbatim, coded in NVivo12, and thematically and inductively analyzed through constant comparisons.

CONCLUSION

Men with prostate cancer have positive experiences toward the use of a holistic multidisciplinary approach (ie, clinical pathway) to combat androgen deprivation therapy-induced side effects in practice. Patients identified several key ingredients of the pathway, such as peer support, physiotherapist involvement, and availability of a multidisciplinary team. Patients were, however, reluctant to continue the exercise component at home because of negative attitudes toward a public gym, practical issues, absence of known facilitators, and other priorities.

IMPLICATIONS FOR NURSING PRACTICE

Referral by a health care provider remains an important motivator for pathway participation. Peer support, physiotherapist involvement, and availability of a multidisciplinary team are crucial components of the clinical pathway and should be taken into account when developing and implementing similar pathways to increase program uptake in daily practice.

Using behavioral theories to study health-promoting behaviors in palliative care research

BACKGROUND

Behavioral theories are often used to better understand and change health-promoting behaviors and develop evidence-based interventions. However, researchers often lack of knowledge on how to use these theories in palliative care and people confronted with serious illness. Clear examples or guidelines are needed.

AIM

To describe how behavioral theories can be used to gain insight into critical factors of health-promoting behavior in seriously ill people, using a case example of "starting a conversation about palliative care with the physician" for people with incurable cancer.

METHODS

We used a health promotion approach. Step 1: We chose a theory. Step 2: We applied and adapted the selected theory by performing interviews with the target population which resulted in a new behavioral model. Step 3: We operationalized the factors of this model. An expert group checked content validity. We tested the questionnaire cognitively. Step 4: We conducted a survey study and performed logistic regression analyses to identify the most important factors.

RESULTS

Step 1: We selected the Theory of Planned Behavior. Step 2: This theory was applicable to the target behavior, but needed extending. Step 3: The final survey included 131 items. Step 4: Attitudinal factors were the most important factors associated with the target behavior of starting a conversation about palliative care with the physician.

CONCLUSIONS

This paper describes a method applied to a specific example, offering guidance for researchers and practitioners interested in understanding and changing a target behavior and its factors in seriously ill people.

Intervention strategies to promote healthy and sustainable food choices among parents with lower and higher socioeconomic status

BACKGROUND

A global shift towards more healthy and sustainable diets is necessary for the prevention of obesity and chronic diseases, as well as for the growing pressure on our ecosystems. Given that parents are important actors in affecting dietary behaviors of their children, developing intervention strategies targeting families and their practices is promising to reach positive behavior change among children. Also, it is important to tailor these interventions to the needs of parents with different socioeconomic statuses (SES), given that health inequalities continue to grow. This study aims to investigate perspectives of lower and higher SES parents on the usability and acceptability of various innovative intervention strategies.

METHODS

Fourteen focus groups and four individual interviews (n = 78, n_lowerSES = 17; n_higherSES = 61) were conducted in Belgium. A semi-structured interview guide was used to facilitate the discussions. The interviews were recorded, transcribed, and analyzed via thematic content analysis using NVivo.

RESULTS

To encourage healthy and sustainable food choices, interventions via online food shopping platforms and nudging strategies in grocery stores were mostly cited by higher SES parents, but these were less applicable for lower SES parents as they buy less online and mainly consider the price of products. Mobile applications that provide inspiration for healthy and sustainable recipes and easily accessible shopping lists received moderate support among lower and higher SES parents. Furthermore, both lower and higher SES parents showed interest in meal boxes delivered at home, but lower SES parents have not yet tried such meal boxes because of their higher prices. Still, both groups of SES parents mentioned many advantages of these meal boxes, such as the convenience and time-saving component, as well as the cooking inspiration aspect.

CONCLUSION

Our study reveals the preferences of lower and higher SES parents for practical intervention strategies, providing insight in what features these strategies should have to be acceptable and useful. Hence, the findings can inform the development of a tailored family-based intervention strategy to improve parental food choices in favor of increased health and sustainability.

Recreational walking and the perceived local environment among socioeconomic disadvantaged adults

Background

Insufficient physical activity (PA) is a risk factor for obesity and non-communicable diseases and seems more prevalent among socioeconomically disadvantaged (SED) adults. Recreational walking (RW) is an important type of leisure time PA which can be done for free and without specific equipment or facilities. Environmental factors influencing PA may be particularly important for SED adults who are more reliant on their direct environment. The objectively measured environment is not always congruent with the perception of residents, and this may differ by socioeconomic group. This study aims to identify the local environmental factors important for RW as perceived by SED adults.

Methods

This study is part of the CIVISANO project. Purposeful convenience sampling was used to recruit 38 SED adults (25-65 y/o) in two Flemish semi-urban municipalities. Individual walk-along interviews have been performed in the participants’ neighborhood. 20 participants joined the focus group discussion (n = 4) that were intended for member checking, to categorize identified environmental factors and to identify local actions to promote recreational walking. MaxQDA was used for content analysis.

Results

The way the environment is perceived by SED adults plays an important role in their RW behavior. Results demonstrate the interrelation of different environmental types (physical, sociocultural, economic, political and information) and sizes (micro, meso, macro). Improving communication and knowledge transfer, stimulation of physical, sociocultural, and economic accessibility, and promotion of physical and social safety are identified most important action points for the local government to facilitate RW.

Conclusions

Our findings indicate that the perceived local environment can play an important role in promoting RW among SED adults. Future studies should investigate if changes in these environments and in residents’ perception lead to changes in RW behavior of SED adults.

Key messages

Individual and food environment factors associated with the diet of disadvantaged adults in Flanders

Background

Health inequalities partially remain due to differences in diet between socioeconomic groups. Examining the association between socio-ecological factors and the diet of socioeconomically disadvantaged (SED) individuals can enhance the development of interventions to decrease health inequalities.

Methods

In total, 278 SED adults residing in two Flemish municipalities completed a survey addressing sociodemographics, diet, health and their perceptions of the food environment. The objective food environment was examined by assessing food retailer information in street network-based buffers of 500m and 1000m around participants’ addresses. Linear regression was used to test assumptions.

Results

Individual factors such as poor subjective health (OR0.58;CI 0.34-0.97), food insecurity (OR0.60;CI 0.38-0.94) and living alone (OR0.86;CI 0.75-0.98) were negatively associated with healthy dietary habits such as daily fruit and vegetable (FV) consumption. Positive perceptions on the availability of FV were positively associated (OR1.09;CI 1.02-1.17) with daily FV consumption. Objective food environmental factors showed a stronger association with unhealthy dietary habits. A greater amount of retailers within 1000m walking distance was negatively associated with fast-food (OR0.96;CI 0.94-0.99) and sugar-sweetened beverages (SSB) consumption (OR0.93; CI 0.88-0.98). More supermarkets within 500m distance was negatively associated (OR0.77;CI 0.58-0.97) with SSB consumption, while more convenience stores within a 1000m distance was positively associated (OR1.48;CI 1.17-1.88) with SSB consumption.

Conclusions

Our findings suggest that factors associated with the diet of SED adults differ according to food and drink items. Interventions focused on this population should take these differences into account.

Key messages

The CIVISANO protocol: a mixed-method study about the role of objective and perceived environmental factors on physical activity and eating behavior among socioeconomically disadvantaged adults

BACKGROUND

Overweight and obesity have a strong socioeconomic profile. Unhealthy behaviors like insufficient physical activity and an unbalanced diet, which are causal factors of overweight and obesity, tend to be more pronounced in socioeconomically disadvantaged groups in high income countries. The CIVISANO project aims to identify objective and perceived environmental factors among different socioeconomic population groups that impede or facilitate physical activity and healthy eating behavior in the local context of two peri-urban Flemish municipalities in Belgium. We also aim to identify and discuss possible local interventions and evaluate the participatory processes of the project.

METHODS

This study (2020-2023) will use community-based participatory tools, involving collaborative partnerships with civic and stakeholder members of the community and regular exchanges among all partners to bridge knowledge development and health promotion for socioeconomically disadvantaged citizens. Furthermore, a mixed-methods approach will be used. A population survey and geographic analysis will explore potential associations between the physical activity and eating behaviors of socioeconomically disadvantaged adults (25-65 years old) and both their perceived and objective physical, food and social environments. Profound perceptive context information will be gathered from socioeconomically disadvantaged adults by using participatory methods like photovoice, walk-along, individual map creation and group model building. An evaluation of the participatory process will be conducted simultaneously.

DISCUSSION

The CIVISANO project will identify factors in the local environment that might provoke inequities in adopting a healthy lifestyle. The combination of perceived and objective measures using validated strategies will provide a robust assessment of the municipality environment. Through this analysis, the project will investigate to what extent community engagement can be a useful strategy to reduce health inequities. The strong knowledge exchange and capacity-building in a local setting is expected to contribute to our understanding of how to maximize research impact in this field and generate evidence about potential linkages between a health enhancing lifestyle among socioeconomically disadvantaged groups and their physical, food and social environments.

Identification of the most important factors related to people with cancer starting a palliative care conversation: A survey study

OBJECTIVE

A late conversation about palliative care needs can lead to suboptimal care in the final months/weeks of life. Insight into factors related to patients' communication about palliative care is needed. This study aims to identify the factors associated with starting/intending to start a conversation about palliative care with the physician.

METHODS

We performed a cross-sectional interviewer-administered survey among people with incurable cancer. Purposive sampling was used, taking into account theoretically relevant heterogeneity. The questionnaire was developed based on the theory of planned behavior. Uni- and multivariable logistic regression analyses were performed.

RESULTS

Out of 80 participants, ten (13%) started the palliative care conversation and 18 (23%) intended to do so. People holding a positive attitude towards starting/intending to start the conversation (OR 4.74; 95%CI 2.35-9.54), perceiving more benefits of it (OR 2.60; 95%CI 1.37-4.96) and perceiving a positive attitude towards the behavior in family/friends (OR 2.07; 95%CI 1.26-3.41) and the physician (OR 2.19; 95%CI 1.39-3.45) were more likely to start/intend to start a palliative care conversation; people perceiving more disadvantages (OR 0.53; 95%CI 0.32-0.87) and barriers (OR 0.31; 95% CI 0.15-0.63) were less likely to do so. These factors explained 64% of the variance.

CONCLUSIONS

Our findings show that psychological and perceived socio-environmental factors, particularly patients' attitudes, are associated with starting a conversation about palliative care. Theory-based interventions targeting these strong associations might have a high potential to empower people with cancer to take the initiative in communication about palliative care and tot improve timely initiation of palliative care. This article is protected by copyright. All rights reserved.

Physical Activity and Health-related Quality of Life from Diagnosis to One Year After Radical Cystectomy in Patients with Bladder Cancer: A Longitudinal Cohort Study

BACKGROUND: Emerging evidence shows a positive impact of physical activity (PA) on health-related quality of life (HRQoL) in cancer patients. However, longitudinal evidence on PA and HRQoL in patients with bladder cancer (BC) undergoing radical cystectomy (RC) is lacking. OBJECTIVES: To investigate PA levels, HRQoL outcomes and their relationship from diagnosis to one year after RC in BC patients. METHODS: A longitudinal cohort study in 90 BC patients was conducted at Ghent and Leuven University Hospitals between April 2017 and December 2020. The Godin Leisure-Time Exercise Questionnaire (GLTEQ) and the EORTC QLQ-C30 and BLM30 were used to measure PA and HRQoL, respectively, before RC, one, three, six and twelve months after RC. Linear mixed models were used for statistical analyses. RESULTS: The majority was physically inactive before RC (58%), at month one (79%), three (53%), six (61%) and twelve (64%). Among (moderately) active patients, light-intensity activities (mainly walking) were important contributors to the total amount of PA. Clinically important and low HRQoL outcomes in different domains were identified with lowest scores at diagnosis and one month after RC. Active patients before RC have better physical functioning (mean difference (MD) -22.7, standard error (SE) 8.7, p = 0.011), global health status (MD -15.9, SE 6.9, p = 0.023) and fatigue (MD 19.9, SE 9.5, p = 0.038) one month after RC, compared to inactive patients. Active patients at month have better physical functioning (MD -16.2, SE 6.9, p = 0.023) and sexual functioning (MD -16.8, SE 5.4, p = 0.003; MD -13.5, SE 5.5, p = 0.017) at month six and twelve, respectively, compared to inactive patients. CONCLUSIONS: Higher PA levels are associated with better HRQoL outcomes for BC patients undergoing RC. The data suggests that PA interventions could be an asset to improve BC patients’ HRQoL, but should be tested in future trials.

Determinants of healthy and sustainable food choices in parents with a higher and lower socioeconomic status: A qualitative study

Establishing healthy and sustainable dietary habits in childhood is necessary for the prevention of obesity and chronic diseases, as well as for the growing pressure on our ecosystems. Considering that parents are the most important actors in affecting dietary behaviors of their children, and that there is a social gradient for obesity, this study aims to investigate differences in determinants of both healthy and sustainable food choices among parents with a higher and lower socioeconomic status (SES). Fifteen focus groups and four individual interviews (n = 78) with parents of children aged 6 to 12 were conducted in Belgium. A semi-structured interview guide based on a socioecological model was used. The interviews were recorded, transcribed and thematic content analysis was performed using NVivo 1.0. Findings indicate some differences in determinants of healthy and sustainable food choices among higher and lower SES parents. Generally, higher SES parents reported more barriers for sustainable than for healthy food choices. They showed more positive attitudes towards healthy than sustainable food choices, and reported low knowledge and self-efficacy to make sustainable food choices, while a lack of time was a barrier to cook both healthy and sustainable meals. Lower SES parents, like higher SES parents, showed more positive attitudes towards healthy food choices. They reported high prices and a lack of inspiration and skills as barriers for both food choices, while also being influenced by their cultural backgrounds. For both SES types of parents, children had a strong influence on their healthy and sustainable food choices. The findings suggest socioeconomic differences in determinants of healthy and sustainable food choices. Hence, these differences should be taken into account when developing intervention strategies to improve food choices in parents.

What do adults want in parks? A qualitative study using walk-along interviews

Background

Parks provide opportunities for physical activity and social interaction and are critical for enhancing public health. It is therefore important to better understand the needs and preferences of park features among adults to help park designers to create parks that optimise use. This qualitative study provided an in-depth examination of factors and characteristics that influence visitation, park-based physical activity, and social interaction among adults (19–64 years). We also explored perceptions of parks and park use and impacts of COVID on park usage and needs.

Methods

Participants (n = 27, 40.4 years [+ 11.9], 70% female) were interviewed from 2017 to 2020 while walking through one of eight diverse parks located in varying socioeconomic areas of metropolitan Melbourne, Australia. Participants were prompted to discuss their experiences, opinions and preferences regarding park features. All interviews were transcribed verbatim and analysed using NVivo 12 software.

Results

Park features and characteristics highly valued for visitation related to aesthetics and atmosphere, including trees, gardens, spaciousness, and water features. Features most valued for physical activity included walking and bike tracks, basketball rings, nice aesthetics, and sports walls. Features most valued for social interaction included seating and tables, and picnic/barbecue areas.

Conclusions

This study highlights features and characteristics that may be important to prioritise, to encourage active and social park visits among adults. This evidence will help policy and decision makers, urban planners, landscape architects, and local, state, and national government organisations to create parks that support adults to lead healthy and active lives. Future research should examine the relative importance of the features identified in this study to inform future park design/redesign.

Trends in material and non-material inequalities in adolescent health and health behaviours: A 12-year study in 23 European countries

Information on trends in adolescent health inequalities is scarce but the available evidence suggests that inequalities are increasing. Prior studies describe associations between material resources of socioeconomic status (SES) and health, while information on non-material SES resources and inequalities in health behaviours is lacking. To improve current understandings of evolutions in adolescent health inequalities, we examined how material and non-material SES resources were associated with changes in selected health outcomes (life satisfaction, physical and psychological symptoms) and health behaviours (physical activity, screen time, breakfast, fruit, vegetables, sweets and soft drinks consumption and alcohol and tobacco use) over a 12-year period. Repeated cross-sectional data came from the 2002, 2006, 2010 and 2014 waves of the Health Behaviour in School-aged Children (HBSC) survey from 23 European countries (n = 480,386). Measures of family affluence and occupational social class were used as indicators of material and non-material SES resources respectively. Regression-based slope indices of inequality indicated that absolute material and non-material inequalities remained stable from 2002 to 2014 in all health outcomes, except for life satisfaction for which a decrease in material inequalities was found between the highest and lowest affluence group (0.81 to 0.68 difference; p < 0.001). In terms of health behaviours, material inequalities decreased in screen time between highest and lowest affluence groups (0.53 to 0.34 h/day difference; p < 0.001), fruit (odds ratio [OR] 1.89 to 1.72 lower odds; p = 0.0088) and soft drinks consumption (OR 1.36 to 1.13 lower odds; p < 0.001) and remained stable in all others. Non-material inequalities increased in all health behaviours (except for sweets consumption) between highest and lowest occupational social class groups: physical activity (0.16 to 0.24 h/day difference; p = 0.0071), screen time (-0.41 to -0.58 h/day difference; p < 0.001), breakfast (0.21 to 0.51 day/week difference; p < 0.001), fruit (OR 1.23 to 1.48 higher odds; p < 0.001), vegetables (OR 1.39 to 1.74 higher odds; p < 0.001) and soft drinks consumption (OR 0.59 to 0.43 lower odds; p < 0.001) and alcohol (OR 0.99 to 0.85 lower odds; p = 0.0420) and tobacco use (OR 0.71 to 0.59 lower odds; p = 0.0183). In summary, non-material inequalities in most health behaviours increased, whereas material inequalities in adolescent health and health behaviours remain stable or decreased. Policies and interventions may consider non-material SES components as these can help in reducing future health inequalities.

Determinants of Changes in Women's and Men's Physical Activity and Sedentary Behavior across the Transition to Parenthood: A Focus Group Study

BACKGROUND

Becoming a parent may cohere with drastic changes in physical activity (PA) and sedentary behavior (SB). A clear understanding of determinants of changes in PA and SB during pregnancy and postpartum is needed to facilitate the development of tailored family-based interventions.

METHODS

Thirteen focus group discussions targeting determinants of changes in PA and SB behavior were conducted, involving a total of 74 expecting and first-time parents. A semi-structured question guide was used to facilitate the discussions.

RESULTS

Four main levels of determinants were identified: the individual (including psychological, situational and biological determinants), interpersonal, environmental and policy level. Some determinants were mentioned to be a barrier (e.g., "barriers to self-care") while others were a facilitator (e.g., "weight control"). Determinants were related to both PA and SB and applicable during pregnancy as well as postpartum (e.g., "self-regulation"), or only related to one behavior and/or one period (e.g., "feeding baby"). Some were described by both parents (e.g., "parenthood perceptions"), whereas others were mentioned by women (e.g., "PA knowledge") or men (e.g., "time opportunities") only.

CONCLUSIONS

Focus should be given to interventions aimed at improving parents' self-regulation skills and support on how to cope with interpersonal and situational constraints as well as parenthood perceptions.

The Online Representation of Palliative Care by Practice, Policy, and Advocacy Organizations: Definitional Variations and Discursive Tensions

Negative beliefs and a lack of clarity surrounding the meaning of palliative care have been widely reported as obstacles to its uptake. Information available to the public possibly contributes to this. A descriptive and discourse-theoretical analysis was conducted of information spread online by palliative care policy, advocacy, and practice organizations. Discrepancies were found in the way palliative care was defined in relation to curative, end-of-life, terminal, and supportive care. Beyond these definitional variations, meaning was generated through the representation of palliative care as a culture, connected to total care, compassion, and openness. Tensions arose around the concepts of autonomy, a natural death, and an emphasis on the quality of life away from death and dying. Overall, this study showed that the online information of palliative care is a potential source of confusion and might even contribute to its stigmatization. Insights are provided that may help improve clarity toward the public.

The perceived obesogenic environment survey in the Flemish municipal context – the CIVISANO project

Background

The prevalence of obesity worldwide has been steadily increasing. This has generated an uptake in research determining the cause of obesity. One of the primary drivers that have been identified is the “obesogenic environment', which is an environment that contains features that increase excess weight in individuals or populations. Obesogenic environments are unevenly distributed with socio-economically disadvantaged neighbourhoods being more affected.

Methods

This survey is part of the CIVISANO (‘Community-based participatory research to tackle the disparities in health-enhancing lifestyle within the municipality environment') project, which will be conducted in two municipalities. Respondents will be socio-economically disadvantaged adults between 25- and 65-years old. To gain information on individual characteristics and perceptions of the obesogenic environment, residents will be invited to complete a survey. Since it is known that socio-economically disadvantaged respondents are difficult to reach a non-random active recruitment approach will be applied. The following variables are included in the survey: sociodemographic information, subjective health and anthropometrics, dietary habits, food security and physical activity. Items from the SPOTLIGHT project survey and NEMS-P survey were added to assess respondent's perceptions of features of the obesogenic environment. Additional variables on individual characteristics were based on items from the Belgian National Health Interview Survey of 2019.

Results

Through the survey, we expect to gain insight into the perceptions of socio-economically disadvantaged adults on obesogenic features of their local environment. Initial results from the survey will be available in the upcoming months.

Conclusions

The construction of instruments to assess the context-specific features, which can be compared with objective measurements, can increase our knowledge of contextual determinants of the obesogenic environment.

Key messages

The first Flemish survey that focuses on perceptions of socio-economically disadvantaged adults on obesogenic features of their local environment in the municipal context. Gaining a better understanding of the local obesogenic environment creates an opportunity to promote and strengthen the development of effective local interventions to build healthier environments.

Understanding children's preference for park features that encourage physical activity: an adaptive choice based conjoint analysis

Background

Parks are a key setting for physical activity for children. However, little is known about which park features children prefer and which features are most likely to encourage them to be active in parks. This study examined the relative importance of park features among children for influencing their choice of park for engaging in park-based physical activity.

Methods

Children (n = 252; 8-12 years, 42% male) attending three primary schools in Melbourne, Australia completed a survey at school. They were required to complete a series of Adaptive Choice-Based Conjoint analysis tasks, with responses used to identify the part-worth utilities and relative importance scores of selected park features using Hierarchical Bayes analyses within Sawtooth Software.

Results

For the overall sample and both boys and girls, the most important driver of choice for a park that would encourage them to be active was presence of a flying fox (overall conjoint analysis relative importance score: 15.8%; 95%CI = 14.5, 17.1), followed by a playground (13.5%; 95%CI = 11.9, 15.2). For the overall sample, trees for climbing had the third highest importance score (10.2%; 95%CI = 8.9, 11.6); however, swings had 3rd highest importance for girls (11.1, 95%CI = 9.3, 12.9) and an obstacle course/parkour area had the 3rd highest importance score for boys (10.7, 95%CI = 9.0, 12.4). For features with two levels, part-worth utility scores showed that the presence of a feature was always preferred over the absence of a feature. For features with multiple levels, long flying foxes, large adventure playgrounds, lots of trees for climbing, large round swings, large climbing equipment, and large grassy open space were the preferred levels.

Conclusion

To ensure parks appeal as a setting that encourages children to engage in physical activity, park planners and local authorities and organisations involved in park design should prioritise the inclusion of a long flying fox, large adventure playgrounds, lots of trees for climbing, large round swings and obstacle courses/parkour areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01203-x.

Important park features for encouraging park visitation, physical activity and social interaction among adolescents: A conjoint analysis

Little is known about what park features adolescents perceive as most important for encouraging them to visit and be active and social in parks. This study examined the relative importance of park features for encouraging these behaviours among adolescents and explored differences according to gender and frequency of visitation. Adolescents were recruited from secondary schools in diverse areas of Melbourne, Australia. In Phase 1 (2018-2019), participants [n = 222; 14.0 years (SD 1.1); 46% female] rated photographs of 40 park features in an online survey, indicating the degree to which each feature encouraged them to visit, and be active and social in the park. In Phase 2 (2019-2020), the top ten-rated features from Phase 1 for each outcome (overall and by gender and frequency of visitation) were presented in Adaptive Choice-Based Conjoint tasks to another sample of participants [n = 244; 14.7 years (SD 1.3); 46% female]. The most important feature for encouraging visitation was large swings; for physical activity was sports courts; and for social interaction was a café. Grassy open space was important for all behaviours, and preferred park features varied among sub-groups. The results highlight which park features park planners and designers should prioritise to support active and social park use among adolescents.

Mental Health in Adolescents with a Migration Background in 29 European Countries: The Buffering Role of Social Capital

Previous research is inconclusive as to whether having an immigration background acts as a risk factor for poor mental health in adolescents, and furthermore, what contribution the social context in which adolescents grow up may make. To address these questions, the current study uses an integrative resilience framework to investigate the association between immigration background and adolescent mental health, and the moderating role of social capital at the individual, the school, and the national level. The study uses data gathered from nationally representative samples of adolescents aged 11, 13, and 15 years (N_girls = 63,425 (52.1%); M_age = 13.57, SD = 1.64) from 29 countries participating in the 2017/18 Health Behaviour in School-aged Children (HBSC) study. Data analysis reveals that first- and second-generation immigrants reported higher levels of life dissatisfaction and psychosomatic symptoms than their native peers, and that this association varied across schools and countries. In addition, social capital was found to moderate the association between immigration background and adolescent mental health. Individual-level social support from peers and family and national-level trust protected against poor mental health in adolescents with an immigration background, while the opposite was true for individual-level teacher support. Supportive teacher-student relationships were found to provide more protection against poor mental health for native adolescents than for immigrant adolescents. Our findings indicate the importance of taking an ecological approach to design interventions to reduce the negative effects of having an immigration background on adolescent mental health.

The impact of non-residential grandchild care on physical activity and sedentary behavior in people aged 50 years and over: study protocol of the Healthy Grandparenting Project

Background

Finding effective ways to support people aged > 50 years to develop adequate levels of physical activity and sedentary behavior is necessary as these behaviors are positively related to the maintenance of functional independence and health-related quality of life. Given the widespread provision of grandparental child care, examining its impact on grandparents’ energy-expenditure related behavior in the broader context of health is imperative. Therefore, the Healthy Grandparenting Project will aim to investigate the levels of physical activity and sedentary behavior, body composition and health-related quality of life in grandparents caring for their grandchildren and to compare these outcomes with non-caregiving grandparents and older adults without grandchildren, both momentarily and over time. An additional purpose is to identify possible predictors of potential changes over time.

Methods

A prospective cohort study will run over a period of 2 years, including three test occasions with a one-year time interval in between (T0 = baseline, T1 = 12 months, T2 = 24 months). A total of 276 participants will be recruited in Flanders through non-probability quota sampling (50–50% men-women), of which 92 caregiving grandparents, 92 non-caregiving grandparents and 92 non-grandparents. All three subsamples will be matched for age and sex. At each test occasion, anthropometric and body composition measurements will be determined. Participants’ levels of physical activity and sedentary behavior will be assessed both objectively and subjectively by means of accelerometry and self-report questionnaires. Information about their grandchildren and the provided grandparental care (if applicable) as well as their health-related quality of life will also be assessed using self-report questionnaires. Mixed modelling will be used to identify differences in physical activity, sedentary behavior, body composition and health-related quality of life between the subsamples at baseline, as well as to evaluate and compare changes in energy-expenditure related behavior over time between subsamples and to identify predictors of the detected changes.

Discussion

The Healthy Grandparenting Project is an innovative study examining the levels of physical activity and sedentary behavior in caregiving grandparents, non-caregiving grandparents and non-grandparents. Obtained results will help in the development of campaigns to maintain/improve health in adults at a more advanced age.

Trial registration

clinicaltrials.gov, Identifier: NTC04307589. Registered March 2020.

Development of a pre- and postoperative physical activity promotion program integrated in the electronic health system of patients with bladder cancer (The POPEYE study): An intervention mapping approach

INTRODUCTION

Uptake of sufficient physical activity before and after radical cystectomy is important to improve physical and psychosocial outcomes in bladder cancer (BC) patients.

METHODS

In this paper, we describe the development of an evidence-based and theory-informed intervention, guided by the steps of the Intervention Mapping approach, to promote physical activity before and after radical cystectomy in patients with BC.

RESULTS

The intervention is a home-based physical activity program. The preoperative timeframe of the intervention is 4 or 12 weeks, depending on administration of neoadjuvant chemotherapy. Postoperatively, the intervention will last for 12 weeks. The intervention consists of a digital oncological platform (DOP), several consultations with healthcare professionals, personal booklet and follow-up phone calls. DOP includes information, diaries, visual representation of progress, mailbox, videos of peers and treating physician explaining the benefits of physical activity, photo material of exercises and a walking program with an activity tracker. Individual goals will be set and will be self-monitored by the patient through DOP. Patients will receive alerts and regular feedback.

CONCLUSIONS

Intervention Mapping ensures transparency of all intervention components and offers a useful approach for the development of behaviour change interventions for cancer patients and for translation of theories into practice.

Cumbersome but desirable-Breaking the code of everyday cycling

Introduction

Cycling for transport could integrate physical activity (PA) into daily routines and potentially increase total PA levels. However, for parents with young children, most factors affecting transport mode choice tend to facilitate car use. Greater insight is necessary into reasons for (not) using sustainable transport modes in parents with young children. Therefore, the objective of this study was to explore the experiences, including motives, perceptions, attitudes, and norms, of parents of young children by using an e-bike, a longtail bike, and a traditional bike for everyday travel to the workplace, kindergarten, and the grocery store during the autumn, winter, and spring, in nine months.

Methods

Semistructured focus group interviews were conducted with 18 parents of young children residing in southern Norway. Parents were recruited through Facebook announcements and direct contact with kindergartens, selected organisations, and companies in the Kristiansand municipality. Data were analysed by systematic text condensation by using NVivo V.11.

Results

Participants’ experiences were summarised by three main themes: ‘cycling is cumbersome’, ‘cycling reflects the desirable me’, and ‘breaking the cycling code’. Time use, planning, logistics, wet and cold weather, long distances, and no cycling habit were frequently mentioned barriers, and the most notable facilitator was the children’s attitude towards cycling. In general, children loved to cycle and preferred cycling to driving. Additionally, the freedom and independence of cycling were emphasised and valued.

Conclusion

In challenging weather conditions, parents of young children may experience cycling as cumbersome but desirable, and bike access could increase the feasibility of daily cycling.

Factors related to sleep behavior in adolescents: a focus group study

Background

Adolescents' sleep behavior has deteriorated over the last decades. However, little research has been conducted into possible psychosocial factors related to this behavior, which is an important prerequisite to develop effective sleep behavior interventions. In addition, previous research showed that actively involving adolescents in the development of interventions increases the chance of effectivity and sustainability. This study examined psychosocial factors related to sleep behavior in adolescents and investigated adolescents' willingness to participate in the development of a sleep behavior intervention.

Methods

Nine focus group interviews were conducted with seventy-two students (63,9% girls, 14.8 (±1.0) years) using a standardized interview guide. Interviews were audio-recorded and thematic content analysis was performed using Nvivo 11.

Results

Adolescents had adequate knowledge of sleep hygiene and short-term consequences of sleep deficiency, but limited knowledge of sleep norms and long-term consequences. Positive attitudes towards sleep were outweighed by positive attitudes towards other behaviours such as screen time. Leisure activities, smartphones, television, schoolwork, early school time and worrying were mentioned as barriers for healthy sleep. Adolescents showed low self-efficacy towards changing their sleep behaviors and perceived a negative social norm towards sleep. Although some adolescents indicated parental rules to have a positive influence on their sleep, others indicated these sometimes provoked frustration. Finally, adolescents emphasized the importance of their participation in the development of a sleep behavior intervention at school, although adult guiding would be needed.

Conclusions

Future interventions promoting heathy sleep in adolescents could focus on psychosocial factors such as knowledge, attitudes, barriers, self-efficacy and social perceived norm and could involve adolescents in intervention development.

Key messages

Future interventions promoting heathy sleep in adolescents should in addition to knowledge, also focus on psychosocial factors such as attitudes, self-efficacy and perceived social norms. Adolescents emphasize the importance of their participation in the development of a sleep behavior intervention. This approach could be worth trying in future research.

Adolescents' sleep quality in relation to peer, family and school factors: findings from the 2017/2018 HBSC study in Flanders

PURPOSE

While a multitude of studies focused on biological and behavioral determinants of adolescents' sleep quality, a paucity of research examined the impact of social factors. The current study therefore examines the relationship between adolescents' sleep quality and peer, family and school factors.

METHODS

Data of Flemish participants in the 2017/2018 Health Behavior in School-aged Children survey (HBSC) were used, which is representative of the adolescent population (11-18 years) in Flanders. Adolescents' sleep quality was linked to individual-level data on peer relationships (i.e., peer support), family relationships (i.e., family support, perceived family wealth, caregiving responsibilities) and school relationships (i.e., teacher support, school support, school pressure) and contextual-level data on the school culture. Three-level multilevel models were fitted to account for the clustering of individuals (N = 8153) within classes (N = 769) and classes within schools (N = 177).

RESULTS

The individual-level results indicated that adolescents' sleep quality was positively related to family support, teacher support, student support and perceived family wealth. In contrast, adolescents' sleep quality was negatively related to caregiving responsibilities and school pressure. In addition, the contextual-level results pointed out that adolescents tended to report better sleep quality in less-demanding schools.

CONCLUSION

These findings highlight the need to consider social factors in promoting better sleep in adolescence.

Palliative care utilisation: family carers' behaviours and determinants-a qualitative interview study

OBJECTIVES

Most research on starting palliative care focuses on the role of healthcare services and professional carers. However, patients and their family carers may also play a role. Especially opportunities for starting palliative care might exist among family carers. This study focused on family carers by identifying their behaviours and underlying determinants that might contribute to starting palliative care.

METHODS

A qualitative study with 16 family carers of deceased persons who used palliative care was conducted using semistructured, face-to-face interviews. Constant comparison analysis was used to identify groups of behaviours that influenced starting palliative care and related determinants. The behavioural determinants were matched with concepts in existing behavioural theories. A preliminary behavioural model was developed.

RESULTS

Most reported behaviours regarding starting palliative care were related to communicating with the seriously ill person, other family members and professional carers; seeking information and helping the seriously ill person process information from professional carers; and organising and coordinating care. Determinants facilitating and hindering these behaviours included awareness (eg, of poor health), knowledge (eg, concerning palliative care), attitudes (eg, negative connotations of palliative care) and social influences (eg, important others' opinions about palliative care).

CONCLUSIONS

This study identified relevant family carers' behaviours and related determinants that can contribute to starting palliative care. As these determinants are changeable, the palliative care behavioural model that resulted from this study can serve as a basis for the development of behavioural interventions aiming at supporting family carers in performing behaviours that might contribute to starting palliative care.

Association of alcohol control policies with adolescent alcohol consumption and with social inequality in adolescent alcohol consumption: A multilevel study in 33 countries and regions

Background Previous research found inconsistent associations between alcohol control policies and socioeconomic inequality with adolescent drinking outcomes. This study expands the focus beyond individual associations to examine whether a combination of policies is related to socioeconomic inequality in adolescent drinking outcomes and whether this relationship varies across survey years. Methods Multilevel modelling of 4 waves of repeat cross-sectional survey data (2001/02, 2005/06, 2009/10, and 2013/14) from the Health Behaviour in School-aged Children (HBSC) study was carried out. The sample was composed of 671,084 adolescents (51% girls) aged 11, 13, and 15 (mean age=13.58; SD=1.65) from 33 European and North American countries/regions. The dependent variables were lifetime alcohol consumption, weekly alcohol consumption, and lifetime drunkenness. Independent variables were of three types: individual-level variables (age, sex, Family Affluence Scale, and the Perceived Family Wealth), time-level variable (survey year), and context-level variables (minimum legal drinking age, physical availability, advertising restrictions, a total alcohol policy index, and affordability of alcohol). Results The total alcohol policy index showed a negative relationship with both lifetime and weekly consumption. Higher affordability of alcohol was related to higher lifetime and weekly consumption and higher lifetime drunkenness. Family Affluence Scale was positively related to all three alcohol measures and Perceived Family Wealth was negatively related to lifetime drunkenness, with these associations increasing across survey years. The total alcohol policy index buffered the associations of Family Affluence Scale and Perceived Family Wealth with adolescent drinking outcomes. Conclusion A combination of alcohol control policies is more effective in reducing adolescent drinking outcomes than single policy measures. Reducing the affordability of alcohol stood out as the most successful single measure. Socioeconomic inequalities (i.e. higher alcohol consumption and drunkenness in adolescents with higher family affluence and higher drunkenness in adolescents perceiving their families to be poor) have persisted and even increased across survey years. A combined alcohol control policy can help in tackling them.

The perception of people with cancer of starting a conversation about palliative care: A qualitative interview study

OBJECTIVE

Communication and patient-centred care are important determinants for timely initiation of palliative care. Therefore, we aimed to understand and explain the behaviour "starting a conversation about palliative care with a professional carer" from the perspective of people with incurable cancer.

METHODS

A qualitative study using semi-structured face-to-face interviews with 25 people with incurable cancer: 13 not (yet) receiving palliative care and 12 receiving palliative care; 4 started the conversation themselves. Determinants related to the defined behaviour were matched with concepts in existing behavioural theories.

RESULTS

Both positive and negative stances towards starting a conversation about palliative care with a professional carer were found. Influencing behavioural factors were identified, such as knowledge (e.g. about palliative care), attitude (e.g. association of palliative care with quality of life) and social influence (e.g. relationship with the professional carer). We modelled the determinants into a behavioural model.

CONCLUSION

The behavioural model developed helps to explain why people with incurable cancer do or do not start a conversation about palliative care with their professional carer. By targeting the modifiable determinants of the model, promising interventions can be developed to help patients taken the initiative in communication about palliative care with a professional carer.

National-Level Wealth Inequality and Socioeconomic Inequality in Adolescent Mental Well-Being: A Time Series Analysis of 17 Countries

PURPOSE

Although previous research has established a positive association between national income inequality and socioeconomic inequalities in adolescent health, very little is known about the extent to which national-level wealth inequalities (i.e., accumulated financial resources) are associated with these inequalities in health. Therefore, this study examined the association between national wealth inequality and income inequality and socioeconomic inequality in adolescents' mental well-being at the aggregated level.

METHODS

Data were from 17 countries participating in three consecutive waves (2010, 2014, and 2018) of the cross-sectional Health Behaviour in School-aged Children study. We aggregated data on adolescents' life satisfaction, psychological and somatic symptoms, and socioeconomic status (SES) to produce a country-level slope index of inequality and combined it with country-level data on income inequality and wealth inequality (n = 244,771). Time series analyses were performed on a pooled sample of 48 country-year groups.

RESULTS

Higher levels of national wealth inequality were associated with fewer average psychological and somatic symptoms, while higher levels of national income inequality were associated with more psychological and somatic symptoms. No associations between either national wealth inequality or income inequality and life satisfaction were found. Smaller differences in somatic symptoms between higher and lower SES groups were found in countries with higher levels of national wealth inequality. In contrast, larger differences in psychological symptoms and life satisfaction (but not somatic symptoms) between higher and lower SES groups were found in countries with higher levels of national income inequality.

CONCLUSIONS

Although both national wealth and income inequality are associated with socioeconomic inequalities in adolescent mental well-being at the aggregated level, associations are in opposite directions. Social policies aimed at a redistribution of income resources at the national level could decrease socioeconomic inequalities in adolescent mental well-being while further research is warranted to gain a better understanding of the role of national wealth inequality in socioeconomic inequalities in adolescent health.

Increasing translation of research evidence for optimal park design: a qualitative study with stakeholders

Background

The design of parks is critical to ensure they are appealing, meet the needs of the community and optimise opportunities for physical activity, relaxation, exposure to nature and social interaction. There is currently a lack of understanding on how research evidence is informing park design and how to reduce the many challenges associated with research-practice-policy translation. Understanding how organisations use evidence for decision-making regarding park design is critical for reducing the research-practice-policy gap and ensuring evidence based strategies inform park design to support healthy active living. This study explored stakeholder perceptions regarding factors that influence the use of research evidence to inform park planning and design, and potential strategies to enhance effective translation of research evidence for optimal park design into policy and practice.

Methods

One-on-one in-depth interviews were conducted with 23 stakeholders within the park design, planning and management sector. Participants shared experiences regarding: influences on park development and design; current park development policies; ways to facilitate use of evidence; and priorities for future research. Interviews were recorded and transcribed verbatim and content analysis performed using NVivo 12.

Results

Research evidence is used and considered important for park planning; however, several barriers were highlighted: time and cost constraints; difficulties accessing research; and limited research relevant to specific needs. Developing partnerships between researchers and park developers and providing evidence in a more accessible format such as short summaries/reports, infographics, presentations, research updates and dedicated research databases emerged as key enablers. The main research gaps identified included research into park features to encourage visitation and cost-benefit analyses studies.

Conclusions

This research is a first step to better understand strategies to promote more effective uptake and use of evidence to inform park planning. Researchers must develop multi-sectoral collaborations and generate policy-relevant research in a readily accessible, timely and user-friendly format to ensure evidence is used to enhance park design and ultimately public health.

Cultural values and adolescents’ health inequalities in 21 European countries

Background

culture is believed to have an important impact on health and health inequalities and this may vary between countries. Empirical data are however scarce, especially in adolescent populations. We examined the impact of cultural values (emancipatory values index) on cross-national variations in adolescent health, health inequalities and evolutions in these inequalities.

Methods

individual-level data from 21 countries participating in the 2002/2006/2010/2014 waves of the Health Behaviour in School-aged Children (HBSC) study were combined with country-level data from the World Values Longitudinal Dataset (n = 416777). Multilevel linear and logistic regression analyses were performed accounting for the hierarchical data structure (individual, country-year and country level).

Results

cultural value differences between countries were weakly related to adolescents’ health and health behaviour but had a profound impact on the magnitude of inequalities. In countries characterised by a high level of emancipatory values, material (family affluence-based) inequalities in both health and health behaviours tended to be lower whereas non-material (occupational social class-based) inequalities tended to be higher, in particular for health behaviours. Preliminary results also indicated that cultural value differences between countries may play a significant role in the evolution of adolescent health inequalities.

Conclusions

our findings suggest that between-countries’ cultural value differences may partly explain cross-national variations in adolescents’ health inequalities and in the evolution of these inequalities. By identifying cultural value differences in health, health inequalities and evolutions in health inequalities, this study helps informing policies better to tackle these inequalities.

Key messages

Cultural value differences between countries have a profound impact on the magnitude of inequalities in adolescents’ health and health behaviours and on the evolution of these inequalities. Identifying cultural value differences in adolescents’ health, health inequalities and evolutions in these inequalities is necessary to inform policies better to tackle these inequalities.

The effect of nudges aligned with the renewed Flemish Food Triangle on the purchase of fresh fruits: An on-campus restaurant experiment

OBJECTIVE

This study examined the effect of nudges, inspired by the recently renewed Flemish Food Triangle, on fruit sales in a Belgian on-campus university restaurant.

METHODS

In this mixed-method real-life experiment, nudges were added weekly over a period of four consecutive weeks: placement of (1) Food Triangle posters in the restaurant, (2) 'green heart' icons above the fruit stands, and (3) substitution and (4) social norm messages at the fruit stands. During baseline (no intervention) and all intervention weeks, dessert sales were registered. Short interviews were used to ask customers about their perceptions regarding the intervention. Follow-up measurements (7 and 30 weeks later) evaluated the longer-term effectiveness, while all nudges remained in place. Dessert sales were analyzed separately for both sexes, students and staff categories (based on academic degree).

RESULTS

Compared to baseline, the combination of the Food Triangle and the green heart intervention materials in week 2 resulted in significant increases in fruit consumption across almost all subgroups. The other intervention materials used in the current study had rather limited effects in the short term. After 7 weeks of follow-up, significant fruit sale increases were established for all subgroups compared to baseline. At 30 weeks follow-up, the effect for staff B (Bachelor's degree) disappeared. The majority of the respondents (66.4%) had noticed at least one of the nudges, while only 3.4% indicated to have adjusted their dessert choice as a result of the nudges.

CONCLUSIONS

The combination of nudges was effective in the long term and increased fruit purchase in nearly all subgroups. Short interviews show that a more active approach may be needed to increase effect sizes.

From cars to bikes - The effect of an intervention providing access to different bike types: A randomized controlled trial

Introduction

We aimed to investigate whether providing parents with children in kindergarten with access to different bicycle types could influence (i) travel behavior and cycling amount, and (ii) intrinsic motivation for cycling and psychological constructs related to car use.

Methods

A randomized, controlled trial was conducted in Southern Norway from September 2017 to June 2018. In total 36 parents were recruited and randomly drawn into an intervention (n = 18) or control group (n = 18). The intervention group was in random order equipped with an e-bike with trailer (n = 6), a cargo (longtail) bike (n = 6) and a traditional bike with trailer (n = 6).

Results

At follow-up, more participants from the intervention group (vs. the control group) were classified as cyclists to the workplace (n = 7 (38.9%) vs. n = 1 (5.9%), p = 0.04), but not to the kindergarten (n = 6 (33.3%) vs. n = 2 (11.8%), p = 0.23) or to the grocery store (n = 2 (11.1%) vs. n = 0 (0%), p = 0.49). A significant (p = ≤0.05) increase in cycling frequency (0.1 to 2.0 days/week) from baseline to follow-up was found in the intervention group for all destinations and seasons, except to the grocery store during winter (p = 0.16). A decrease in frequency of car driving (-0.2 to -1.7 days/week) was found to be apparent in terms of travelling to the workplace and the kindergarten for all seasons, yet not to the grocery store for any season (p = 0.15–0.49). The intervention group (vs. the control group) reported significantly higher “intrinsic regulation” for cycling (p = 0.01) at follow-up.

Conclusion

Access to different bike types for parents with children attending kindergarten resulted in overall increased cycling, decreased car use and higher intrinsic motivation for cycling. E-bikes obtained the greatest cycling amount in total, with the smallest sample variability. Hence, providing parents with children in kindergarten with access to e-bikes might result in increased and sustained cycling, also during the winter season.

Opinions towards physical activity interventions using Facebook or text messaging: Focus group interviews with vocational school-aged adolescents

Feasible and effective interventions to promote physical activity among vocational school-aged adolescents are strongly needed. Text messaging and Facebook are feasible and acceptable delivery modes for PA interventions among youth. However, little is known about the opinion of vocational school-aged adolescents regarding behavioural change techniques that can be applied through Facebook or text messaging. Therefore, our aim was to gain insight into the opinions of vocational school-aged adolescents towards the use of different behaviour change techniques and towards Facebook/text messaging as a delivery mode for PA interventions. Six focus groups were conducted with 41 adolescents from the first grade (12-14 years) of secondary vocational schools in Flanders (Belgium). In total 41 adolescents participated and completed a questionnaire about their text messaging and Facebook use prior to group discussions. Focus group discussions were audio-recorded and analysed using a thematic analysis method in Nvivo. Participants thought that different behaviour change techniques (e.g., providing feedback, goal setting, self-monitoring, social comparison) could be integrated in a PA intervention using text messaging and Facebook and were enthusiastic about participating in such an intervention. They indicated that text messages are an easy way to receive information about PA, and that a group page on Facebook is ideal to share information with others. Participants deemed it very important that the group page on Facebook would only include peers with whom they also share an offline connection. Furthermore, adolescents stressed the importance of having autonomy (e.g., to determine their personal activity goals, to self-monitor their behaviour) and of being active together with friends. This qualitative study revealed that the use of Facebook and text messaging is promising as a delivery method for PA interventions among vocational school-aged adolescents. The adolescents were keen to participate in an intervention that integrates behaviour change techniques using text messaging or Facebook.

Does Sleep Mediate the Association between School Pressure, Physical Activity, Screen Time, and Psychological Symptoms in Early Adolescents? A 12-Country Study

This study examines the mediating role of sleep duration and sleep onset difficulties in the association of school pressure, physical activity, and screen time with psychological symptoms in early adolescents. Data were retrieved from 49,403 children (13.7 ± 1.6 years old, 48.1% boys) from 12 countries participating in the World Health Organization (WHO) “Health Behaviour in School-aged Children” 2013/2014 study. A validated self-report questionnaire assessed psychological symptoms (feeling low, irritability or bad temper, feeling nervous), school pressure, physical activity (number of days/week 60 min moderate-to-vigorous), screen time, sleep duration on week- and weekend days, and perceived difficulties in getting asleep. Multilevel mediation analyses were conducted. School pressure and screen time were positively associated with psychological symptoms, whereas physical activity was negatively associated. With the exception of sleep duration in the association between physical activity and psychological symptoms, all associations were significantly mediated by sleep duration on week- and weekend days and sleep onset difficulties. Percentages mediated ranged from 0.66% to 34.13%. This study partly explains how school pressure, physical activity, and screen time are related to adolescents’ psychological symptoms. Future interventions improving adolescents’ mental well-being could target schoolwork, physical activity, and screen time, as these behaviours are directly and indirectly (through sleep) related to psychological symptoms.

Effect and process evaluation of a real-world school garden program on vegetable consumption and its determinants in primary schoolchildren

OBJECTIVES

This study aimed to investigate the effectiveness of a school garden program on children's vegetable consumption and determinants and to gain insight into the process of the program.

METHODS

The "Taste Garden" is a real-world nine-week school garden program developed and implemented by a local organization. A total of 350 children (149 intervention group, 201 control group) filled out questionnaires on vegetable consumption, determinants and process of the program. Additionally, teachers filled out a process evaluation questionnaire. For effect evaluation, interaction effects (time x group) were considered, using multilevel repeated measures analyses in MLwiN 3.02. Interaction effects were repeated, taking into account quality of implementation (time x implementation group). Process evaluation was descriptively assessed with SPSS 24.0.

RESULTS

Overall, beside some practical concerns of teachers, the program was well perceived by teachers and children. However, an intervention effect of "The Taste Garden" was only found for knowledge (p = 0.02), with a very small effect size (0.55%). When taking into account implementation quality, only small effects were found for awareness (p between 0.005 and 0.007 and an effect size of 0.63%) and knowledge (p between 0.04 and 0.09 and an effect size of 0.65%).

CCONCLUSIONS

Evaluation of the real-world "Taste Garden" program, which was positively perceived by teachers, showed no effects on vegetable consumption and small effects on its determinants. Adaptations of the current format and longer follow-up periods are therefore recommended.

Individual, social, and physical environmental factors related to changes in walking and cycling for transport among older adults: A longitudinal study

To date, no longitudinal studies examined the change in walking and cycling for transport as distinct outcomes over time and investigated the predictors of those changes. Therefore, this present study examined the change in odds of engagement in walking and cycling for transport as distinct outcomes among Belgian older adults over a three-year follow-up period, and examined factors (i.e. socio-demographics, psychosocial, perceived social and physical environmental characteristics) related to these changes in engaging in walking and cycling for transport. Against our expectations, we found significantly higher odds of engaging in cycling for transport among older adults at follow-up compared to baseline and no significant differences in the odds of engaging in walking for transport. Interventions should assist older adults to increase their self-efficacy towards PA, their perceived benefits of PA, and their perception of land use mix diversity in their neighborhood in order to increase the engagement in walking/cycling for transport over time, or help to decrease their perceived barriers towards PA or their perception to have a lot of physical barriers to walk/cycle in their neighborhood. Future longitudinal studies with larger samples are warranted investigating interaction effects between different predictors at various levels to find out which factors can be further integrated into active transport interventions in older adults.

Understanding physical activity behavior in patients with bladder cancer before and after radical cystectomy: a qualitative interview study

OBJECTIVE:

To explore the determinants of physical activity in patients with bladder cancer before and after radical cystectomy.

DESIGN:

A qualitative research design using semi-structured face-to-face interviews.

SETTING AND SUBJECTS:

A total of 30 interviews were conducted with people diagnosed with bladder cancer and treated with radical cystectomy at Ghent University Hospital.

MAIN MEASURES:

The interviews were audiotaped and transcribed verbatim. Framework analysis with constant comparison between and within interviews was applied until final topics were derived from interpreting the data.

RESULTS:

Physical activity behavior in patients with bladder cancer is determined multifactorial with condition-related (e.g. urinary symptoms, comorbidities), therapy-related (e.g. fatigue, diarrhea), patient-related (e.g. outcome expectations, coping skills, definitions of physical activity), social/economic-related (e.g. social support, attractive environment) and health system-related (e.g. physicians' advice, information) factors.

CONCLUSION:

The results of this study can guide the development of theory-based behavior change interventions to increase physical activity in bladder cancer patients.