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We examined if the assessment of the health impact of a national Dutch regeneration programme depends on using either a repeated cross-sectional or longitudinal study design. This is important as only the latter design can incorporate migration patterns. For both designs, we compared trends in medication use between target and control districts. We found differences in medication use trends to be modest under the longitudinal design, and not demonstrable under the repeated cross-sectional design. The observed differences were hardly influenced by migration patterns. We conclude that in the Netherlands migration patterns had little effect on the health impact assessment of this national urban regeneration programme, so either the cross-sectional or longitudinal evaluation study design will do.

Background We propose using neighborhood characteristics as demand-related morbidity adjusters to improve prediction models such as the risk equalization model. Results Since the neighborhood has no explicit ‘place’ in healthcare demand models, we have developed the “Neighborhood and healthcare utilization model” to show how neighborhoods matter in healthcare utilization. Neighborhood may affect healthcare utilization via (1) the supply-side, (2) need, and (3) demand for healthcare – irrespective of need. Three pathways are examined in detail to explain how neighborhood characteristics influence healthcare utilization via need: the physiological, psychological and behavioral pathways. We underpin this theoretical model with literature on all relevant neighborhood characteristics relating to health and healthcare utilization. Conclusion Potential neighborhood characteristics for the risk equalization model include the degree of urbanization, public and open space, resources and facilities, green and blue space, environmental noise, air pollution, social capital, crime and violence, socioeconomic status, stability, and ethnic composition. Air pollution has already been successfully tested as an important predictive variable in a healthcare risk equalization model, and it might be opportune to add more neighborhood characteristics. Electronic supplementary material The online version of this article (10.1186/s13561-019-0226-x) contains supplementary material, which is available to authorized users.

Aim: To study the general health impact of urban regeneration programmes in deprived Dutch districts. We compared initiatives that focused on the improvement of place with initiatives that mainly invested in people. Method: A quasi-experimental design compared the trend in good perceived general health in the target districts with comparison districts. Generalized general mixed models assessed the rate of change in prevalence of good health per half year during a prolonged period before and after the start of the interventions. Results: Neither the target districts that invested mainly in place nor the ones with interventions focused on people showed trends in general health different than comparison districts (p > 0.05). However, only districts with interventions focused on place showed no deterioration in general health during the intervention period. The trend change in these districts differed significantly from the change in the districts that invested mainly in people (p

Item does not contain fulltext The aim of the study is to assess the impact of perceived and objective changes in greenery on physical activity and mental health of adolescents and adults living in severely deprived neighborhoods in the Netherlands. Longitudinal data regarding changes in greenery, walking, cycling, and depressive symptoms (CES-D), were gathered for 401 adolescents and 454 adults, using questionnaires and interviews with local district managers. Multivariate linear regression models examined the association between greenery and outcome variables, correcting for demographic and socioeconomic covariates and season. Overall, the results showed small and non-significant associations, with two exceptions. Objective improvements in greenery were associated with smaller decline in adolescents' leisure time cycling, and improvements in perceived greenery were related to a decrease in adults' depressive symptoms. In addition, there were several subgroup effects. In conclusion, changes in greenery did not yield consistent positive results among residents of severely deprived neighborhoods. However, there are some indications regarding positive effects of greenery in certain subgroups. 8 p.

Background This paper aims to assess the mental health impact of an urban regeneration programme implemented from 2008 onwards in the 40 most deprived districts in the Netherlands. Interventions varied from improvements in the built environment to activities promoting social cohesion.Methods We accessed repeated cross-sectional data from the annual Health Interview Survey, for the period 2004–2011 among adults (n target districts=1445, n rest of the Netherlands=44 795). We used multilevel logistic regression models to compare the development of mental health in the target districts with the rest of the Netherlands and with comparably deprived districts. Results were presented as ‘slope estimates’ with corresponding 95% CIs. Finally, we analysed the trends by gender and by the intensity of the programme.Results The trend change in mental health between the intervention and preintervention period was approximately the same in the target districts as in broadly comparably deprived control districts (Δ slope 0.06 (−0.08 to 0.20)). However, among women, a tendency was found towards more positive trend changes in the target districts compared with control districts (Δ slope 0.17 (−0.01 to 0.34)). Those districts that implemented an intensive programme experienced an improvement in mental health, while residents of the comparably deprived control districts experienced a deterioration, resulting in a statistically significantly more positive trend change between the preintervention and intervention period in those target districts (Δ slope 0.19 (0.01 to 0.38)).Conclusions Implementing an urban regeneration programme with a wide range of intensive interventions may be effective in promoting good mental health. Further research is required to examine which mix of interventions is needed for the programme to be effective.

BackgroundLarge-scale regeneration programmes to improve the personal conditions and living circumstances in deprived areas may affect health and the lifestyle of the residents. Previous evaluations concluded that a large-scale urban regeneration programme in the Netherlands had some positive effects within 3.5 years. The aim of the current study was to evaluate the effects at the longer run.MethodsWith a quasi-experimental research design we assessed changes in the prevalence of general health, mental health, physical activity, overweight, obesity, and smoking between the pre-intervention (2003–04 –mid 2008) and intervention period (mid 2008–2013–14) in 40 deprived target districts and comparably deprived control districts. We used the Difference-in-Difference (DiD) to assess programme impact. Additionally, we stratified analyses by sex and by the intensity of the regeneration programme.ResultsChanges in health and health related behaviours from pre-intervention to the intervention period were about equally large in the target districts as in control districts. DiD impact estimates were inconsistent and not statistically significant. Sex differences in DiD estimates were not consistent or significant. Furthermore, DiD impact estimates were not consistently larger in target districts with more intensive intervention programmes.ConclusionWe found no evidence that this Dutch urban regeneration programme had an impact in the longer run on self-reported health and related behaviour at the area level.

Dit artikel geeft een samenvatting van de huidige, beschikbare kennis in reviews over de gezondheidseffecten van veranderingen in verschillende maatschappelijke determinanten van gezondheid, te weten werksituatie, inkomen, opleidingsniveau, fysieke woonomgeving en sociale veiligheid. We vonden negen reviews. Drie reviews rapporteren dat mensen die gaan werken in een betaalde baan een duidelijke verbetering van hun geestelijk welbevinden ervaren. De effecten op fysieke gezondheidsuitkomsten zijn niet eenduidig. Een inkomensstijging gaat gepaard met een betere algemene ervaren gezondheid en minder depressieve symptomen, maar ook met ongezonder gedrag, bleek uit vier reviews. De enige review over veranderingen in het opleidingsniveau concludeert dat er aanwijzingen zijn dat scholing op een positieve manier de gezondheid beinvloedt, maar er is nog te weinig onderzoek naar verricht voor een definitieve conclusie. De twee reviews over de gezondheidseffecten van verandering in de woonomgeving betreffen alleen evaluatiestudies uit Groot-Brittannie met bovendien inconsistente resultaten. Wij vonden geen reviews over de mogelijke gezondheidswinst die is te behalen door de verbetering van sociale veiligheid. We concluderen dat er voldoende bewijs is dat het verwerven van een betaalde baan of het verhogen van het inkomen van lagere sociaal-economische groepen gepaard gaat met positieve ontwikkelingen in de gezondheid. Dit ondersteunt de gedachte dat het bevorderen van de werkgelegenheid en verhogen van inkomens aangrijpingspunten vormen voor het bevorderen van de volksgezondheid. Of ook veranderingen in het opleidingsniveau, de fysieke woonomgeving en sociale veiligheid potentieel gezondheidswinst opleveren, kan op basis van het beschikbare onderzoek niet geconcludeerd worden.

There is limited evidence on the causality of previously observed associations between neighborhood characteristics and physical activity (PA). We aimed to assess whether individual-level PA was associated with changes in fear of crime, social cohesion, green spaces, parking facilities, social disorder, and physical disorder that occurred over the past 3 years. In general, in neighborhoods where residents had more favorable perceptions of the environment in 2006, residents were more likely to be physically active in 2009. In addition, improvements between 2006 and 2009 with respect to perceived social cohesion, green spaces, social disorder, and physical disorder were associated with increased odds of being active in 2009. For both the levels in 2006 and trends in the period 2006-2009, the associations were somewhat stronger among women than among men, but associations did not vary by age or length of residence. For several environmental factors, we observed that not only the levels at a certain point in time, but also recent improvements over time were related to PA. These results provide new support for a causal relationship between these environmental factors and PA.

Objectives The purpose of this review was to systematically summarise the literature on the health effects of employment. Methods A search for prospective studies investigating the effect of employment on health was executed in several electronic databases, and references of selected publications were checked. Subsequently, the methodological quality of each study was assessed by predefined criteria. To draw conclusions about the health effect of employment, a best evidence synthesis was used, and if possible, data were pooled. Results 33 prospective studies were included, of which 23 were of high quality. Strong evidence was found for a protective effect of employment on depression and general mental health. Pooled effect sizes showed favourable effects on depression (OR=0.52; 95% CI 0.33 to 0.83) and psychological distress (OR=0.79; 95% CI 0.72 to 0.86). Insufficient evidence was found for general health, physical health and mortality due to lack of studies or inconsistent findings. Conclusions This systematic review indicates that employment is beneficial for health, particularly for depression and general mental health. There is a need for more research on the effects of employment on specific physical health effects and mortality to fill the knowledge gaps.

International audience; Background: The role of differences in diet on the relationship between socioeconomic factors and cardiovascular diseases remains unclear. We studied the contribution of diet and other lifestyle factors to the explanation of socioeconomic inequalities in cardiovascular diseases. Methods: We prospectively examined the incidence of coronary heart disease (CHD) and stroke events amongst 33,106 adults of the EPIC-NL cohort. Education and employment status indicated socioeconomic status. We used Cox proportional models to estimate hazard ratios ((HR (95% confidence intervals)) for the association of socioeconomic factors with CHD and stroke and the contribution of diet and lifestyle. Results: During 12 years of follow-up, 1617 cases of CHD and 531 cases of stroke occurred. The risks of CHD and stroke were higher in lowest (HR = 1.98 (1.67; 2.35); HR = 1.55 (1.15; 2.10)) and lower (HR = 1.50 (1.29; 1.75); HR = 1.42 (1.08; 1.86)) educated groups than in the highest. Unemployed and retired subjects more often suffered from CHD (HR = 1.37 (1.19; 1.58); HR = 1.20 (1.05; 1.37), respectively), but not from stroke, than the employed. Diet and lifestyle, mainly smoking and alcohol, explained more than 70% of the educational differences in CHD and stroke and 65% of employment status variation in CHD. Diet explained more than other lifestyle factors of educational and employment status differences in CHD and stroke (36% to 67% vs. 9% to 27%). Conclusion: The socioeconomic distribution of diet, smoking and alcohol consumption largely explained the inequalities in CHD and stroke in the Netherlands. These findings need to be considered when developing policies to reduce socioeconomic inequalities in cardiovascular diseases. (C) 2013 Elsevier Ireland Ltd. All rights reserved.

Health literacy has been put forward as a potential mechanism explaining the well-documented relationship between education and health. However, little empirical research has been undertaken to explore this hypothesis. The present study aims to study whether health literacy could be a pathway by which level of education affects health status. Health literacy was measured by the Health Activities and Literacy Scale, using data from a subsample of 5,136 adults between the ages of 25 and 65 years, gathered within the context of the 2007 Dutch Adult Literacy and Life Skills Survey. Linear regression analyses were used in separate models to estimate the extent to which health literacy mediates educational disparities in self-reported general health, physical health status, and mental health status as measured by the Short Form-12. Health literacy was found to partially mediate the association between low education and low self-reported health status. As such, improving health literacy may be a useful strategy for reducing disparities in health related to education, as health literacy appears to play a role in explaining the underlying mechanism driving the relationship between low level of education and poor health.

Background Earlier research has shown that residents of Dutch deprived neighbourhoods drink less alcohol than people in other areas. We aimed to assess the role of individual and neighbourhood characteristics in a cross-sectional, nationwide, multilevel study. Methods Individual data of 30 117 Dutch adults, living in 1722 neighbourhoods across the Netherlands, were obtained from the 2004 to 2009 national health survey (POLS). Chronic heavy alcohol consumption was measured as ≥14 drinks/week for women and ≥21 for men, and episodic heavy drinking as ≥6 drinks/day at least once a week. Neighbourhood deprivation was dichotomous; deprived districts as selected by the Dutch government versus other areas. Multilevel logistic regression models of the association between deprivation and heavy drinking were corrected for age, gender, household composition, population density and potential predictors ethnicity, socioeconomic status (education, income), neighbourhood-level social cohesion and percentage Muslims. Results The prevalence of heavy drinking was lower in deprived neighbourhoods than in the rest of the Netherlands. This association was found for both chronic and episodic heavy drinking (OR=0.58 (0.47 to 0.72) and OR=0.57 (0.45 to 0.72), respectively). Adding ethnicity to the model reduced these associations by approximately one half. Socioeconomic composition did not contribute to the relationship. The proportion of Muslims explained a small part, while social cohesion explained even less of the association. Stronger associations were observed for women and older adults than for men and younger adults. Conclusions The lower prevalence of heavy drinking occurring in deprived areas is largely explained by the ethnicity of neighbourhood residents.

Quantifying the impact of different modifiable behavioral and biological risk factors on socioeconomic disparities in coronary heart disease (CHD) may help inform targeted, population-specific strategies to reduce the unequal distribution of the disease. Previous studies have used analytic approaches that limit our ability to disentangle the relative contributions of these risk factors to CHD disparities. The goal of this study was to assess mediation of the effect of low education on incident CHD by multiple risk factors simultaneously. Analyses are based on 15,067 participants of the Dutch Monitoring Project on Risk Factors for Chronic Diseases aged 20-65 years examined 1994-1997 and followed for events until January 1, 2008. Path analysis was used to quantify and test mediation of the low education-CHD association by behavioral (current cigarette smoking, heavy alcohol use, poor diet, and physical inactivity) and biological (obesity, hypertension, diabetes, and hypercholesterolemia) risk factors. Behavioral and biological risk factors accounted for 56.6 % (95 % CI 42.6-70.8 %) of the low education-incident CHD association. Smoking was the strongest mediator, accounting for 27.3 % (95 % CI 17.7-37.4 %) of the association, followed by obesity (10.2 %; 95 % CI 4.5-16.1 %), physical inactivity (6.3 %; 95 % CI 2.7-10.0 %), and hypertension (5.3 %; 95 % CI: 2.8-8.0 %). In summary, in a Dutch cohort, the majority of the relationship between low education and incident CHD was mediated by traditional behavioral and biological risk factors. Addressing barriers to smoking cessation, blood pressure and weight management, and physical activity may be the most effective approaches to eliminating socioeconomic inequalities in CHD.

Background Many problems concentrate in deprived neighbourhoods, among which is poor health. One possible way to address these health problems is to invest in the green space in deprived neighbourhoods. The number of evaluations of the public health impact of actual changes in neighbourhood green space is still limited. This study investigated the impact of real-life changes in the quality or quantity of green space in severely deprived neighbourhoods on physical activity and perceived general health.Methods Repeated cross-sectional surveys from 2004 till 2011 yielded self-reported information on leisure time walking, cycling and sports, and perceived general health of 48 132 adult residents. We fitted generalised mixed models to assess the rate of change per half year, estimate the linear trend, and the change in trends before and after the start of the urban regeneration mid-2008. Using a quasi-experimental design, we compared the trends in the intervention neighbourhoods with different selections of control areas.ResultsThe deprived neighbourhoods that intervened in green space did not show more favourable changes in the trend of physical activity and good general health compared to all the different groups of control areas.Conclusions We did not observe short-term positive effects on physical activity and general health among adults from improvements in green space in deprived neighbourhoods. This suggests that greening interventions that have been carried out in the context of the Dutch District Approach did not achieve short-term health gains among adults.

We estimate to what extent migration contributes to inequalities in health between rich and poor neighbourhoods in The Netherlands. We used a sample from the survey WoonOnderzoek Nederland 2006. Using multilevel logistic regression analyses, we assessed the magnitude of health differences between poor vs. rich areas for the migrant and total population. Next, we compared the health of migrants to non-migrant populations and we assessed the role of sociodemographic characteristics. For most health indicators, area inequalities in health were much smaller in the migrant population than in the total population. The health of migrants was generally in-between the health of non-migrants who lived in areas of origin and destination. The differences in health with the population in the areas of origin were almost completely explained by sociodemographic characteristics. Health is related to risk of migration between poor and rich areas, mostly through sociodemographic selection instead of a direct effect of health. Despite the relationship with health, migration does not enlarge inequalities in health between poor and rich neighbourhoods but possibly attenuates the health differences.

Sinds 2007 investeert het kabinet in 40 krachtwijken waar grote maatschappelijke problemen spelen, waaronder een slechte gezondheid. In dit artikel wordt de gezondheidssituatie in 30 krachtwijken vergeleken met die in andere wijken in dezelfde steden en wordt nagegaan in hoeverre verschillen in bevolkingssamenstelling de gezondheidsverschillen verklaren. Methode: De gegevens komen uit de Lokale en Nationale Monitor Gezondheid (n=28.256) en zijn tussen 2003 en 2008 door de GGD’en verzameld. General Linear Models (GLM) en logistische regressieanalyses zijn gebruikt om verschillen in rookgedrag, alcoholconsumptie, lichaamsbeweging, groente- en fruitconsumptie, ervaren gezondheid, gewicht, diabetes en astma te analyseren. Resultaten: De bewoners in de krachtwijken ervaren hun gezondheid als slechter (odds ratio (OR) 1,39), hebben vaker obesitas (OR 1,16), astma (OR 1,33) en diabetes (OR 1,54). Ze roken vaker (OR 1,35) en bewegen minder vaak (OR 1,20). Er zijn geen verschillen in voeding, terwijl overmatig alcoholgebruik iets minder vaak voorkomt in krachtwijken en meer mensen geen alcohol drinken (OR 1,85). De verschillen worden grotendeels verklaard door de verschillen in opleiding en etnische achtergrond. Conclusie: Deze resultaten bevestigen dat aandacht voor gezondheid in de krachtwijken belangrijk is. Te verwachten valt dat maatregelen gericht op bewoners (scholing, arbeid) en omgeving (wonen, veiligheid) de gezondheid in de krachtwijken positief kan beinvloeden. Vooral de aanpak van astma en roken zijn daarbij belangrijk. Om een effect van de wijkenaanpak te kunnen vaststellen blijft het evalueren van de gezondheidssituatie in de krachtwijken nodig.

Het URBAN40 onderzoek concludeerde dat de wijkgerichte aanpak van leefbaarheidsproblemen in de aandachtswijken, binnen een beperkt aantal jaren na start ervan heeft geleid tot relatief gunstige ontwikkelingen op een aantal gezondheidsaspecten.

Background: Urban residents have higher mortality risks than rural residents. These urban- rural differences might be more pronounced within certain demographic sub-populations. Aim: To determine urban- rural differences in all- cause and cause- specific mortality within specific demographic subpopulations of the Dutch population. Method: Mortality records with information on gender, age, marital status, region of origin and place of residence were available for 1995 through 2000. Neighbourhood data on address density and socioeconomic level were linked through postcode information. Variations in all-cause and cause- specific mortality between urban and rural neighbourhoods were estimated through Poisson regression. Additionally, analyses were stratified according to demographic subpopulation. Result: After adjustments for population composition, urban neighbourhoods have higher all- cause mortality risks than rural neighbourhoods ( RR= 1.05; Cl 1.04 to 1.05), but this pattern reverses after adjustment for neighbourhood socioeconomic level ( RR= 0.98; Cl 0.97 to 0.99). The beneficial effect of living in an urban environment applies particularly to individuals aged 10 - 40 years and 80 years and above, people who never married and residents from non- Western ethnic origins. The beneficial effect of urban residence for non- married people is related to their lower cancer and heart disease mortality. The beneficial effect of urban residence for people of non- Western ethnic origin is related to their lower cancer and suicide mortality. Conclusion: In The Netherlands, living in an urban environment is not consistently related to higher mortality risks. Young adults, elderly, single and non- Western residents, especially, benefit from living in an urban environment. The urban environment seems to offer these subgroups better opportunities for a healthy life.

In general, inhabitants of low socio-economic areas are unhealthier than inhabitants of high socio-economic areas, but some areas are an exception to this rule. These exceptions imply that other factors besides the socio-economic level of an area contribute to the health of the inhabitants of an area, e.g. environmental factors. In our study we concentrate on areas within the Netherlands that are healthier or unhealthier than could be expected based on their socio-economic level. This study first identifies these areas and secondly determines which area characteristics distinguish these areas from those areas where the level of health is in agreement with their socio-economic level. We used nation-wide data on neighbourhood differences in population composition (gender, age, marital status and ethnicity), urbanisation and two health indicators: mortality and hospitalisation rates. In the Netherlands, many areas are healthier or unhealthier than could be expected based on their income level alone. Areas with higher mortality rates than expected are mainly urban areas with high percentages of elderly people and persons living alone. Similar but opposite associations are observed for areas with lower mortality rates than expected, which are further characterised by a low percentage of non-western immigrants. Areas with lower hospitalisation rates than expected are mainly rural areas with few non-western immigrants. From these results, we conclude that urbanisation and residential segregation based on age, ethnicity and marital status might be important contributors to geographical health inequalities.

Background When striving for health equity, we need to find ways to improve the circumstances in which people are born, grow, live, work, and age, also called the social determinants of health. However, we still lack sufficient knowledge on evidence-based strategies addressing these social determinants of health. Area-based interventions that target deprived neighbourhoods are one possible way to deliver the complex interventions needed to tackle these determinants of health. In the URBAN40 study, we …

Background Area crime and perceived safety are two components of social safety that are presumed to affect individual health and health related behaviour. So far, most studies have used cross-sectional data to study this relation. We have investigated changes in social safety in relation to self-rated general health and physical activity (PA), in order to provide support for a causal relationship between social safety and health. Additionally, we investigated whether social cohesion modifies this relation. Methods The Dutch Housing Survey 2012 provided information …

Objectives. We investigated the relationship among father’s occupational group, daily smoking, and smoking determinants in a cohort of New Zealand adolescents. Methods. The longitudinal Multidisciplinary Health and Development Study provided information on adolescents’ self-reported smoking behavior and potential predictors of smoking, such as social and material factors, personality characteristics, educational achievement, and individual attitudes and beliefs regarding smoking. Longitudinal logistic generalized estimating equation analyses were used. Results. Adolescents whose fathers were classified in the lowest-status occupational group were twice as likely as those whose fathers occupied the highest-status occupational group to be daily smokers. This high risk of daily smoking among the adolescents from the lowest occupational group was largely predicted by their lower intelligence scores and by the higher prevalence of smoking among fathers and friends . Conclusions. To prevent socioeconomic differences in smoking, school-based interventions should seek to prevent smoking uptake among adolescents, particularly those of lower socioeconomic status. Programs need to provide positive, nonsmoking role models consonant with the culture and norms of lower-socioeconomic-status groups. Adolescents need to acquire resistance skills and protective behaviors against social pressure and influences.

Geographic patterns of poor health and mortality risk are found in most countries. Important health effects at the neighborhood level are mortality, general health, illness and disabilities, mental health, and healthcare utilization. Awareness of the influence of social class on health has been growing during the last decades. Studies show that individuals with lower socioeconomic status (SES) have a shorter life expectancy than do their 'well-off' counterparts. Yet SES-related health inequalities cannot be fully explained by individual characteristics, and environmental qualities should be taken into account. Many aspects of local areas that might be related to health or access to opportunities to live healthily are systematically poorer in socially disadvantaged areas. Such factors have the potential to explain health differences between deprived and prosperous neighborhoods. Investigating health differences at the neighborhood level implies conceptual as well as methodological issues pertaining to selection, accumulation, multiple level measurement, objective features versus perceptions, and time dynamic aspects. This article reviews such issues and evaluates several exemplary theoretical approaches from the fields of public health and environmental health in their ability to overcome such problems.

Background Numerous area-based initiatives have been implemented in deprived areas across Western-Europe with the aim to improve the socio-economic and environmental conditions in these areas. Only few of these initiatives have been scientifically evaluated for their impact on key social determinants of health, like perceived area safety. Therefore, this study aimed to assess the impact of a Dutch area-based initiative called the District Approach on trends in perceived area safety and underlying problems in deprived target districts. Methods A quasi-experimental design was used. Repeated cross-sectional data on perceived area safety and underlying problems were obtained from the National Safety Monitor (2005?2008) and its successor the Integrated Safety Monitor (2008?2011). Study population consisted of 133,522 Dutch adults, including 3,595 adults from target districts. Multilevel logistic regression analyses were performed to assess trends in self-reported general safety, physical order, social order, and non-victimization before and after the start of the District Approach mid-2008. Trends in target districts were compared with trends in various control groups. Results Residents of target districts felt less safe, perceived less physical and social order, and were victimized more often than adults elsewhere in the Netherlands. For non-victimization, target districts showed a somewhat more positive change in trend after the start of the District Approach than the rest of the Netherlands or other deprived districts. Differences were only statistically significant in women, older adults, and lower educated adults. For general safety, physical order, and social order, there were no differences in trend change between target districts and control groups. Conclusions Results suggest that the District Approach has been unable to improve perceptions of area safety and disorder in deprived areas, but that it did result in declining victimization rates.

Background: Social and physical environments are important drivers of socioeconomic inequalities in health behaviour. Although many interventions aiming to improve such environments are being implemented in underprivileged neighbourhoods, implementation processes are rarely studied. Acquiring insight into successful implementation may improve future interventions. The present study aimed to investigate factors influencing the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of social and physical environmental interventions aimed at promoting healthy behaviour in underprivileged neighbourhoods in The Netherlands. Methods: A large set of theory-based factors of successful implementation was assessed for 18 implemented interventions in three underprivileged neighbourhoods. Expert and target group panels scored the RE-AIM dimensions for each intervention. We analyzed the statistical significance of associations between theory-based factors and the actual RE-AIM in a statistical model, to identify factors associated with increased RE-AIM. Results: Six factors were identified: effectiveness and implementation success were higher when the target group was involved in the planning process, whereas maintenance increased in the absence of competition with other projects. If the current situation was inventoried during intervention development, the effectiveness, adoption and implementation were higher. These dimensions were also higher when the target group was informed before implementation. Involvement of the target group during implementation resulted in higher reach, effectiveness and adoption. Finally, lack of intervention staff worsened the reach. Discussion: This study contributes to the evidence base for effective implementation of environmental measures aimed at promoting healthy behaviours. In particular, interventions in which the target group was involved in the implementation process were associated with higher RE-AIM outcomes.

INTRODUCTION: Little is known about the cost-effectiveness of tobacco control policy for different socioeconomic status (SES) groups. We aimed to evaluate SES-specific cost-effectiveness ratios of policies with known favorable effect in low-SES groups: a tobacco tax increase and reimbursement of cessation support.METHODS: A computer model of the adult population specified by smoking behavior (never/current/former smoker), age, gender, and SES simulated policy scenarios reflecting the implementation of a €0.22 tobacco tax increase or full reimbursement of cessation support, which were compared. Relating differences in costs to quality-adjusted life years (QALYs) gained generated cost-effectiveness ratios for each SES group.RESULTS: In a cohort of 11 million people, the tobacco tax increase resulted in 27,000 additional quitters after 5 years, who were proportionally divided among the SES groups. Reimbursement led to 59,000 additional quitters, with relatively more quitters in higher-SES groups. The number of QALYs gained were 3,400-6,200 among the various SES groups for the tax increase and 6,300-14,000 for the reimbursement scenario. For both interventions, favorability of the cost-effectiveness ratios increased with SES: costs per QALY decreased from €6,100 to €4,500 for the tax increase and from €21,000 to €11,000 for reimbursement.CONCLUSIONS: The reimbursement policy produced the greatest overall health gain. Surprisingly, neither tax increase nor reimbursement reduced health disparities. Differences in use were too small to compensate for improved health gains per quitter among higher-SES groups. Both policies qualified as cost-effective overall, with more favorable cost-effectiveness ratios for high-SES than for low-SES groups.

Corresponding Author: Eelco A. B. Over, PhD, Center for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), PO Box 1, 3720 BA Bilthoven, The Netherlands. Telephone: +31-30-274-2700; Fax: +31-30-274-4407; E-mail: eelco.over@rivm.nlReceived March 18, 2014; accepted March 25, 2014We would like to thank Van der Deen, Wilson, and Blakely for their thoughtful comments on our article (Over et al., 2014). They clearly explain the importance of modeling in order to investigate the long-term (cost-) effectiveness of tobacco prevention programs. We gladly take the opportunity to elaborate on our projections of health disparities and cost-effectiveness, starting with the sugges-tion that there may be a methodological reason for the finding that neither tax increase nor reimbursement reduced health disparities.We agree with Van der Deen et al. that socioeconomic status (SES) and age are not independent in the Netherlands. Also in the Chronic Disease Model, these parameters are dependent. This dependency is an additional important factor that affects SES dif-ferences in health gain and cost-effectiveness ratios, besides the five that we already mentioned: differences in baseline start and quit rates, differences in program participation, differences in pol-icy effect, and differences in all-cause mortality risks. According to the suggestion by Van der Deen et al., we reran our analyses for three age groups: 25–40, 41–60, and 61–80. Table 1 shows the stratified results. The cost-effectiveness ratios increase with age, so that the youngest age group is the most cost-effective. In addition, quality-adjusted life years gained per 1,000 smokers is lowest in the oldest group. Only for tax increases in the youngest age group, the cost-effectiveness ratio is slightly more favorable in low compared to high SES groups. However, none of the age groups showed reduced health disparities.The second comment of Van der Deen et al. refers to the importance of uncertainty analyses in cost-effectiveness mod-eling. This is certainly important, especially with regard to the price elasticity values. Because we were unable to find directly usable Dutch data on tobacco price elasticity in four-category-SES groups, we calculated best estimates based on adjusted for-eign data. These calculations obviously introduce an additional source of uncertainty. The health-disparity effect of reimburse-ment is also uncertain. For example, when we would have taken into account the uncertainty of participation for different SES groups in our reimbursement analyses, they would probably show increased as well as reduced health disparities. Van den Berg et al. did not find any significant differences in quit attempts between the SES groups (Van den Berg, Soethout, Hollinga, & Schipperen, 2009). With no significant differences in participa-tion, the smaller baseline quit rates of low SES groups drive the results toward a lower effectiveness in these groups.The final suggestion by Van der Deen et al. is to exploit the possibility of simulation modeling to evaluate “what-if” scenarios. Indeed, these possibilities are virtually infinite. However, we performed our studies in support of the Dutch Ministry of Health, Welfare, and Sport. Their main interest is in the evaluation existing or new actual policy measures that are feasible in “real life.” Evaluating continuous reimbursement is an interesting option however.Our initial expectations were that the financial incentives for smokers in the investigated interventions would provide an advantage to lower SES groups. This was mainly based on previ-ous reviews of the literature, revealing small advantages in effec-tiveness for the low SES groups for this type of interventions. The modeling results did not clearly show reduced health dispari-ties, and this may be explained by the rather unfavorable settings of the other factors mentioned previously for low SES groups: their baseline start rates are higher and quit rates are lower, they show lower participation and larger all-cause mortality, leaving less potential to profit from an effective intervention. It, therefore, seems that financial incentives alone are insufficient to reduce health disparities, and that every effort should be made to prevent tobacco use, particularly among lower SES groups. Our addi-tional analyses further show that even in younger age groups—that show most value for money for both the tax increase and reimbursement policies—these interventions did not reduce health disparities.

Background Literature suggests that children’s educational achievement is associated with their health status and the socioeconomic position of their parents. Few studies have investigated this association in adolescence, while this is an important period affecting future life trajectories. Our study investigates the relationship between adolescents’ health and their subsequent school career, taking into account their parents’ socioeconomic position. Methods Data of all Dutch adolescents who entered secondary education in 2003, according to the national education register, were linked to electronic health records from general practices and to data from the Dutch population register on a patient by patient basis. Secondary school career data of 2455 adolescents were available for several years, resulting in a longitudinal prospective cohort. School career was measured by the completion of secondary education within the research period. Results For most health problems, adolescents’ health status at the moment of entering secondary education showed no association with the subsequent course of their school career. However, adolescents who had more frequent contact with their general practitioner for acute psychosocial problems (e.g. enuresis or overactive/hyperkinetic disorder), were less likely to complete their secondary education, also after adjustment for parental socioeconomic position. They were also less likely to complete their secondary education at the level of entry. Conclusions Adolescents’ secondary school career is negatively affected by the presence of acute psychosocial health problems, but not by the presence of physical health problems. This underlines the importance of adequately addressing mental health problems in adolescence. Electronic supplementary material The online version of this article (doi:10.1186/1471-2458-14-1104) contains supplementary material, which is available to authorized users.

Objective We studied the local manifestation of a national procedural program that addressed problems regarding employment, education, housing and the physical neighborhood environment, social cohesion, and safety in the most deprived neighborhoods in the Netherlands. We aimed to assess if such a program, without the explicit aim to improve health, results in area-based interventions that address the social determinants of health to such an extent that future health impacts may be expected. Methods We used standardized questionnaires and face-to-face interviews with 39 local district managers. We analyzed the content of the area-based interventions to assess if the activities addressed the social determinants of health. We assessed the duration and scale of the activities in order to estimate their potential to change social determinants of health. Results Most districts addressed all six categories of social determinants of health central to the procedural program. Investments in broad-based primary schools, housing stock, green space, and social safety seemed to have the potential to result in district-level changes in social determinants. The scale of activities aimed at employment, income, educational attainment, and the social environment seemed too small to expect an impact at the district level. Conclusion We conclude that the area-based interventions addressed the neighborhood environment to such an extent that future health impacts of the Dutch District Approach may be expected. The health effects in the long term might be more substantial when area-based interventions were devoted more to the improvement of the socioeconomic circumstances of residents.

STUDY OBJECTIVE—This study describes educational differences in decreases in leisure time physical activity among an adult, physically active population and additionally attempts to identify predictors of these differences from information on health status and individual and environmental factors. DESIGN—Prospective population based study. Baseline measurement were carried out in 1991 and follow up in 1997. SETTING—South eastern part of the Netherlands. PARTICIPANTS—The study included 3793 subjects who were physically active in 1991 and who participated in the follow up. METHODS—Potential predictors of decreasing physical activity were measured in 1991. Logistic regression analyses were carried out for two age groups (

Objectives We aim to describe the intention to quit smoking among Chinese male smokers from different educational backgrounds and to explain this intention from their attitude, perceived social norms and self-efficacy regarding smoking cessation. Setting Participants were recruited from workplaces and communities to reflect the occupational distribution in three cities (Shanghai, Nanning and Mudanjiang) in China. Design and participants In 2013 interviews were conducted with 3676 male smokers aged 18 years and older. Outcome measures Multivariate logistic regression analyses calculated educational differences in the intention to quit smoking as well as the association between the intention to quit smoking and attitude, subjective norms, and self-efficacy. Bootstrapping estimated to what extent the educational disparities in the intention to quit smoking were mediated by these three determinants. Results No educational disparities in the intention to quit smoking within 1 or 6 months were observed among male Chinese smokers (p=0.623 and p=0.153, respectively). A less negative attitude, a higher perceived subjective norm towards smoking cessation, and a higher perceived self-efficacy to quit smoking were all associated with intention to quit (all p values

Background: Body mass index (BMI) differs by socio-demographic variables, but the origin of these associations remains relatively unknown. Objective: To investigate the association between socio-demographic variables and the subsequent change in BMI over six years. Design: A Dutch prospective cohort study (GLOBE) from which data were used from initially 20–49-year-old subjects (males: n=362; females: n=405). BMI was calculated from self-reported body height and weight data obtained in 1991 and 1997. Socio-demographic variables used were sex, age, educational level and the occupational level of the main breadwinner, family income, marital status, religious affiliation and degree of urbanization and measured in 1991. Results: Cross-sectionally, BMI was higher in males than in females. BMI was positively associated with age and negatively associated with educational level in both sexes, after adjustment for the other socio-demographic variables. A positive association of BMI with family income was found in males and a negative association with occupational level was found in females. During follow-up, BMI increased significantly more in females (from 23.0 (s.d. 3.3) to 24.2 (s.d. 3.8)) than in males (from 24.3 (s.d. 2.9) to 25.1 (s.d. 3.5)). With the exception of a significant lesser increase in BMI in initially 30–39-year-old women compared to initially 40–49-year-old women, no other statistically significant associations were found between socio-demographic variables and the 6-year change in BMI. Conclusions: Cross-sectional differences in BMI by socio-demographic variables are not due to different 6-year changes in BMI for categories of these variables in adulthood. Cross-sectional differences in BMI by educational level are probably established at the end of adolescence.

Background . Socioeconomic differences in health are determined mainly by socioeconomic differences in unhealthy behavior. Little is known, however, about the mechanisms that account for socioeconomic differences in unhealthy behavior, such as excessive alcohol consumption. In this paper we examined educational differences in excessive alcohol consumption in The Netherlands and whether these may be explained by educational differences in experienced stress and stress-moderating factors. Methods . Data were obtained from the baseline survey of the Longitudinal Study on Socio Economic Health Differences in 1991. Excessive drinking was defined as drinking more than six glasses on 3 or more days a week or more than four glasses on 5 or more days a week. Socioeconomic status was indicated by educational level. Stressors were divided into psychosocial and material factors. Analyses were performed for women ( n = 756) and men ( n = 1,006) separately, among drinkers only. Results . Excessive alcohol consumption was more common among lower educational groups. Material stressors, such as financial problems, deprivation, and income, were related to part of the educational gradient in excessive alcohol consumption. Differences in stress-moderating factors were not related to the educational gradient in excessive drinking. Conclusions . Our results suggest that improvement of material conditions among the lower educational groups could result in a reduction of socioeconomic differences in excessive alcohol consumption.

In this study we aim to explain educational differences in leisure-time physical inactivity in terms of psychosocial and material factors. Cross-sectional data were obtained from the baseline of the Dutch GLOBE study in 1991, including 2598 men and women, aged 15-74 years. Physical inactivity during leisure time was defined as not participating in any activity, such as sports, gardening, walking or cycling. Psychosocial factors included in the study were coping resources, personality, and stressors. Material factors were financial situation, employment status, and living conditions. Logistic regression models were used to calculate educational differences in physical inactivity. Physical inactivity was more prevalent in lower educational groups. Psychosocial factors related to physical inactivity were locus of control, parochialism, neuroticism, emotional social support, active problem focussing, optimistic and palliative coping styles. Material factors associated with physical inactivity were income, employment status and financial problems. All correlates of physical inactivity were unequally distributed over educational groups, except optimistic and palliative coping. Personality and coping style were the main contributors to the observed educational differences in physical inactivity. That is to say, parochialism, locus of control, neuroticism and active problem focussing explained about half of elevated odds ratios of physical inactivity in the lower educational groups. The material factors, equivalent income and employment status explained about 40% of the elevated odds ratios. Psychosocial and material correlates together reduced the odds ratios of lower educational groups by on average 75%. These results have practical consequences for the design of more effective interventions to promote physical activity. In particular, personality and coping style of risk groups, such as lower educational groups, should be taken into consideration at the future development of these interventions, as well as inequalities in material restrictions related to engaging in physical activity. Supplementary interventions focussing on childhood conditions which, partly, influence both personality and physical inactivity may also contribute to a reduction of socio-economic differences in physical inactivity.

Early environmental justice studies were exposure-oriented, lacked an integrated approach, and did not address the health impact of environmental inequalities. A coherent conceptual framework, needed to understand and tackle environmental inequalities and the related health effects, was lacking. We analyzed the more recent environmental justice literature to find out how conceptual insights have evolved. The conceptual framework of the WHO Commission on Social Determinants of Health (CSDH) was analyzed for additional explanations for environmental inequalities and the related health effects. This paper points out that recent environmental justice studies have broadened their scope by incorporating a broader set of physical and social environmental indicators, and by focusing on different geographic levels and on health impacts of environmental inequalities. The CSDH framework provided additional elements such as the role of structural determinants, the role of health-related behavior in relation to the physical and social environment, access to health care, as well as the life course perspective. Incorporating elements of the CSDH framework into existing environmental justice concepts, and performing more empirical research on the interactions between the different determinants at different geographical levels would further improve our understanding of environmental inequalities and their health effects and offer new opportunities for policy action.

Background: Evidence on the effect of community social capital on suicide mortality rates is fragmentary and inconsistent. The present study aims to determine whether geographic variations in suicide mortality across the Netherlands were associated with community social capital. Methods: We included 3507 neighbourhoods with 6207 suicide deaths in the period 1995-2000. For each neighbourhood, we measured perceived social capital using information from interview surveys, and we measured structural aspects of social capital using population registers. Associations with mortality were determined using Poisson regression analysis with control for confounders at individual level (age, sex, marital status, country of origin) and area level (area income, population density, religious orientation). Results: Suicide mortality rates were related to the measure of perceived social capital. Mortality rates were 8 percent higher (95% confidence interval (CI): 2 to 16 percent) in areas with low capital. In stratified analyses, this difference was found to be significantly larger among men (12 percent, CI: 2 to 22) than women (1 percent, CI: -9 to 13), larger among those age 0-50 (18 percent, CI: 8 to 29) than older residents (-2 percent, CI: -12 to 8), and larger among the unmarried (30 percent, CI: 16-45) than the married (-2 percent, CI: -12 to 9). Associations with the structural aspect of social capital were in the same direction, but weaker, and not statistically significant. Conclusions: This study contributed some evidence to assume a modest effect of community social capital on suicide mortality rates. This effect may be restricted to specific population groups such as younger unmarried men.

Background: Relatively little knowledge is available to date about health literacy among the general population in Europe. It is important to gain insights into health literacy competences among the general population, as this might contribute to more effective health promotion and help clarify socio-economic disparities in health. This paper is part of the European Health Literacy Survey (HLS-EU). It aims to add to the body of theoretical knowledge about health literacy by measuring perceived difficulties with health information in various domains of health, looking at a number of competences. The definition and measure of health literacy is still topic of debate and hardly any instruments are available that are applicable for the general population. The objectives were to obtain an initial measure of health literacy in a sample of the general population in the Netherlands and to relate this measure to education, income, perceived social status, age, and sex. Methods: The HLS-EU questionnaire was administered face-to-face in a sample of 925 Dutch adults, during July 2011. Perceived difficulties with the health literacy competences for accessing, understanding, appraising and applying information were measured within the domains of healthcare, disease prevention and health promotion. Multiple linear regression analyses were applied to explore the associations between health literacy competences and education, income, perceived social status, age, and sex. Results: Perceived difficulties with health information and their association with demographic and socio-economic variables vary according to the competence and health domain addressed. Having a low level of education or a low perceived social status or being male were consistently found to be significantly related to relatively low health literacy scores, mainly for accessing and understanding health information. Conclusions: Perceived difficulties with health information vary between competences and domains of health. Health literacy competences are associated with indicators of socio-economic position and with the domain in which health information is provided.

Background. Active modes of transport like walking and cycling have been shown to be valuable contributions to daily physical activity. The current study investigates associations between personal and neighbourhood environmental characteristics and active transport among inhabitants of Dutch deprived districts.Method. Questionnaires about health, neighbourhoods, and physical activity behaviour were completed by 742 adults. Data was analysed by means of multivariate linear regression analyses.Results. Being younger, female, and migrant and having a normal weight were associated with more walking for active transport. Being younger, male, and native Dutch and having a normal weight were associated with more cycling for active transport. Neighbourhood characteristics were generally not correlated with active transport. Stratified analyses, based on significant person-environment interactions, showed that migrants and women walked more when cars did not exceed maximum speed in nearby streets and that younger people walked more when speed of traffic in nearby streets was perceived as low. Among migrants, more cycling was associated with the perceived attractiveness of the neighbourhood surroundings.Discussion and Conclusion. Results indicated that among inhabitants of Dutch deprived districts, personal characteristics were associated with active transport, whereas neighbourhood environmental characteristics were generally not associated with active transport. Nevertheless, interaction effects showed differences among subgroups that should be considered in intervention development.

Background: Studies in the USA have shown ethnic inequalities in quality of hospital care, but in Europe, this has never been analysed. We explored variations in indicators of quality of hospital care by ethnicity in the Netherlands. Methods: We analysed unplanned readmissions and excess length of stay (LOS) across ethnic groups in a large population of hospitalized patients over an 11-year period by linking information from the national hospital discharge register, the Dutch population register and socio-economic data. Data were analysed with stepwise logistic regression. Results: Ethnic differences were most pronounced in older patients: all non-Western ethnic groups > 45 years had an increased risk for excess LOS compared with ethnic Dutch patients, with odds ratios (ORs) (adjusted for case mix) varying from 1.05 [95% confidence intervals (95% CI) 1.02–1.08] for other non-Western patients to 1.14 (95% CI 1.07–1.22) for Moroccan patients. The risk for unplanned readmission in patients >45 years was increased for Turkish (OR 1.24, 95% CI 1.18–1.30) and Surinamese patients (OR 1.11, 95% CI 1.07–1.16). These differences were explained partially, although not substantially, by differences in socio-economic status. Conclusion: We found significant ethnic variations in unplanned readmissions and excess LOS. These differences may be interpretable as shortcomings in the quality of hospital care delivered to ethnic minority patients, but exclusion of alternative explanations (such as differences in patient- and community-level factors, which are outside hospitals’ control) requires further research. To quantify potential ethnic inequities in hospital care in Europe, we need empirical prospective cohort studies with solid quality outcomes such as adverse event rates.

Background: The more diseases one suffers from, the higher the number of health care services attended. This study aims to examine the role this association plays in socio-economic differences in multiple health care utilization. Methods: The study population derived from the Netherlands Health Interview Surveys (1990–1998) and was 25 years or older (N=53,339). Socio-economic position was indicated by educational level. Comorbidity was defined as the concurrence of multiple health conditions in the same person. Multiple health care utilization was measured by the number of different health care services contacted in the preceding year. Logistic multiple regression was used, adjusted for age, gender and year of interview. Results: The lower the socioeconomic status, the more often people used multiple health care services (OR 1.46) and the higher the prevalence of comorbidity (OR 2.47). Conclusions: Lower socioeconomic groups use more health care services, partly because they suffer from more illnesses.

Contains fulltext : 108077.pdf (Publisher’s version ) (Open Access) BACKGROUND: In the Netherlands, as in many European countries, inequalities in health exist between people with a high and a low socioeconomic status (SES). From the perspective of the 'indirect selection hypothesis', this study was designed to expand our understanding of the role of Type D personality as an explanation of health inequalities. METHODS: Data came from two cross-sectional Dutch surveys among the general population (aged between 19 and 64 years, response 53.7%, n = 12,090). We analyzed the relative risks of low SES, assessed using education and income, and Type D personality, assessed using the Type D Scale-14 (DS14), for different outcomes regarding lifestyle-related risk factors and health, using multivariate Generalized Linear Models. RESULTS: Results showed that Type D personality was significantly associated with low SES (OR = 1.7 for both low education and low income). Moreover, the relative risks of Type D personality and low SES were significantly elevated for most adverse health outcomes, unconditionally as well as conditionally. CONCLUSION: The cross-sectional design hinders the making of definite etiological inferences. Nevertheless, our findings suggest that Type D personality does not explain the socioeconomic health inequalities, but is a risk factor in addition to low SES. Prevention of adverse health outcomes in low SES populations may have more effect when it takes into account that persons with a low SES in combination with a Type D personality are at highest risk. 10 p.

Background People with higher socio-economic status (SES) are generally in better health. Less is known about when these socio-economic health differences set in during childhood and how they develop over time. The goal of this study was to prospectively study the development of socio-economic health differences in the Netherlands, and to investigate possible explanations for socio-economic variation in childhood health. Methods Data from the Dutch Prevention and Incidence of Asthma and Mite Allergy (PIAMA) birth cohort study were used for the analyses. The PIAMA study followed 3,963 Dutch children during their first eight years of life. Common childhood health problems (i.e. eczema, asthma symptoms, general health, frequent respiratory infections, overweight, and obesity) were assessed annually using questionnaires. Maternal educational level was used to indicate SES. Possible explanatory lifestyle determinants (breastfeeding, smoking during pregnancy, smoking during the first three months, and day-care centre attendance) and biological determinants (maternal age at birth, birthweight, and older siblings) were analysed using generalized estimating equations. Results This study shows that socio-economic differences in a broad range of health problems are already present early in life, and persist during childhood. Children from families with low socio-economic backgrounds experience more asthma symptoms (odds ratio (OR) 1.27; 95% Confidence Interval (CI) 1.08-1.49), poorer general health (OR 1.36; 95% CI 1.16-1.60), more frequent respiratory infections (OR 1.57; 95% CI 1.35-1.83), more overweight (OR 1.42; 95% CI 1.16-1.73), and more obesity (OR 2.82; 95% CI 1.80-4.41). The most important contributors to the observed childhood socio-economic health disparities are socio-economic differences in maternal age at birth, breastfeeding, and day-care centre attendance. Conclusions Socio-economic health disparities already occur very early in life. Socio-economic disadvantage takes its toll on child health before birth, and continues to do so during childhood. Therefore, action to reduce health disparities needs to start very early in life, and should also address socio-economic differences in maternal age at birth, breastfeeding habits, and day-care centre attendance.

International audience; Background: Studies suggest that the neighbourhoods in which people live influence their health. The main objective of this study was to investigate the associations of neighbourhood-level income and unemployment/social security benefit on pregnancy outcomes: preterm delivery, small for gestational age (SGA), pregnancy induced hypertension (PIH) and miscarriage/perinatal death in Amsterdam, the Netherlands. Methods: A random sample of 7883 from 82 neighbourhoods in Amsterdam. Individual–level data from the Amsterdam Born Children and their Development (ABCD) study were linked to data on neighbourhood-level factors. Multilevel logistic regression was used to estimate odds ratios and neighbourhood-level variance. Results: After adjustment for individual-level factors (age, parity, education, ethnicity, smoking and obesity), women living in low income neighbourhoods (third, second and first quartiles) were more likely than women living in high income neighbourhoods (fourth quartile) to have SGA births: odds ratios were 1.32 (95% CI: 1.04-1.68), 1.42 (1.11-1.82) and 1.62 (1.25–2.08) respectively. Women living in the quartile of neighbourhoods with the highest unemployment/social security benefit were more likely than those living in the quartile with the lowest unemployment/social security benefit to have SGA births 1.36 (1.08-1.72). The neighbourhood-level variance was significant only for SGA births. No significant associations were found between neighbourhood-level factors and other pregnancy outcomes. Conclusion: Our findings suggest that neighbourhood income and deprivation are related to SGA births. More research is needed to explore possible mechanisms underlying poor neighbourhood environment and pregnancy outcomes, in particular through stress mechanisms. Such information might be necessary to help improve maternal and foetal health.