Validity and reliability of the short Test Anxiety Inventory (TAI-5) in Dutch adolescents.

The present study examined the psychometric properties of the short Test Anxiety Inventory (TAI-5) in a Dutch adolescent sample. The sample consisted of 2063 secondary school students (mean age 13.6 years, 48% girls) who filled out a battery of screening questionnaires for a routine health check. We investigated structural validity with a confirmatory factor analysis, scale reliability with internal consistency coefficients, and construct validity with hypotheses testing and convergent validity. The proposed one-factor structure fitted well in the present sample. However, there was an indication of measurement variance for gender. Scale reliability was high (ω = 0.88), and sufficient positive correlations were found between TAI-5 scores and anxiety, depression, worry, executive functioning, and sleep problems (r ranging from 0.36 to 0.56). Girls had significantly higher test anxiety scores than boys (d = 0.47). The present study provided evidence for the validity and reliability of TAI-5 scores in a general population of Dutch adolescents.

Differences in Anxiety and Depression Among Migrant and Non-Migrant Primary School Children in The Netherlands.

This is the first Dutch study investigating symptoms of five DSM-IV-classified anxiety disorders and depression in a large sample of pre-adolescent children with and without a migration background, adjusting for socioeconomic position (SEP) and social preference. Both are potential explanatory factors for differences in mental health among migrant children. We measured anxiety and depression scores with the self-report Revised Child Anxiety and Depression Scale (RCADS) in 2063 children (aged 8-13 years, 55% girls) in the Netherlands. Surinamese/Antillean, Turkish, and Moroccan children reported significantly higher anxiety scores than Dutch children. SEP and peer rejection partly explained higher anxiety scores. Surinamese/Antillean and Turkish children reported comparable depression scores to Dutch children, but Moroccan children reported lower depression scores after adjusting for SEP and peer rejection. Girls reported higher anxiety and depression levels across all four subgroups. Although differences between children with or without a migration background were small, these may increase in later life as the prevalence of anxiety and depression increases with age.

Exploring the Association of Age with Depressive Symptomatology in Childhood and Adolescence: A Network Study.

OBJECTIVE: This study aimed to explore the association of age with individual depression and anxiety symptoms and their connectivity (i.e., number/strength of connections with other symptoms) in girls and boys. METHOD: Our study comprised cross-sectional data from 31,960 Dutch girls and 32,162 Dutch boys aged 8 to 18 and considered 11 depression symptoms and 14 anxiety symptoms measured by the Revised Child Anxiety and Depression Scale. Network estimations were used to examine whether age was associated with individual symptoms and, in a separate step, with the connectivity of depression symptoms with other depression symptoms and with the connectivity of depression symptoms with anxiety symptoms. RESULTS: Age was, in general, positively associated with depression symptoms in girls, but not in boys, and with the connectivity of depression symptoms with other depression symptoms in both sexes. These findings were the most profound for energy-related symptoms in girls. Age was, in general, negatively associated with anxiety symptoms and not or negatively associated with the connectivity of depression symptoms with anxiety symptoms in girls and boys, respectively. Substantial differences across symptoms were found. CONCLUSIONS: This study shows that it is important to focus on individual symptoms, for age is mainly associated with energy-related depression symptoms and their connectivity in girls. Future etiologic studies may examine the role of energy-related depression symptoms in the development of depressive symptomatology in girls as these symptoms seem potential targets for the prevention of depression in the female population.

Adolescent anxiety and depression: burden of disease study in 53,894 secondary school pupils in the Netherlands.

BACKGROUND: Prevalence rates of anxiety and depression in adolescence are rising markedly in early adolescence. It is important to quantify the non-fatal disease burden of anxiety and depression, such that early interventions can be well targeted, and resources can be allocated in a just and optimal way. This study aimed to estimate the non-fatal disease burden of anxiety and depression with and without suicidal ideation in girls and boys aged 13, 14, and 15 years. METHODS: Participants were 53,894 secondary school pupils who completed health questionnaires between September 2018 and July 2019. A design-based approach was used for complex survey data with post-stratification weights and taking clustering at school-level into account. At individual level, disability weights (DWs) were calculated for each disorder. At population level, DWs were multiplied by the point-prevalence per one thousand population of the respective disorders to compute years lived with disability (YLD). DWs and YLD of anxiety and depression were calculated with and without adjustment for comorbid eating disorders, substance use disorders and somatic illnesses. RESULTS: The unadjusted DW of depression with suicidal ideation (0.30) was greater than without suicidal ideation (0.26), and both were greater than the DW of anxiety (0.24). A similar ranking was obtained after adjusting for comorbidities. At population level, where the prevalence of the disorders come into play, the YLD disease burden was greatest for anxiety, followed by depression with suicidal ideation and depression without suicidal ideation with 17.40, 9.85, and 5.28 YLD per one thousand population, unadjusted for comorbidities. This pattern was the same after adjustment, but then the total YLD of depression with and without suicidal ideation was similar to the YLD of anxiety (12.47 and 12.46, respectively). Girls showed a significantly greater YLD burden of anxiety and depression than boys, but no differences were found between different age groups. CONCLUSIONS: From an individual clinical perspective, depression, especially when accompanied by suicidal ideation, was identified as a major health concern, especially in girls. From a public health perspective, both anxiety and depression, especially when accompanied by suicidal ideation, were identified as major drivers of disease burden, again most notably in girls.

Linking the RCADS-25 to the PROMIS® pediatric item banks Anxiety and Depressive Symptoms in a general Dutch population sample.

PURPOSE: This study aims to link scores of the Revised Child Anxiety and Depression Scale short version (RCADS-25) to the metric of the PROMIS pediatric item banks Anxiety and Depressive Symptoms in a general Dutch population sample. METHODS: The RCADS-25 and PROMIS pediatric item banks Anxiety and Depressive Symptoms were administered online to 2,893 Dutch children and adolescents aged 8-18. Assumptions for linking methods were checked. Linking was achieved by using three item response theory (IRT) and two equipercentile methods. For each method, the observed PROMIS metric scores were compared to the ones predicted from the RCADS-25 subscale scores using correlations, mean and SD of differences, and RMSD. RESULTS: The assumptions for IRT-based and equipercentile linking were met. The IRT-based method using separate calibration with Stocking-Lord constants was considered the optimal choice for linking both RCADS-25 subscales to the PROMIS metric. Based on this Stocking-Lord approach, we created item parameters for RCADS-25 items and two crosswalk tables. CONCLUSION: The RCADS-25 item parameters and crosswalk tables presented in this study are sufficiently valid. Researchers can use these products to translate the RCADS-25 anxiety and depression subscales scores to the PROMIS metric in order to ensure comparability with the previous research.

Human papillomavirus vaccination uptake: a longitudinal study showing ethnic differences in the influence of the intention-to-vaccinate among parent-daughter dyads.

INTRODUCTION: It is unclear what role daughters play in the decision-making process regarding HPV vaccination. Therefore, we explored the impact of HPV vaccination intention among parents and their 12-13 year-old daughters on HPV vaccination uptake. METHODS: In February 2014 parents/guardians and their 12-13 year-old daughters were invited to complete a questionnaire about socio-psychological determinants of the decision-making process regarding HPV vaccination. Vaccination status of the daughter was retrieved from the national vaccination database after the last possible vaccination date in 2014. The association between HPV vaccination uptake and intention, and determinants of intention, was jointly assessed using a generalized structural equation model, stratified by origin of parents (Dutch versus non-Dutch). RESULTS: In total, 273 Dutch parent-daughter dyads and 165 non-Dutch dyads were analyzed for this study. HPV vaccination uptake was 90% (246/273) and 84% (139/165) in the Dutch and non-Dutch group, respectively. In the Dutch group, high parental intention (ß = 2.3, 95%CI 1.2-3.3) and high daughters' intention (ß = 1.5, 95%CI 0.41-2.6) were significantly associated with HPV vaccination uptake. In the non-Dutch group, high daughters' intention (ß = 1.2, 95%CI 0.16-2.2) was significantly associated with HPV vaccination, but high parental intention was not (ß = 0.52, 95%CI -0.47-1.5). Attitude was the most prominent socio-psychological determinant associated with vaccination intention among all groups. CONCLUSION: In the non-Dutch group, only daughters' intention was significantly associated with HPV vaccination uptake, whereas in the Dutch group both the parents' and the daughters' intention were significantly associated with uptake. The role of the child in the decision-making process might need to be taken into account when developing new interventions focused on increasing HPV vaccination uptake, especially among individuals of non-Dutch origin.

Are Suicidal Thoughts and Behaviors a Temporary Phenomenon in Early Adolescence?

Background: The incidence of first suicidal thoughts and behaviors (STBs) peaks during early adolescence. After experiencing their first STBs, adolescents differ greatly in the extent to which they continue to have STBs. Aim: We determined the course of STBs in Dutch students at two ages: 13-14 years (t1) and 15-16 years (t2). Methods: Longitudinal data on STBs and sociodemographic factors were collected by self-report (n = 8,499). Associations between having STBs at t1 and t2 were determined with multinomial logistic regression analysis. Results: Students who reported suicidal thoughts at baseline (n = 1,077; 13%) reported suicidal thoughts (OR = 6.60; 95% CI [5.52, 7.88]) and suicidal attempts (OR = 6.97; 95% CI [4.20, 11.54]) at t2 more often than students with no STBs at t1. Students who reported a suicidal attempt at baseline (n = 144; 2%) also reported suicidal thoughts and suicidal attempts more often at t2 (OR = 5.98; 95% CI [3.89, 9.21]; OR = 30.00; 95% CI [15.84, 56.82], respectively). Limitations: The use of confidential self-reported data and the loss of cases after merging could have biased the results. Conclusion: For a subgroup of adolescents, STBs persisted and worsened over the 2 years. This demonstrates the importance of accurate identification of those at increased risk of suicide, in combination with personalized care.

Sociodemographic Differences in Time Trends of Suicidal Thoughts and Suicide Attempts Among Adolescents Living in Amsterdam, The Netherlands.

Background: Suicidal thoughts and suicide attempts among adolescents are major public health problems. More insight into secular changes in suicidal thoughts and suicide attempts among adolescents from various sociodemographic groups is crucial for adequate and targeted policy-making and prevention. We therefore examined 5-year time trends in suicidal thoughts and suicide attempts among adolescents and potential differences in time trends between sociodemographic groups. Methods: Logistic regression analyses were based on annually repeated cross-sectional data including 26,273 multi-ethnic students (13-14 years old) in the second year of various levels of secondary education in Amsterdam, The Netherlands. Results: Overall, the prevalence of adolescents in Amsterdam with suicidal thoughts decreased from 17.6% during 2010-2011 to 13.2% during 2014-2015. The prevalence of adolescents reporting suicide attempts decreased from 2.9% to 1.9% over the observed 5-year period. We found differences in these time trends between subgroups based on ethnicity and educational level. Limitations: The use of confidential and self-reported data could have biased the results. Conclusion: In order for prevention policy to be effective it is important to pay attention to changes in risk groups for suicidal thoughts and suicide attempts over time.

Psychometric evaluation of two short versions of the Revised Child Anxiety and Depression Scale.

BACKGROUND: Anxiety and depression are common in children and adolescents, which can be detected via self-report questionnaires in non-clinical settings like the school environment. Two short versions of the Revised Child Anxiety and Depression Scale (i.e., RCADS-25 and RCADS-20) seem to be feasible for administering at schools. The present study evaluated the psychometric properties of the RCADS-25 and RCADS-20 used as screening instruments for anxiety and depression in a general population of schoolchildren and adolescents. METHODS: The RCADS-25 was completed by 69,487 schoolchildren and adolescents aged 8 to 18. The RCADS-25 and RCADS-20 broad anxiety scales are equal (15 items), but there are two versions of the major depressive disorder (MDD) scale: the RCADS-25 MDD scale (10 items) and the RCADS-20 MDD scale (5 items). The three scales were assessed on structural validity, internal consistency, test-retest reliability, criterion validity, and hypotheses for construct validity. RESULTS: The RCADS-25/RCADS-20 broad anxiety scale demonstrated a sufficient structural validity (CFI = 0.98, TLI = 0.99, RMSEA = 0.03, SRMR = 0.03), internal consistency (alpha = 0.82), test-retest reliability (ICC = 0.73), criterion validity (AUC = 0.79), and all four hypotheses concerning construct validity were confirmed. The RCADS-25 MDD scale demonstrated a sufficient test-retest reliability (ICC = 0.70) and three out of four hypotheses concerning construct validity were confirmed, but its structural validity was suspect (CFI = 0.89, TLI = 0.94, RMSEA = 0.09, SRMR = 0.06). The RCADS-20 MDD scale demonstrated a sufficient structural validity (CFI = 0.97, TLI = 0.97, RMSEA = 0.08, SRMR = 0.04) and internal consistency (alpha = 0.72). Two out of four hypotheses concerning construct validity were confirmed. The test-retest reliability (ICC = 0.60) was insufficient. Since both MDD scales showed shortcomings, the shortening of the RCADS-25 MDD scale was re-examined post hoc by principal component and reliability analyses. The result was an MDD scale with seven items. CONCLUSIONS: The RCADS-25/RCADS-20 broad anxiety scale is valid and reliable for screening schoolchildren and adolescents, but the RCADS-25 and RCADS-20 MDD scales showed shortcomings. An MDD scale of seven items showed acceptable psychometric properties.

Associations between overweight and mental health problems among adolescents, and the mediating role of victimization.

BACKGROUND: Evidence has not been conclusive on whether adolescent overweight is associated with mental health, possibly caused by indirect, yet untested associations. Therefore, the purpose of this study was to examine the association between overweight or obesity and mental health problems among adolescents, and to determine whether victimization plays a mediating role in these associations. METHODS: Self-reported data on mental health and victimization and objectively measured Body Mass Index data were used, using three cohorts (2010-2011 until 2012-2013) and an interval between the measurement waves of two years later. We performed a multi-level mediation analysis with a two-level structure to incorporate the clustering of the measurements within individuals. The study population consisted of 13,740 secondary school students, 13-14 years old at the first measurement moment, in Amsterdam, the Netherlands. RESULTS: Compared to their normal-weight peers, adolescents with overweight or obesity reported psychosocial problems and suicidal thoughts more often. Victimization was a significant mediator in the relationship between having overweight, and psychosocial problems (indirect effect OR: 2.3; 95% CI 1.5, 3.7 and direct effect OR: 1.4; 95% CI 1.2, 1.7) or suicidal thoughts (indirect effect OR: 2.1; 95% CI 1.4, 3.2 and direct effect OR: 1.3; 95% CI 1.1, 1.5). The associations between obesity, and psychosocial problems (indirect OR: 6.2; 95% CI 2.8, 14.7 and direct effect OR: 1.4; 95% CI 1.0, 2.0), or suicidal thoughts (indirect OR: 4.5; 95% CI 2.3, 9.1 and direct effect OR: 1.5; 95% CI 1.1, 2.0) were even stronger. CONCLUSIONS: Overweight and obesity were significantly associated with mental health problems in adolescents, and victimization played a mediating role in this association. Victimization and mental health should be integrated into prevention programs that address healthy weight development. Moreover, overweight should be given more attention in programs to prevent victimization and promote adolescent mental health.

Sociodemographic differences in 10-year time trends of emotional and behavioural problems among adolescents attending secondary schools in Amsterdam, The Netherlands.

Societal change in western societies may impact emotional and behavioural problems of adolescents. Firm epidemiological evidence of changes in emotional and behavioural problems during the last decade is lacking. Insight into secular changes in emotional and behavioural problems among adolescents from various sociodemographic groups is crucial for adequate and targeted policy making. Therefore, the purpose of this study was to examine 10-year time trends in emotional and behavioural problems among adolescents, and potential differences in time trends between sociodemographic groups. Analyses were based on annually repeated cross-sectional data including 56,159 multi-ethnic students (13-14 years old) in the second year of various levels of secondary education in Amsterdam, The Netherlands, using the internationally validated Strengths and Difficulties Questionnaire. In general, emotional and behavioural problems increased over a 10-year time period (i.e., relative increase of total difficulties by 19%). This increase was mainly due to an increase in hyperactivity/inattention problems, while peer-relationship problems decreased. Time trends differed somewhat by sex: total difficulties and emotional problems increased in girls but remained fairly stable in boys. In Amsterdam, emotional and behavioural problems in adolescents seemingly increased over time, especially hyperactivity/inattention problems. Further research is needed to clarify the underlying causes. We cannot totally exclude potential confounders underlying our findings. Our findings can inform policies to target health programs at sociodemographic groups at increased risk.

A longitudinal study on determinants of HPV vaccination uptake in parents/guardians from different ethnic backgrounds in Amsterdam, the Netherlands.

BACKGROUND: Human papillomavirus (HPV) vaccination coverage in the Netherlands is low (~60%) compared to other childhood vaccinations (>90%), and even lower among ethnic minorities. The aim of this study was to explore the possible impact of ethnicity on the determinants of both HPV vaccination intention and HPV vaccination uptake among parents/guardians having a daughter that is invited for the HPV vaccination. METHODS: In February 2014, parents/guardians living in Amsterdam were invited to complete a questionnaire about social-psychological determinants of their decision making process regarding the HPV vaccination of their daughter and socio-demographic characteristics. This questionnaire was sent approximately one month before the daughter was scheduled to receive her first HPV vaccine dose. Their daughters' HPV vaccination status was retrieved from the national vaccination database. We distinguished four ethnic groups: Dutch (NL), Surinamese, Netherlands Antillean, and Aruban (SNA), Middle-Eastern and North-African (MENA), and Other. To assess the impact of determinants on both intention and uptake, linear and logistic regression analyses were used respectively. Missing data were imputed using multiple imputation by chained equation. RESULTS: In total 1,309 parents/guardians participated (33% participation rate). In all groups we found the mothers' intention to be the strongest predictor of their daughters' HPV vaccination uptake. Explained variance of uptake was highest in the NL-group (pseudo-R2:0.56) and lower in the other ethnic groups (pseudo-R2 varied between 0.23 and 0.29). The lower explained variance can be attributed to the relative large proportion of participants with a positive intention that finally did not go for vaccination in the SNA-group (11%) and MENA-group (30%). Explained variance (R2) of intention varied between 0.66 and 0.77 across ethnic groups, and was best explained by the proximal social-psychological determinants. The strength of association of these determinants with both intention and uptake were largely similar across ethnic groups. CONCLUSION: We conclude that the same determinants should be targeted in the different ethnic groups, although the mode of delivery of the intervention needs to be tailored to the different cultural backgrounds. Further research is needed to explain the observed discrepancy between intention and uptake, especially among parents/guardians in the non-Dutch groups.

Sustainability of the good behaviour game in Dutch primary schools.

Summary: Sustainability of health promotion programs is essential to maintain their positive effects. However, few studies have examined the extent of program sustainability and the factors influencing it. We examined these issues through the Good Behaviour Game (GBG), a classroom-based program in primary schools with beneficial behavioural and health-related effects that was implemented in 2008. GBG coordinators of 17 participating schools were invited in the study 2 years after the initial program implementation. Sustainability was measured using a 20-item checklist comprised of four dimensions of routinization including: memory, adaptation, values and rules. A semi-structured interview was then completed with 16 of the GBG coordinators to discuss the checklist scores and to probe in more depth the current level of sustainability. Based on the checklist scores, sustainability of the GBG was considered 'high' in five schools, 'medium' in another five and 'weak' in six. Factors influencing sustainability identified by GBG coordinators were organizational strength, strong leadership, program championship and the perceived modifiability and effectiveness of the GBG. Also, different factors were related to different dimensions of routinization. The combination of a sustainability checklist and an interview about influential factors may help to further clarify the sustainability construct and reveal which implementation sites, routinization dimensions and influential factors should be explored to further facilitate the sustaining of programs with proven effectiveness.

[Thinness and overweight in children from Amsterdam: a trend analysis and forecast]. / Onder- en overgewicht bij Amsterdamse kinderen: een trendanalyse en prognose.

OBJECTIVE: To determine the trends in prevalence of moderate and severe thinness, overweight and obesity in children living in Amsterdam between 2009 and 2013 and estimate prevalences for 2020. DESIGN: Historical cohort study. METHOD: 158,730 measurements of height and weight of 112,405 children from Amsterdam were analysed. Moderate thinness, severe thinness, overweight and obesity were determined using international BMI cut-off values. Trends were analysed using Generalized Estimating Equations (GEE) for two age groups: pre-schoolers (2 and 3 years) and school-aged children (5, 10 and 14 years). The 'self-projecting method,' which allowed us to extend former trends into the future, was used to estimate prevalences for 2020. RESULTS: The prevalence of moderate thinness increased significantly in both age groups. The prevalence of severe thinness did not change. The prevalences of overweight and obesity declined significantly in both age groups. These trends were most evident in children of Dutch origin. Other ethnic groups also showed declining prevalences but not in both age groups or both categories of overweight. The prognosis for 2020 shows a further decline in the prevalence of overweight and obesity and an increase in the prevalence of thinness. CONCLUSION: A decline in the prevalences of overweight and obesity was observed in Amsterdam children, including children of Turkish and Moroccan origin. The prevalence rates are still high, so investing in prevention remains necessary. The prevalence of moderate thinness also seems to be increasing. Continued monitoring of children in all BMI classes is therefore important.

Indicated Prevention of Childhood Anxiety and Depression: Results From a Practice-Based Study up to 12 Months After Intervention.

OBJECTIVES: We investigated whether intervention effects of FRIENDS for Life, a school-based prevention program for children with anxiety or depression symptoms, were maintained over a period of 12 months after the intervention in a naturalistic setting. METHODS: We used a quasi-experimental design, with 339 children in the intervention group and 157 in the control group (aged 8-13 years) in schools in Amsterdam, the Netherlands. We collected self-, teacher, and peer reports of anxiety and depression scores before and after intervention, and 6 and 12 months after intervention, from 2010 to 2012. RESULTS: Intervention-group children reported a continuing and significant decrease in anxiety and depression scores compared with the control group. Twelve months after the intervention, participants' anxiety and depression levels were comparable to those of the general population. Girls reported a stronger decrease in anxiety scores than did boys. Teacher reports suggested no effects. Although classmates reported increased internalizing problems in intervention-group children immediately after intervention, these effects disappeared over time. CONCLUSIONS: FRIENDS for Life, an indicated prevention program, yielded long-lasting and continuing reduction in anxiety and depression problems when implemented in daily school practice.

Structure, reliability, and validity of the revised child anxiety and depression scale (RCADS) in a multi-ethnic urban sample of Dutch children.

BACKGROUND: Although anxiety and, to a lesser extent, depression are highly prevalent in children, these problems are, difficult to identify. The Revised Anxiety and Depression Scale (RCADS) assesses self-reported symptoms of anxiety and depression in youth. METHODS: The present study examined the factor structure, internal consistency, short-term stability, and validity including sensitivity to change of the RCADS in a multi-ethnic urban sample of 3636 Dutch children aged 8 to 13 years old. RESULTS: Results indicate that the RCADS is a reliable and valid instrument. The original 6-factor structure was replicated to a fair extent in the present study (RMSEA = 0.048) and internal consistency was good (αs = 0.70-0.96). ICCs for short-term stability were 0.76 to 0.86. Girls and children who indicated wishing to participate in a program targeting anxiety and depression had higher RCADS scores. Sensitivity to change analyses showed that the RCADS can detect changes in anxiety and depression symptoms in children who participated in a preventive intervention. The study showed low agreement between teacher and self-reported internalizing problems, even for children scoring above the 90(th) percentile of the RCADS, indicating a high level of problems, emphasizing the need to also take child reports into account when screening for anxiety and depression in children. CONCLUSION: This study shows that the RCADS can yield reliable data on a diversity of anxiety disorders and depression in urban children aged 8-13 from very diverse ethnic backgrounds. TRIAL REGISTRATION: Netherlands Trial Register: NTR2397 . Registered 30 June 2010.

Neighborhood socioeconomic deprivation characteristics in child (0-18 years) health studies: a review.

BACKGROUND: Growing up in socioeconomically deprived neighborhoods has been shown to have negative health effects on children. However, the most recent review on which measures are used to investigate the association between neighborhood characteristics and child (0-18 year) health included studies only until 2004. Insight into more recent research is needed for the further development of these measures. OBJECTIVES: To review neighborhood socioeconomic deprivation characteristics used in recent studies investigating the relationship between neighborhood socioeconomic deprivation and child health. METHODS: Sensitive search in MEDLINE, Embase, PsycINFO, Sociological Abstracts databases (2004-2013). RESULTS: Ultimately, 19 studies were included. We found ten neighborhood socioeconomic deprivation constructs, of which income/wealth, employment, and education were most frequently used. The choice for neighborhood characteristics seemed independent of the health outcome and in most cases was not based on a specific theoretical background or earlier work. CONCLUSION: Studies vary regarding study designs, measures and outcomes. Researchers should clearly specify their choice of neighborhood socioeconomic deprivation characteristics; preferably, these should be theory-based and used consistently.

A mixed methods process evaluation of the implementation of JUMP-in, a multilevel school-based intervention aimed at physical activity promotion.

BACKGROUND: The aim of the present study was to investigate factors influencing the adoption, implementation, and institutionalization process of JUMP-in-a multilevel school-based physical activity promotion program-to optimize the dissemination of the intervention and improve its effectiveness. The process evaluation concerned the constraints and success and failure factors at sociopolitical, organizational, user, and intervention levels. METHODS: A mixed methods approach including qualitative and quantitative data was conducted during two school years (2006-2008). RESULTS: JUMP-in was successfully embedded in the Amsterdam municipal policy and in the organizational structure and daily practices of the sectors involved. A general impeding factor was the complexity of the multilevel programme requiring multidisciplinary collaboration between organizations. In addition, there was a discrepancy between the recommendation to standardize and simplify the innovation and the need to tailor the strategies to local environmental, social, and cultural aspects. CONCLUSIONS: This process evaluation provides challenges and remedies for managing discrepancies between prerequisites for an effective innovation and demands of daily implementation practice. The main recommendations are (a) standardized, simplified guidelines; (b) stepwise implementation; (c) formalized coalitions, integration of policy, and synchronization of tasks and protocols; and (d) smart planning and control by clear communication and feedback instruments. If these recommendations are incorporated into the JUMP-in intervention and organization, increased effectiveness and long-term effects can be expected.