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The health of mothers and neonates is a concern for many countries, because they form the future of every society. In Ghana efforts have been made to address quality health care in order to accelerate progress in maternal and child health and reduce maternal and neonatal mortality through the implementation of a number of polices including a fee exemption for pregnant women for antenatal, delivery and postnatal care and a national health insurance scheme among others. However these interventions have not led to an improvement in the quality of health care and concerns have been raised whether health workers are sufficiently motivated to provide health care that is responsive to the needs of mothers and children. This study set out to study motivation as an individual quality of the worker, however it became obvious in the analytical phase that motivation is an outcome of interactions between the worker and the work environment. So the research resorted to analyse and understand the various ways in which interpersonal interactions and organisational processes contribute to the motivation of health workers and quality of care in a Ghanaian hospital setting. The research tried to answer the following questions: what are the interpersonal processes that influence health worker motivation; what are the organisational and managerial processes that influence health worker motivation; how does the setup of the Ghana health sector and its associated policies influence health worker motivation and how does health worker motivation influence health worker response to client health needs? The research focused on the quality of interpersonal interaction, such as attitudes, motivation, trust and conflict, on a number of organizational characteristics such as power relations, power being defined as the ability to affect organizational outcomes, uncertainty in decision-making and the provision of resources to deliver quality health care and on wider policy-making that affects the ability of health care institutions to take care of the staff (remuneration, human resource management) and the decision-making space of health facility managers. In order to investigate health worker motivation in a real life setting ethnographic research was conducted for twenty months in two hospitals; a specialist referral hospital and a district hospital that offer basic maternal and child health services in the greater Accra region in Ghana. Between 2011 and 2013, data was collected in mostly the maternity and new-born units of both hospitals. The researcher interacted with hospital staff including nurses, doctors, anaesthetists, orderlies, laboratory technicians, accounts officers and managers and collected data on daily activities and interactions in the hospital environment. The hospitals, which had different characteristics, were not selected for comparative purposes, but to enable a better understanding of how the organizational context influences worker motivation. Conversations were useful in helping the researcher to understand social phenomena. Interviews were conducted to explore social phenomena in depth. Participant observation was also a very important tool in helping the researcher to observe at first- hand how health care is provided in a natural hospital environment. An important source of information consisted of the reactions of hospital staff on the research and the researcher and the researcher’s emotional reactions to this, as it helped her to experience motivation, which was very useful in understanding and analysing motivational processes in the hospital environment. Ethical clearance was obtained from the Ghana Health Service Ethics Review board (approval number GHS-ERC:06/01/12) and the proposal was reviewed by the Wageningen School of Social Sciences board. Written informed consent was obtained from all interview participants. Verbal consent was obtained for conversations and pseudonyms are used for the names of the study hospitals and frontline workers throughout the thesis. Interpersonal processes including limited interaction and communication between collaborating frontline workers and perceived disrespect from colleagues and managers contributed to poor relations between frontline workers. A high number of frontline workers engaged in locum (private practice) in private hospitals. Such workers came to work late, or left early and some even skipped their official work to engage in locum practice. Workers also believed that some of their colleagues sneaked in their clients from their locum site to the hospital and charged them illegal fees, which they did not share with colleagues. Such practices and perceptions contributed to distrust relations among workers and to a poor organisational climate, which resulted in demotivation of staff, poor collaboration in the provision of health care, and eventually to conflicts. Conflicts contributed to delays in the provision of care and those who were willing to work felt disempowered, as they were unable to marshal their resources with collaborating professionals to respond to clients’ needs. They also contributed to angry and bitter workers and negative perceptions of other professional groups. Sometimes cases were postponed and on some occasions clients had to be referred to other facilities. Organisational and managerial processes equally influenced health worker motivation in various ways. Health workers perceived distributive, procedural and interactional injustice in organisational and managerial processes as they perceived that managers were not responding to their personal and organisational needs, which compromised their ability to offer quality health care. Health workers perceived distributive injustice in the fact that they worked hard and deserved to be given incentives to offset the stoppage of bonuses that the government initially paid to workers when the fee exemption for maternal health was introduced. Workers felt their managers were not meeting the hospitals’ needs for essential medical supplies, equipment and were incapable of putting up appropriate infrastructure to accommodate workers and an overwhelming number of clients. They perceived interactional injustice because of the fact that managers did not communicate with them on decisions that affected them and that managers were out of touch with the needs of workers. They complained that they were not respected by their superiors, who shouted at them when they made mistakes, and suggested that managers and superiors did not treat them with dignity in matters of discipline. Workers further argued that managers did not care whether they had adequate workforce to support them to provide quality health care. Some felt overworked and some felt burn out. However, managers felt disempowered at their level as well. The setup of the Ghana health sector and its associated policies remains largely centralised, so managers who are expected to meet the needs of frontline health workers and their hospitals, do not have the power to do so. They could not beef up staff numbers, since recruitment and allocation of staff to health facilities is centralised. In addition, managers received little financial support to run their hospitals. Their main source of funding was from reimbursement of funds from the National Health Insurance Authority, but reimbursement usually delayed for up to six months and they did not receive subvention from the Ghana Health Service or the Ministry of Health (MOH) to run their hospitals, so they were always cash strapped. Also the MOH, which is the body responsible for putting up infrastructure, could not meet the infrastructure needs of the hospitals. Additionally managers had to deal with conflicting policies including procurement policies that made decisions on purchasing essential supplies and drugs bureaucratic and slowed managers’ response to frontline worker and organisational needs. As a result, managers faced uncertainty in securing human and physical resources. To cope with uncertainties managers had to distribute their funds thinly among competing priorities of worker and organisational needs. At times managers had to sacrifice certain needs of workers and their hospitals in order to meet others. Consequently, workers lost trust in managers, which demotivated them in the provision of health care. Also the fee exemption policy made health care accessible to the general populace, but it did not lead to a commensurate increase in salaries, infrastructure development and increase in staff numbers. For that matter managers and frontline workers were overwhelmed with client numbers and had to turn some away. Both hospital managers and frontline workers perceived that policy makers and their superiors were not interested in how they provided care to clients or even their own safety, which demotivated them. It is important to note that some workers were observed to be intrinsically motivated and responded to the health needs of clients, despite the fact that they faced similar challenges as those who were demotivated. Such workers explained that their sources of motivation included a belief in a supreme being, the desire to maintain work standards and others perceived that clients had a right to quality health care. Also some indicated that they derived inner satisfaction when they were able to provide quality care to clients. Demotivation contributed to absenteeism, workers reporting to work late and some closing early as strategies to avoid collaborating with colleagues that they did not feel comfortable working with, which further worsened the conflict situation. Some workers also picked and chose to work with particular professionals. Workers exercised power negatively in two ways: 1. Some workers exhibited negative attitudes towards their colleagues, which contributed to poor interaction and poor communication. It further created gaps in clinical decision making. 2. Workers transferred their frustrations and disappointments to clients by shouting at clients and insulting them, which compromised with the quality of care that clients received. Another important consequence of demotivation was that workers got angry, some felt frustrated, and some reported experiencing high blood pressure. Consequently it affected the wellbeing of health workers who were supposed to cater for clients. Also demotivation became so deeply seated in some workers that they appeared to be beyond redemption. Some even hated the hospital environment that they worked in and others chose to leave the hospital. For health workers to be able to respond to the health needs of clients who visit the hospital there is the need that their personal needs including demand for better terms and conditions of service, incentives and training needs are catered for. Also their organisational needs including demand for essential supplies, equipment, appropriate infrastructure among others need to be addressed. Additionally managers have to be transparent, communicate and interact more frequently with frontline workers to enable them appreciate managers’ efforts in meeting workers’ personal and organisational needs. Also for managers to be able to meet the needs of frontline workers and their organisations managers must be given the power to make decisions on human and other resources. Also managers should be supported with the necessary funds, so that they can meet the multiple needs of their workers and hospitals. Health worker motivation in the hospital context is determined by an interaction of interpersonal and organisational processes that are shaped by external and internal influencers, who exercise power in their bid to influence organisational outcomes. Thus this study contributes to theory by propounding that motivation is not an individual quality of the worker, but it is an outcome of interactions between the worker and the work environment. Also power and trust relations within and outside the hospital influence worker motivation and for that matter theories on organisational power and trust relations are central to understanding and analysing worker motivation.

Trudy M.A. Wijnhoven Overweight and obesity in primary-school children: a surveillance system for policy-making in Europe from 2007 onwards. Background As a follow-up to the European Ministerial Conference on Counteracting Obesity convened in 2006 in Turkey, the European Childhood Obesity Surveillance Initiative (COSI) was launched by the Regional Office for Europe of the World Health Organization (WHO). COSI, a collaboration between WHO and interested Member States, aims to monitor the magnitude of overweight and obesity among primary-school children in European countries, to allow intercountry comparisons and to identify regional differences for informed policy-making. It collects at regular intervals data on weight and height of primary-school children and on their nutrition and physical activity behaviours, as well as on school environmental characteristics supportive to healthy nutrition and physical activity. Methods The research described in this PhD thesis is based on the data collected in the first two COSI rounds by 12 European countries in school year 2007/2008 and by 13 European countries in school year 2009/2010. Nationally representative samples of children aged 6–9 years were drawn, whereby a majority of the countries applied a two-stage school-based cluster sampling approach. A total of 168 832 children in school year 2007/2008 and 224 920 children in school year 2009/2010 were included in the anthropometric intercountry data analyses. Children's weight and height were measured by trained examiners using standardized procedures. Participating countries were allowed to adhere to their local legal requirements by specified deviations from standardized procedures, such as in types of clothing worn by the children during weight and height measurements. For each country, the prevalence of overweight and obesity, as well as mean Z-scores of anthropometric indices of height, weight and body mass index (BMI) were computed. The characteristics included in the analyses on the school environment referred to the frequency of physical education lessons, the availability of school playgrounds, the possibility to obtain food items and beverages on the school premises, and the organization of school initiatives to promote a healthy lifestyle. The school form was usually completed by the school principal or the teachers involved with the sampled classes. Data from 1831 schools in school year 2007/2008 and from 2045 schools in school year 2009/2010 were used. For each school, a school nutrition environment score (range: 0–1) was determined whereby higher scores correspond to higher support for a healthy school nutrition environment and the mean of the children's BMI-for-age Z-scores calculated. Five countries in school year 2007/2008 provided children's data on 13 health-risk behaviours related to breakfast and food consumption frequency, physical activity, screen time and sleep duration (n = 15 643). These data were reported by the caregivers alone or jointly with their child. For each country, the prevalence of the risk behaviours was estimated, and associations between them and overweight and obesity examined by multilevel logistic regression analyses. Results In both school years, a wide range in overweight and obesity prevalence estimates was found that differed significantly by country, as well as by European region. In all countries, the percentage of overweight children was about 20% or more (range: 18–57%), and the percentage of obese children was 5% or more (range: 5–31%). The findings suggest the presence of a north–south gradient with the highest overweight and obesity prevalence estimates found in southern European countries. Furthermore, changes in mean BMI-for-age Z-scores (range: from –0.21 to +0.14) and prevalence of overweight (range: from –9.0% to +6.2%) from school year 2007/2008 to school year 2009/2010 varied significantly among countries, whereas a period of two years is considered too short to identify these developments. The clothes-adjusted overweight prevalence estimates were lower by as much as 12% than the unadjusted estimates. Monthly BMI-for-age Z-score values within countries did not show systematic seasonal effects. Large between-country differences were observed in both school years in the availability of food items or beverages on the school premises (e.g., fresh fruit could be obtained in 12–95% of schools) and in the organization of initiatives to promote a healthy lifestyle in the selected classes (range: 42–97%). The provision of physical education lessons and the availability of school playgrounds were more uniformly present across the countries (range: 76–100%). A large variation was also seen in school nutrition environment scores (range: 0.30–0.93) whereby countries with a low score (< 0.70) graded less than three out of five characteristics as supportive. High-score countries showed more often than low-score countries a combined absence of cold drinks containing sugar, sweet snacks and salted snacks on the school premises. The prevalence of all 13 health-risk behaviours differed significantly across countries. For instance, the percentage of children who ate ‘foods like candy bars or chocolate’ > 3 days/week ranged from 2.2% to 63.4%; this figure ranged from 1.1% to 46.5% for those who ate ‘foods like potato chips (crisps), corn chips, popcorn or peanuts’ > 3 days/week. The range for children who did not have breakfast every day was between 4.4% and 32.5%, and from 4.8% to 35.0% for those who did not play outside ≥ 1 hour/day. Not having breakfast daily and spending screen time ≥ 2 hours/day were clearly positively associated with obesity. The same was true for eating ‘foods like pizza, French fries, hamburgers, sausages or meat pies’ > 3 days/week and playing outside < 1 hour/day. While a combination of multiple less favourable physical activity behaviours was clearly positively associated with obesity, a combination of the presence of multiple unhealthy eating behaviours did not lead to higher odds of obesity. Conclusions The results found in both COSI school years show that overweight and obesity among 6–9-year-old children are a serious public health concern, especially in southern European countries, and show the need for accelerated efforts to prevent excess body weight early in life by all participating countries. It was possible to detect relevant changes within a period of two years but to identify clear trends within countries, a longer time interval is necessary. The data on the school nutrition environment and the children's health-risk behaviours may assist policy-makers in monitoring their national policies targeting school settings and childhood obesity. In particular, promoting physical activity-related and discouraging sedentary behaviours among schoolchildren in the context of obesity preventive interventions seem to be essential.

In deze studie is gekeken naar de relatie tussen de hoeveelheid groen in de woonomgeving en het gebruik van ADHD-medicatie door kinderen. De gegevens over het medicijngebruik zijn afkomstig uit de Achmea Health Database. Uit deze database zijn kinderen die in 2011 tussen de 5 en 12 jaar waren, geselecteerd, ongeacht of ze ADHD-medicatie gebruikten of niet. Hieraan zijn middels de 6-positie postcode van het woonadres gegevens over het groen in de woonomgeving (250 m en 500 m) gekoppeld alsmede enkele buurtkenmerken. Van de 274.698 kinderen in de database waren voor 248.270 kinderen alle gegevens beschikbaar. De uitval werd voornamelijk veroorzaakt door tussentijdse verhuizingen. Middels multilevel logistische regressieanalyse is de relatie tussen de hoeveelheid groen in de woonomgeving en het al dan niet gebruiken van een ADHD-medicijn geanalyseerd.

Trudy M.A. Wijnhoven Overweight and obesity in primary-school children: a surveillance system for policy-making in Europe from 2007 onwards. Background As a follow-up to the European Ministerial Conference on Counteracting Obesity convened in 2006 in Turkey, the European Childhood Obesity Surveillance Initiative (COSI) was launched by the Regional Office for Europe of the World Health Organization (WHO). COSI, a collaboration between WHO and interested Member States, aims to monitor the magnitude of overweight and obesity among primary-school children in European countries, to allow intercountry comparisons and to identify regional differences for informed policy-making. It collects at regular intervals data on weight and height of primary-school children and on their nutrition and physical activity behaviours, as well as on school environmental characteristics supportive to healthy nutrition and physical activity. Methods The research described in this PhD thesis is based on the data collected in the first two COSI rounds by 12 European countries in school year 2007/2008 and by 13 European countries in school year 2009/2010. Nationally representative samples of children aged 6–9 years were drawn, whereby a majority of the countries applied a two-stage school-based cluster sampling approach. A total of 168 832 children in school year 2007/2008 and 224 920 children in school year 2009/2010 were included in the anthropometric intercountry data analyses. Children's weight and height were measured by trained examiners using standardized procedures. Participating countries were allowed to adhere to their local legal requirements by specified deviations from standardized procedures, such as in types of clothing worn by the children during weight and height measurements. For each country, the prevalence of overweight and obesity, as well as mean Z-scores of anthropometric indices of height, weight and body mass index (BMI) were computed. The characteristics included in the analyses on the school environment referred to the frequency of physical education lessons, the availability of school playgrounds, the possibility to obtain food items and beverages on the school premises, and the organization of school initiatives to promote a healthy lifestyle. The school form was usually completed by the school principal or the teachers involved with the sampled classes. Data from 1831 schools in school year 2007/2008 and from 2045 schools in school year 2009/2010 were used. For each school, a school nutrition environment score (range: 0–1) was determined whereby higher scores correspond to higher support for a healthy school nutrition environment and the mean of the children's BMI-for-age Z-scores calculated. Five countries in school year 2007/2008 provided children's data on 13 health-risk behaviours related to breakfast and food consumption frequency, physical activity, screen time and sleep duration (n = 15 643). These data were reported by the caregivers alone or jointly with their child. For each country, the prevalence of the risk behaviours was estimated, and associations between them and overweight and obesity examined by multilevel logistic regression analyses. Results In both school years, a wide range in overweight and obesity prevalence estimates was found that differed significantly by country, as well as by European region. In all countries, the percentage of overweight children was about 20% or more (range: 18–57%), and the percentage of obese children was 5% or more (range: 5–31%). The findings suggest the presence of a north–south gradient with the highest overweight and obesity prevalence estimates found in southern European countries. Furthermore, changes in mean BMI-for-age Z-scores (range: from –0.21 to +0.14) and prevalence of overweight (range: from –9.0% to +6.2%) from school year 2007/2008 to school year 2009/2010 varied significantly among countries, whereas a period of two years is considered too short to identify these developments. The clothes-adjusted overweight prevalence estimates were lower by as much as 12% than the unadjusted estimates. Monthly BMI-for-age Z-score values within countries did not show systematic seasonal effects. Large between-country differences were observed in both school years in the availability of food items or beverages on the school premises (e.g., fresh fruit could be obtained in 12–95% of schools) and in the organization of initiatives to promote a healthy lifestyle in the selected classes (range: 42–97%). The provision of physical education lessons and the availability of school playgrounds were more uniformly present across the countries (range: 76–100%). A large variation was also seen in school nutrition environment scores (range: 0.30–0.93) whereby countries with a low score (< 0.70) graded less than three out of five characteristics as supportive. High-score countries showed more often than low-score countries a combined absence of cold drinks containing sugar, sweet snacks and salted snacks on the school premises. The prevalence of all 13 health-risk behaviours differed significantly across countries. For instance, the percentage of children who ate ‘foods like candy bars or chocolate’ > 3 days/week ranged from 2.2% to 63.4%; this figure ranged from 1.1% to 46.5% for those who ate ‘foods like potato chips (crisps), corn chips, popcorn or peanuts’ > 3 days/week. The range for children who did not have breakfast every day was between 4.4% and 32.5%, and from 4.8% to 35.0% for those who did not play outside ≥ 1 hour/day. Not having breakfast daily and spending screen time ≥ 2 hours/day were clearly positively associated with obesity. The same was true for eating ‘foods like pizza, French fries, hamburgers, sausages or meat pies’ > 3 days/week and playing outside < 1 hour/day. While a combination of multiple less favourable physical activity behaviours was clearly positively associated with obesity, a combination of the presence of multiple unhealthy eating behaviours did not lead to higher odds of obesity. Conclusions The results found in both COSI school years show that overweight and obesity among 6–9-year-old children are a serious public health concern, especially in southern European countries, and show the need for accelerated efforts to prevent excess body weight early in life by all participating countries. It was possible to detect relevant changes within a period of two years but to identify clear trends within countries, a longer time interval is necessary. The data on the school nutrition environment and the children's health-risk behaviours may assist policy-makers in monitoring their national policies targeting school settings and childhood obesity. In particular, promoting physical activity-related and discouraging sedentary behaviours among schoolchildren in the context of obesity preventive interventions seem to be essential.

Steeds vaker komt overgewicht voor bij kinderen. Doelgroepen bereiken is grote uitdaging.

Steeds vaker komt overgewicht voor bij kinderen. Doelgroepen bereiken is grote uitdaging.

In deze studie is gekeken naar de relatie tussen de hoeveelheid groen in de woonomgeving en het gebruik van ADHD-medicatie door kinderen. De gegevens over het medicijngebruik zijn afkomstig uit de Achmea Health Database. Uit deze database zijn kinderen die in 2011 tussen de 5 en 12 jaar waren, geselecteerd, ongeacht of ze ADHD-medicatie gebruikten of niet. Hieraan zijn middels de 6-positie postcode van het woonadres gegevens over het groen in de woonomgeving (250 m en 500 m) gekoppeld alsmede enkele buurtkenmerken. Van de 274.698 kinderen in de database waren voor 248.270 kinderen alle gegevens beschikbaar. De uitval werd voornamelijk veroorzaakt door tussentijdse verhuizingen. Middels multilevel logistische regressieanalyse is de relatie tussen de hoeveelheid groen in de woonomgeving en het al dan niet gebruiken van een ADHD-medicijn geanalyseerd.

Er zijn steeds meer aanwijzingen dat groen in de woonomgeving goed is voor de gezondheid. Vooral het rustgevende en herstellende vermogen van contact met groen lijkt daarbij van belang. Voorbeelden uit onderzoek zijn: sneller herstel van een stressvolle gebeurtenis, beter concentratievermogen en meer zelfbeheersing. Het meeste onderzoek kijkt echter alleen naar volwassenen; onderzoek onder kinderen is relatief schaars. Een nieuwe studie heeftving gekeken naar de relatie tussen de hoeveelheid groen in de woonomgeen het gebruik van ADHD-medicatie door kinderen.

This report describes the consumption of children who participated in aduplicate diet study. Furthermore it provides additional information onthe collected duplicate diets, for example if a child had followed aspecific diet. Duplicate diet studies are conducted periodically since 1976in the Netherlands and provide the opportunity to monitor the quantitiesof certain substances people ingest daily over time (chemicals,mycotoxins). Moreover, it can be assessed if these quantities remainwithin the safety limits.This duplicate diet study was conducted during the spring and autumn of2014 by RIVM and RIKILT and was commissioned by the Dutch Food andConsumer Product Safety Authority (NVWA). Parents/ carers of 126children aged 2 to 6 years in the region of Wageningen participated inthe study. They collected duplicate portions (duplicate diet) of all foodsand beverages their child consumed over a 24-hour period. They alsokept food diaries to record what the child had consumed during the day.The duplicate diets were processed into freeze-dried samples and storedat RIKILT.The results of this study showed that for many children less duplicatediet was collected than what they probably consumed. This should betaken into account when interpreting the results of dietary exposure toharmful substances.

Er zijn steeds meer aanwijzingen dat groen in de woonomgeving goed is voor de gezondheid. Vooral het rustgevende en herstellende vermogen van contact met groen lijkt daarbij van belang. Voorbeelden uit onderzoek zijn: sneller herstel van een stressvolle gebeurtenis, beter concentratievermogen en meer zelfbeheersing. Het meeste onderzoek kijkt echter alleen naar volwassenen; onderzoek onder kinderen is relatief schaars. Een nieuwe studie heeftving gekeken naar de relatie tussen de hoeveelheid groen in de woonomgeen het gebruik van ADHD-medicatie door kinderen.

This report describes the consumption of children who participated in aduplicate diet study. Furthermore it provides additional information onthe collected duplicate diets, for example if a child had followed aspecific diet. Duplicate diet studies are conducted periodically since 1976in the Netherlands and provide the opportunity to monitor the quantitiesof certain substances people ingest daily over time (chemicals,mycotoxins). Moreover, it can be assessed if these quantities remainwithin the safety limits.This duplicate diet study was conducted during the spring and autumn of2014 by RIVM and RIKILT and was commissioned by the Dutch Food andConsumer Product Safety Authority (NVWA). Parents/ carers of 126children aged 2 to 6 years in the region of Wageningen participated inthe study. They collected duplicate portions (duplicate diet) of all foodsand beverages their child consumed over a 24-hour period. They alsokept food diaries to record what the child had consumed during the day.The duplicate diets were processed into freeze-dried samples and storedat RIKILT.The results of this study showed that for many children less duplicatediet was collected than what they probably consumed. This should betaken into account when interpreting the results of dietary exposure toharmful substances. Dit rapport beschrijft de consumptie van kinderen die in 2014 hebben deelgenomen aan het zogeheten duplicaatvoedingsonderzoek. Daarnaast geeft het aanvullende informatie over de verzamelde voedingen, bijvoorbeeld of een dieet is gevolgd. Duplicaatvoedingsonderzoek wordt sinds 1976 periodiek in Nederland uitgevoerd en maakt het mogelijk om door de jaren heen te volgen welke hoeveelheden van bepaalde chemische stoffen en schimmels een bevolkingsgroep dagelijks via voeding binnenkrijgen. Voorbeelden hiervan zijn gewasbeschermingsmiddelen of zware metalen. Bovendien kan worden gecontroleerd of deze hoeveelheden binnen de gestelde veiligheidsgrenzen blijven. Dit duplicaatvoedingsonderzoek vond plaats in het voor- en najaar van 2014 en is uitgevoerd door het RIVM en het RIKILT, in opdracht van de Nederlandse Voedsel en Warenautoriteit (NVWA).