Strengthening collaboration within Dutch municipalities for a healthier living environment: experiences and possible improvements according to civil servants.

Background: Health is partly determined by the physical environment in which people live. It is therefore crucial to consider health when designing the physical living space. This requires collaboration between the social and physical domains within municipalities. Collaboration is not self-evident, however, and it is difficult to achieve due to barriers relating to culture, language and work processes. Additionally, improvements in collaboration are desperately needed to address complex health issues, and working according to the new Environment and Planning Act in the Netherlands requires more collaboration. One relevant question concerns how civil servants describe the current collaboration between the social and physical domain and the concrete improvements they propose to improve such collaboration to build a healthier living environment. Methods: In this qualitative study, the Collaborative Governance framework was used to present data from semi-structured interviews with 21 civil servants in five Dutch municipalities. Respondents were asked to reflect on their current experiences with collaboration and suggest concrete opportunities for improving collaboration. Results: The results indicate that enhancing collaboration between the social and physical domains can be achieved by proceeding from the inhabitants' perspective, as well as by encouraging aldermen and managerial personnel to take a more active and committed role in collaboration. This involves formulating and communicating a joint vision, in addition to guiding and facilitating collaboration through integrated assignments, forming multidisciplinary teams and appointing boundary-spanners. Civil servants see a clear role for themselves in the collaborative process. They recognize their own contributions to and obligations in enhancing collaboration by actively seeking contact, absorbing each other's perspectives and pursuing common ground, starting today. Conclusion: There are many concrete opportunities to improve collaboration between the social and physical domains. This could be initiated immediately if civil servants, managers and aldermen approach collaboration as an essential part of their jobs and acknowledge the interdependency that exits.

Fidelity, adaptation and integration of whole-school health promotion within Dutch schools: a cross-sectional survey study.

Implementing comprehensive health promotion programs in the school setting can be challenging, as schools can be considered complex adaptive systems. As a first step towards understanding what works in improving implementation for which schools and under which conditions, this study aimed to examine the degree of implementation of health promoting school (HPS) programs, in terms of five dimensions of fidelity (adherence, dose, participant responsiveness, quality of delivery and program differentiation), and the dimensions of adaptation and integration. The HPS Implementation Questionnaire was distributed among ±â€…2400 primary, secondary, secondary vocational and special needs schools in the Netherlands. Employees of 535 schools (22.3%) filled out the questionnaire. Data were analysed by descriptive statistics and ANOVA tests. The average degree of implementation was 2.55 (SD = 0.58, range = 0.68-3.90; scaled 0-4). The lowest scores were achieved for participant responsiveness and adherence, and the highest for integration and adaptation. Schools that identified as HPS reported significantly higher overall degree of implementation, adherence, dose, participant responsiveness, program differentiation and adaptation than schools that didn't. Primary schools achieved a significantly higher degree of implementation, dose, participant responsiveness, quality of delivery and integration than other school types. In conclusion, many schools work on student health and well-being to some extent, but the vast majority have much room for improvement. Higher implementation scores for schools that identified as HPS underline the value of HPS programs. A broader perspective on health and more insight into conditions for effectiveness and implementation in secondary and secondary vocational schools are needed.

Leverage point themes within Dutch municipalities' healthy weight approaches: A qualitative study from a systems perspective.

INTRODUCTION: Despite all efforts of national and local approaches, obesity rates continue to rise worldwide. It is increasingly recognized that the complexity of obesity should be further addressed by incorporating a systems perspective when implementing approaches. Such an approach has four interconnected system levels: events, structures, goals, and beliefs, in which small changes ('leverage points') can lead to substantial changes in the functioning of the entire system. The current research examined the functioning of five Dutch municipalities' healthy weight approaches (HWAs) and the leverage point themes that can be identified in their system. METHODS: Thirty-four semi-structured interviews were conducted with various stakeholders about the HWA, including policy advisors, care professionals, practice professionals, and citizens. An inductive thematic analysis was performed. RESULTS: Three main themes were identified: 1) HWA organization structure, 2) collaboration between professionals, and 3) citizen participation. Across all system levels, we identified leverage point themes. The upper-levels events and structures occurred the most and were explained by underlying goals and beliefs. Leverage point themes regarding "HWA organization structure" were municipal processes, such as perceived impact; diversity of themes, activities, and tasks; network; and communication strategies, such as messages about the HWA. Leverage point themes regarding "collaboration between professionals" were linking pins, indicating central players within the network; motivation and commitment including support base; and stimulating one another to work on the HWA by spurring other professionals into action. Lastly, leverage point themes under "citizen participation" included reaching the target group, e.g., look for entry points; and citizens' motivation, including customization. DISCUSSION: This paper provides unique insights into HWAs' leverage point themes that can lead to substantial changes in how the entire system functions and makes suggestions about underlying leverage points to help stakeholders improve their HWA. Future research could focus on studying leverage points within leverage point themes.

Measuring Implementation of Health Promoting School (HPS) Programs: Development and Psychometric Evaluation of the HPS Implementation Questionnaire.

BACKGROUND: Implementation of Health Promoting School (HPS) programs can be challenging due to the dynamic school context. Navigating between program fidelity and adaptation, as well as integrating the program, is essential for successful implementation, and consequently, for program effects. As part of an evaluation study in the Netherlands, this study aimed to develop a measurement instrument that differentiates schools according to fidelity, adaptation, and integration of HPS implementation. METHODS: This study presents the development and psychometric evaluation of the 28-item HPS Implementation Questionnaire, covering 7 dimensions: adherence, dose, participant responsiveness, quality of delivery, program differentiation, adaptation, and integration. The questionnaire, to be filled out by school employees, was developed for primary, secondary, secondary vocational, and special needs education, in close collaboration with experts (n = 54) in school health promotion. RESULTS: Semi-structured interviews aimed at dimension clarification resulted in a list of 58 items. Items were revised, combined, and/or removed based on quantitative and qualitative feedback by the evaluation study's Community of Practice, 2-round expert consultation, and pre-tests. Psychometric evaluation (n = 535 schools), consisting of calculating Cronbach's α and confirmatory factor analysis (CFA), confirmed internal consistency (α > .72) and the 7-dimension framework. CONCLUSION: The brief yet comprehensive HPS Implementation Questionnaire offers possibilities for research into HPS implementation in various educational sectors and contexts, as well as self-monitoring by individual schools. This study provides first evidence for internal consistency and validity of the questionnaire.

The effectiveness of a web-based Dutch parenting program to prevent overweight in children 9-13 years of age: Results of a two-armed cluster randomized controlled trial.

INTRODUCTION: Although parental support is an important component in programs designed to prevent overweight in children, current programs pay remarkably little attention to the role of parenting. We therefore developed a web-based parenting program entitled "Making a healthy deal with your child". This e-learning program can be incorporated into existing overweight prevention programs. The aim of this study was to determine the effectiveness of this e-learning program. MATERIALS AND METHODS: The effectiveness was examined in a two-armed cluster randomized controlled trial. The participants were 475 parent-child dyads of children 9-13 years of age in the Netherlands who participated in an existing schoolclass-based overweight prevention program. At the school grade level, parents were randomly assigned to either the intervention or the control condition. Measurements were taken from both parents and children at baseline, and 5 and 12 months after baseline. Primary outcomes included the child's dietary and sedentary behavior, and level of physical activity. Secondary outcomes included general parenting style, specific parenting practices, and parental self-efficacy. Linear mixed effects models and generalized linear mixed effects models were conducted in R. RESULTS: Intention-to-treat analyses and completers only revealed no significant effects between the intervention and control condition on energy balance-related behaviors of the child and parenting skills after correction for multiple testing. The parents' mean satisfaction with the e-learning program (on a 10-point scale) was 7.0±1.1. CONCLUSIONS: Although parents were generally satisfied with the parenting program, following this program had no significant beneficial effects regarding the children's energy balance-related behaviors or the parenting skills compared to the control condition. This program may be more beneficial if used by high-risk groups (e.g. parents of children with unhealthy energy balance-related behaviors and/or with overweight) compared to the general population, warranting further study.

The degree of consistency of applying parental dietary and sedentary behavior rules as indicators for overweight in children: a cross-sectional study.

BACKGROUND: Review studies increasingly emphasize the importance of the role of parenting in interventions for preventing overweight in children. The aim of this study was to examine typologies regarding how consistently parents apply energy-balance related behavior rules, and the association between these typologies and socio-demographic characteristics, energy balance-related behaviors among school age children, and the prevalence of being overweight. METHODS: For this cross-sectional study, we had access to a database managed by a Municipal Health Service Department in the Netherlands. In total, 4,865 parents with children 4-12 years of age participated in this survey and completed a standardized questionnaire. Parents classified their consistency of applying rules as "strict", "indulgent", or "no rules". Typologies were identified using latent class analyses. We used regression analyses to examine how the typologies differed with respect to the covariates socio-demographic characteristics, children's energy balance-related behaviors, and weight status. RESULTS: We identified four stable, distinct parental typologies with respect to applying dietary and sedentary behavior rules. Overall, we found that parents who apply "overall strict EBRB rules" had the highest level of education and that their children practiced healthier behaviors compared to the children of parents in the other three classes. In addition, we found that parents who apply "indulgent dietary rules and no sedentary rules" had the lowest level of education and the highest percentage of non-Caucasians; in addition, their children 8-12 years of age had the highest likelihood of being overweight compared to children of parents with "no dietary rules". CONCLUSIONS: Parents' consistency in applying rules regarding dietary and sedentary behaviors was associated with parents' level of education and ethnic background, as well as with children's dietary and sedentary behaviors and their likelihood of becoming overweight. Our results may contribute to helping make healthcare professionals aware that children of parents who do not apply sedentary behavior rules are more likely to become overweight, as well as the importance of encouraging parents to apply strict dietary and sedentary behavior rules. These results can serve as a starting point for developing effective strategies to prevent overweight among children.

The perceptions and priorities of professionals in health and social welfare and city planning for creating a healthy living environment: a concept mapping study.

BACKGROUND: It is helpful for collaboration if professionals from the field of health and social welfare and the field of city planning are aware of each other's concepts of what a healthy living environment entails and what its components are. This study examined perceptions about creating a healthy living environment of professionals from these two fields, as well as the differences between them. METHODS: We recruited 95 professionals from Nijmegen, the Netherlands who worked in the fields of health, social welfare and city planning in governmental and non-governmental capacities. We used the concept mapping method to collect and analyse their thoughts on healthy living environments. Participants first submitted statements on this subject in a brainstorming session, using an online mapping tool. Then they sorted these statements and rated them on priorities and opportunities within urban planning processes. RESULTS: During the brainstorm, 43 professionals generated 136 statements. After the elimination of duplicates, 92 statements were individually sorted by 32 professionals. Concept mapping software was used to create an overall map, in which the statements were sorted into ten clusters. Each of these clusters represented one of the main features of a healthy living environments. After 36 participants rated these statements, it emerged that professionals from both fields agreed on priorities and opportunities for the clusters 'Spatial quality' and 'Conducive to exercise'. Professionals also agreed on which three clusters had the fewest priorities and possibilities ('Promotes personal wellbeing', 'Encourages healthy choices', 'Conducive to social connections'). CONCLUSION: We found that professionals in health and social welfare and city planning have similar views concerning the most and least important features of a healthy living environment in urban planning process. This could indicate that the differences between the two fields may be more nuanced and specific than previously thought. This knowledge offers perspectives for professionals to strengthen their collaboration and to come to a joint result in urban planning projects.

General practitioners' views on the influence of long-term care reforms on integrated elderly care in the Netherlands: a qualitative interview study.

This study explores the long-term care (LTC) reform in the Netherlands and its relation to the day-to-day integrated care for frail elderly people, from the perspective of general practitioners (GPs). We assessed GP perspectives regarding which elements of the LTC reform have promoted and hindered the provision of person-centred, integrated care for elderly people in the Netherlands. We performed case studies conducted by semi-structured interviews, using the Healthy Alliances (HALL) framework as a framework for thematic analysis. GPs reported that the ideals of the LTC reform (self-reliance) were largely achievable and listed a number of positive effects, including increased healthcare professional engagement and the improved integration of the medical and social domains through the close involvement of social support teams. The reported negative implications were a lack of co-ordination in the implementation of the reforms by the municipality, insufficient funding for multidisciplinary team meetings and the reinforced fragmentation of home care. In particular, the implementation of the system reforms took place with little regard for the local context. We suggest that the implementation of national care reforms should be aligned with factors operating at the micro level and make the following recommendations: use one central location for primary health and social services, integrate regional ICT structures to improve the exchange of patient information, and reduce fragmentation in home care.

How to recruit inactive residents for lifestyle interventions: participants' characteristics based on various recruitment strategies.

Care Sport Connectors (CSCs) have been appointed to create a connection between primary care and physical activity (PA) sectors to stimulate inactive residents into becoming physically active. Adequate recruitment strategies are necessary to reach the intended target group in order to foster the sustainability of lifestyle interventions. The objective of this study is to explore PA behavior and health characteristics of the target group reached by CSCs and if these characteristics differ between participants when grouped based on how they were recruited. Participants from lifestyle interventions were included between September 2014 and April 2016 using a purposive sampling method. Participants were recruited through CSCs via public relations (n = 135), a personal letter (n = 136), or a referral (n = 98) and compared based on their PA level, health-related quality of life, motivation, self-efficacy, morbidity and health-related fitness. Scores were analyzed with a multi-level (mixed model) analysis measured before the intervention. The three groups were different in PA level (p = 0.002). The outcomes regarding health-related quality of life, motivation, and number of somatic disorders were also significantly different for the three groups, except for the categories of mental health (p = 0.145) and self-efficacy (p = 0.464). For all dimensions, the referral group scored the least favorable. The investment in time and money for an active recruitment strategy like referrals is worthwhile because it provides CSCs the opportunity to reach people who are inactive and at risk of chronic disease. Future studies are necessary to reveal the effect on PA levels and health in the long-term.

Perceptions of Care Sport Connectors' Tasks for Strengthening the Connection Between Primary Care, Sports and Physical Activity: A Delphi Study.

INTRODUCTION: Care sport connectors stimulate physical activity and facilitate collaboration between the primary care and physical activity sectors in the Netherlands. To strengthen intersectoral collaboration between the primary care and sports sectors, it is necessary to study which tasks a care sport connector must fulfil according to their own and other professionals' perceptions. METHODS: A Delphi study was conducted with 182 professionals from the primary care, public health and physical activity sectors. Rounds 1 and 2 included questions about task perception, willingness to collaborate and expectations of care sport connectors. Rounds 3 and 4 were used to reach consensus. RESULTS: All professions acknowledged physical activity promotion tasks, but they are not all willing to collaborate. They expect a broad range of roles from care sport connectors: informative, executive, guiding and intermediate. Care sport connectors reached consensus on two roles: informative and intermediate. DISCUSSION: Care sport connectors have an important role in strengthening intersectoral collaboration. All the professions acknowledged a task concerning physical activity promotion and accepted a broker role. Thus, a public health mind-set seems to be present to some extent. However, challenges remain, such as the lack of willingness to collaborate among primary care professionals and sports policies not (yet) supporting intersectoral collaboration.

Professional Care Networks of Frail Older People: An Explorative Survey Study from the Patient Perspective.

BACKGROUND: Frail older people living in the community require multidisciplinary care. Despite the fact that patient participation is high on the public agenda, studies into multidisciplinary care mainly focus on the viewpoints of professionals. Little is known about frail older patients' experiences with care delivered by multidisciplinary teams and their perception of collaboration between professional and informal caregivers. OBJECTIVE: To gain more insight into the experiences of frail older patients with integrated multidisciplinary care by mapping the care networks of this patient group and their perception of the interconnection between professional and informal caregivers. METHODS: Survey study to facilitate a care network analysis. Due to the vulnerable health status of the respondents, questionnaires were completed during interviews. Analysis was performed using an iterative process, using both visual and metric techniques. PARTICIPANTS: 44 older persons, considered 'frail' by their general practitioner. SETTING: Four general practices in The Netherlands. RESULTS: The networks of the participants consisted of an average of 15 actors connected by 54 ties. General practitioners were the most common actors in the networks, and were well connected to medical specialists and in-home care providers. The participants did not always perceive a connection between their general practitioner and their informal caregiver. The network analyses resulted in the identification of three subtypes: simple star (n = 16), complex star (n = 16), and sub-group networks (n = 12). CONCLUSIONS: Our findings indicate that the elderly often do not experience the integration of multidisciplinary care as such. This is a real opportunity for MTs to improve their care and to make the patients' experiences better in line with what they are aiming: allowing patients to live at home as healthy and independently as possible for as long as possible. We showed that informal caregivers often form communication bridges between patients and professionals. Having a better knowledge of the patient perspective enables the gaps in professional care networks of frail older people to be filled and facilitates the anticipation of crisis situations.

A set of pedagogical recommendations for improving the integrated approach to childhood overweight and obesity: A Delphi study.

BACKGROUND: Tackling the increasing global problem of childhood overweight and obesity requires an integrated approach. Studies increasingly emphasize the importance of the parents' role in interventions designed to prevent overweight in children. The aim of this study was to develop a unified set of recommendations for healthy parenting practices that can be applied by all professionals who work with children age 4-13 years and can contribute to strengthening the integrated approach to childhood overweight. METHODS: A modified Delphi procedure was used to reach consensus regarding what these pedagogical recommendations should encompass. The 30 panelists were professionals and researchers who work with children age 4-13 in the domains of health care, overweight, parenting, education, nutrition, and/or sports. The procedure consisted of: i) extracting existing pedagogical recommendations from national guidelines and professional protocols, ii) appraising and prioritizing these recommendations in terms of relevance through two rounds of questionnaires, and iii) meeting to discuss and approve the set of recommendations. RESULTS: Consensus was reached for one set of eleven pedagogical theme-based recommendations designed to support and instruct parents how to stimulate healthy energy balance‒related behaviors in their child. Each recommendation contained information regarding: i) which behaviors in the child and/or parent are important, ii) why this is important, and iii) how parents can stimulate this behavior by applying parenting skills in daily life. The eleven themes were: modeling, positive parenting, breakfast, varied diet, sugar-sweetened beverages, snacks, physical activity, playing sports, quantity of screen time, screen time during meals, and sleep. CONCLUSION: We developed a set of recommendations for healthy parenting that can be used by various professionals working with children age 4-13 and can contribute to creating an integrated approach to childhood overweight. We also developed a web-based app called "Recommendations for Healthy Parenting" as a convenient tool for following these recommendations.

Parents' underestimation of their child's weight status. Moderating factors and change over time: A cross-sectional study.

BACKGROUND: Parents' underestimation of their child's weight status can hinder active participation in overweight prevention programs. We examined the level of agreement between the parents' perception of their child's weight status and the child's actual weight status, moderating factors, and change over time. METHODS: This cross-sectional study used data collected in 2009 (n = 8105), 2013 (n = 8844) and 2017 (n = 11,022) from a community-based survey conducted among parents of children age 2-12 years in the Netherlands. Parents classified their perception of their child's weight status on a 5-point Likert scale. In 2009 and 2013, the child's BMI was calculated from self-reported data by parents. The level of agreement between the parent's perception of the weight status and the actual weight status was examined using Cohen's kappa. The role of demographic factors on parents' perception were examined using logistic regression. RESULTS: In 2009, 2013 and 2017, 6%, 6% and 5% of the parents, respectively, classified their child as heavy/extremely heavy. In 2009 and 2013, 64.7% and 61.0% of parents, respectively, underestimated the weight status of their overweight child. This was even higher among parents of obese children. Overall, the agreement between the parents' perception and the actual weight status improved from 2009 (kappa = 0.38) to 2013 (kappa = 0.43) (p<0.05), but remained unsatisfactory. The parents' underestimation of their child's overweight/obesity status was associated with the child's age in 2009 and 2013 (2-7 years; OR: 0.18), the child's gender in 2009 (male; OR: 0.55), and the parents' education level in 2009 (middle and high education; OR: 0.56 and 0.44 respectively). CONCLUSIONS: Parents' underestimation of their child's weight status remains alarmingly high, particularly among parents of young, obese children. This underestimation is a barrier to preventing childhood overweight/obesity. Healthcare professionals should take this underestimation into consideration and should actively encourage parents to take steps to prevent overweight/obesity in their children.

Everyday life situations in which mothers experience difficulty stimulating healthy energy balance-related behavior in their school-age children: a focus group study.

BACKGROUND: Parental support is an important element in overweight prevention programs for children. The purpose of this study was to examine everyday life situations in which mothers encounter difficulties encouraging healthy energy balance-related behavior in their school-age children. METHODS: We formed four focus groups containing 6-9 participants each. The participants were mothers of Dutch, Turkish, or Moroccan descent with a child 8-13 years of age. All focus group sessions were recorded, transcribed, and coded. Content was analyzed conventionally using ATLAS.ti 6. RESULTS: Twenty-seven difficult everyday life situations were identified in 14 settings. The five most frequently reported situations were a daily struggle regarding eating vegetables, eating breakfast on time before going to school, eating candy and snacks between meals, and spending excessive time watching television and using the computer. A perceived loss of parental control, the inability to establish rules and the failure to consistently enforce those rules were the most commonly cited reasons for why the mothers experience these situations as being difficult. CONCLUSIONS: We identified five difficult everyday life situations related to healthy energy balance-related behavior. These five difficult situations were used as the input for developing a web-based parenting program designed to prevent children from becoming overweight. We reasoned that if we use these situations and the underlying reasons, many parents would recognize these situations and are willing to learn how to deal with them and complete the e-learning.

Mirror meetings with frail older people and multidisciplinary primary care teams: Process and impact analysis.

OBJECTIVES: To analyse the process and impact of confronting multidisciplinary teams (MTs) in primary care with the experiences of frail older patients through mirror meetings (MMs), with the aim of supporting teams to organize care in a more patient-oriented way. METHODS: Process and impact analyses were performed using a mixed-method approach. MMs were held with 14 frail older patients and four MTs comprising 23 health-care professionals (HCPs) in primary care in the Netherlands. RESULTS: Mirror meetings were feasible for frail older people living at home, although their recruitment was time-consuming. Interaction between the patients was scarce, but they valued the opportunity to share their stories. HCPs preferred MMs overwritten reports about patient experiences. An impact analysis revealed four dominant professional areas for improvement: improve alignment with patient goals, improved communication with patients both orally and in writing, developing new pathways to connect with informal caregivers and an increased understanding that most HCPs are relative strangers to their patients. CONCLUSIONS: Mirror meetings are a relatively simple and promising method for exploring the ways in which frail older patients experience care. PRACTICE IMPLICATIONS: Given the right conditions, MMs could result in valuable processes to enable MTs to improve their working methods.

The role of the general practitioner in multidisciplinary teams: a qualitative study in elderly care.

BACKGROUND: In the western world, a growing number of the older people live at home. In the Netherlands, GPs are expected to play a pivotal role in the organization of integrated care for this patient group. However, little is known about how GPs can play this role best. Our aim for this study was to unravel how GPs can play a successful role in elderly care, in particular in multidisciplinary teams, and to define key concepts for success. METHODS: A mixed qualitative research model in four multidisciplinary teams for elderly care in the Netherlands was used. With these four teams, consisting of 46 health care and social service professionals, we carried out two rounds of focus-group interviews. Moreover, we performed semi-structured interviews with four GPs. We analysed data using a hybrid inductive/deductive thematic analysis. RESULTS: According to the health care and social service professionals in our study, the role of GPs in multidisciplinary teams for elderly care was characterized by the ability to 'see the bigger picture'. We identified five key activities that constitute a successful GP role: networking, facilitating, team building, integrating care elements, and showing leadership. Practice setting and phase of multidisciplinary team development influenced the way in which GPs fulfilled their roles. According to team members, GPs were the central professionals in care services for older people. The opinions of GPs about their own roles were diverse. CONCLUSIONS: GPs took an important role in successful care settings for older people. Five key concepts seemed to be important for best practices in care for frail older people: networking (community), facilitating (organization), team building (professional), integrating care elements (patient), and leadership (personal). Team members from primary care and social services indicated that GPs had an indispensable role in such teams. It would be advantageous for GPs to be aware of this attributed role. Attention to leadership competencies and to the diversity of roles in multidisciplinary teams in GP training programmes seems useful. The challenge is to convince GPs to take a lead, also when they are not inclined to take this role in organizing multidisciplinary teams for older people.

Exploring the impact of the care sport connector in the Netherlands.

BACKGROUND: Regular physical activity (PA) is deemed to contribute to the primary and secondary prevention of several chronic diseases, like diabetes mellitus, cancer, cardiovascular diseases, and osteoporosis. In 2012, Care Sport Connectors (CSC), to whom a broker has been ascribed, were introduced in the Netherlands to stimulate PA and guide primary care patients towards local sport facilities. The aim of this study was to explore which structural embedding is the most promising for CSCs' work. METHODS: In three rounds of interviews, 13 CSCs were followed for 2 years in their work. In these interviews, a network survey was used to identify organisations in the CSCs' network, whether they collaborated with these organisations, and the role of the organisations in the connection. Data from the network survey were analysed using the RE-AIM framework and disaggregated into how CSCs were structurally embedded (Type A: only PA sector; Type B: different sectors; Type C: partnership). A related samples Wilcoxon signed rank test was performed to study how the CSCs' network developed between 2014 and 2016. RESULTS: All CSCs established a connection between the primary care and the PA sector in which the average number of organisations with which CSCs collaborated increased significantly between 2014 (8.3) and 2016 (19.8) (p = 0.002). However, differences were identified in the way CSCs were structurally embedded and in the way they established the connection. Type A CSCs established the connection mostly around their own activities, supported PA organisations with their activities, and collaborated with primary care and welfare professionals around their own activities. Type B and Type C CSCs established the connection by organising, supporting, and implementing different kinds of activities targeting different kinds of audiences, and collaborated mostly with primary care professionals around the referral of professionals' patients. CONCLUSIONS: The results of this study suggest that adopting an integral approach (Type B and C) for the structural embedding of the CSC is more promising for reaching the desired outcomes. Whether CSCs really improve the target groups' PA level and health needs to be further studied. TRIAL REGISTRATION: Dutch Trial Register NTR4986 . Registered 14 December 2014.

The connection between the primary care and the physical activity sector: professionals' perceptions.

BACKGROUND: To stimulate physical activity (PA) and guide primary care patients towards local PA facilities, Care Sport Connectors (CSC), to whom a broker role has been ascribed, were introduced in 2012 in the Netherlands. The aim of this study is to assess perceptions of primary care, welfare, and sport professionals towards the CSC role and the connection between the primary care and the PA sector. METHODS: Nine focus groups were held with primary care, welfare and sport professionals within the CSC network. In these focus groups the CSC role and the connection between the sectors were discussed. Both top-down and bottom-up codes were used to analyse the focus groups. RESULTS: Professionals ascribed three roles to the CSC: 1) broker role, 2) referral, 3) facilitator. Professionals were enthusiastic about how the current connection was established. However, barriers relating to their own sector were currently hindering the connection: primary care professionals' lack of time, money and knowledge, and the lack of suitable PA activities and instructors for the target group. CONCLUSIONS: This study provides further insight into the CSC role and the connection between the sectors from the point of view of primary care, welfare, and sport professionals. Professionals found the CSC role promising, but barriers are currently hindering the collaboration between both sectors. More time for the CSC and changes in the way the primary care and PA sector are organized seem to be necessary to overcome the identified barriers and to make a success of the connection. TRIAL REGISTRATION: Dutch Trial register NTR4986 . Registered 14 December 2014.

The effectiveness of a web-based Dutch parenting program to prevent overweight in children 9-13 years of age: study protocol for a two-armed cluster randomized controlled trial.

BACKGROUND: Although parental support is an important component in overweight prevention programs for children, current programs pay remarkably little attention to the role of parenting. To close this gap, we developed a web-based parenting program for parents entitled "Making a healthy deal with your child". This e-learning program can be incorporated into existing prevention programs, thereby improving these interventions by reinforcing the role of parenting and providing parents with practical tools for use in everyday situations in order to stimulate a healthy lifestyle. Here, we report the research design of a study to determine the effectiveness of our e-learning program. METHODS/DESIGN: The effectiveness of an e-learning program was studied in a two-armed cluster randomized controlled trial. Parents of children 9-13 years of age who live in the Nijmegen region, the Netherlands, and who participated in the existing school-based overweight prevention program "Scoring for Health" were invited to participate in this study. Our goal was to recruit 322 parent-child dyads. At the school grade level, parents were randomly assigned to either the intervention group (which received e-learning and a brochure) or the control group (which received only the brochure); the participants were stratified by ethnicity. Measurements were taken from both the parents and the children at baseline, and then 5 and 12 months after baseline. Primary outcomes included the child's dietary and sedentary behavior, and level of physical activity. Secondary outcomes included general parenting style, specific parenting practices (e.g., set of rules, modeling, and monitoring), and parental self-efficacy. DISCUSSION: We hypothesize that children of parents who follow the e-learning program will have a healthier diet, will be less sedentary, and will have a higher level of physical activity compared to the children in the control group. If the e-learning program is found to be effective, it can be incorporated into existing overweight prevention programs for children (e.g., "Scoring for Health"), as well as activities regarding Youth Health Care. TRIAL REGISTRATION: Dutch Trial Register: NTR3938 . Date of registration: April 7(th), 2013.

Design of CIAO, a research program to support the development of an integrated approach to prevent overweight and obesity in the Netherlands.

BACKGROUND: The aim of this paper is to describe the research aims, concepts and methods of the research Consortium Integrated Approach of Overweight (CIAO). CIAO is a concerted action of five Academic Collaborative Centres, local collaborations between academic institutions, regional public health services, local authorities and other relevant sectors in the Netherlands. Prior research revealed lacunas in knowledge of and skills related to five elements of the integrated approach of overweight prevention in children (based upon the French EPODE approach), namely political support, parental education, implementation, social marketing and evaluation. CIAO aims to gain theoretical and practical insight of these elements through five sub-studies and to develop, based on these data, a framework for monitoring and evaluation. METHODS/DESIGN: For this research program, mixed methods are used in all the five sub-studies. First, problem specification through literature research and consultation of stakeholders, experts, health promotion specialists, parents and policy makers will be carried out. Based on this information, models, theoretical frameworks and practical instruments will be developed, tested and evaluated in the communities that implement the integrated approach to prevent overweight in children. Knowledge obtained from these studies and insights from experts and stakeholders will be combined to create an evaluation framework to evaluate the integrated approach at central, local and individual levels that will be applicable to daily practice. DISCUSSION: This innovative research program stimulates sub-studies to collaborate with local stakeholders and to share and integrate their knowledge, methodology and results. Therefore, the output of this program (both knowledge and practical tools) will be matched and form building blocks of a blueprint for a local evidence- and practice-based integrated approach towards prevention of overweight in children. The output will then support various communities to further optimize the implementation and subsequently the effects of this approach.