Staff Publications

Staff Publications

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    'Staff publications' is the digital repository of Wageningen University & Research

    'Staff publications' contains references to publications authored by Wageningen University staff from 1976 onward.

    Publications authored by the staff of the Research Institutes are available from 1995 onwards.

    Full text documents are added when available. The database is updated daily and currently holds about 240,000 items, of which 72,000 in open access.

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Frontline health worker motivation in the provision of maternal and neonatal health care in Ghana
Aberese-Ako, Matilda - \ 2016
Wageningen University. Promotor(en): Han van Dijk; I.A. Agyepong, co-promotor(en): G.J.E. Gerrits. - Wageningen : Wageningen University - ISBN 9789462578937 - 160
health care workers - motivation - organizations - management - ghana - attitudes to work - patient care - health policy - ethnography - reproductive health - child health - gezondheidswerkers - motivatie - organisaties - bedrijfsvoering - houding t.o.v. werk - patiëntenzorg - gezondheidsbeleid - etnografie - reproductieve gezondheid - gezondheid van kinderen

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.

National level maternal health decisions : towards an understanding of health policy agenda setting and formulation in Ghana
Koduah, A. - \ 2016
Wageningen University. Promotor(en): Han van Dijk; I.A. Agyepong. - Wageningen : Wageningen University - ISBN 9789462578951 - 180
family planning - reproductive health - health policy - ghana - government policy - primary health care - gezinsplanning - reproductieve gezondheid - gezondheidsbeleid - overheidsbeleid - eerstelijnsgezondheidszorg

Maternal and neonatal deaths and morbidity still pose an enormous challenge for health authorities in Ghana, a lower middle income country. Despite massive investments in maternal and neonatal health and special attention through Millennium Development Goals (MDG) 4 and 5, Ghana still have high mortality rates. At national level, policy decision makers to improve maternal outcomes have over the years developed several public policies to increase financial and geographical access to maternal care; space child birth; provide essential obstetric care; expand midwifery coverage; make equipment available and many more.

The problem of maternal mortality persist and this raises the question of what essentially goes into public policy making given the failure to achieve targets despite several maternal health policies developed for implementation. This thesis thus aims to advance our understanding of who makes maternal health policies and the agenda setting and formulation decision making processes through which they operate, in Ghana; and out of these understanding present potential lessons for policy actors to engage in making better informed policy decisions to improve maternal health.

To understand factors and processes that influence national level maternal policy agenda and formulation decisions; we conceptualised that maternal policy decision making is predominately influenced by how policy actors within specific context use their power sources to define issues and frame accompanying course of action. The main research questions are:

Which policy actors have been involved in maternal health policy agenda setting and formulation and what roles did they play and why?What are the decision making processes related to maternal health policy agenda setting and formulation?How did contextual factors influenced maternal health policy agenda setting and formulation and why?How did policy actors define maternal health issues and why?

To investigate maternal policy agenda setting and formulation decision making in-depth, a multiple case study design with qualitative methods of data collection was used. The case study approach allowed me to look at maternal health policy decisions not merely as inputs and outputs but to better understand within context the processes and policy actors involved. Field work in the Ghanaian health sector, through observation and participation in the work of the Ministry of Health, steered the selection of the cases. Four cases: maternal (antenatal, delivery, and postnatal) fee exemption policy decisions, health sector programme of work maternal health policy decisions, free family planning as part of NHIS policy decision, and primary care maternal health service capitation policy decisions were investigated.

The field work was conducted between May 2012 and August 2014. Multiple data collection methods including document review, interviews and observations were used to collect historical and current information and contribute to the validity and reliability of the research findings. Data were analysed drawing on an analytical framework in which concepts of organizational power, context, policy actors and problem definition were central elements.

Case 1

Historical and contemporary fee exemption policies for maternal (antenatal, skilled delivery and postnatal) health services were explored. Specifically we ask: How have maternal user fee exemption policies evolved in Ghana since independence? Which actors have been involved in the policy agenda setting and formulation and why? What contextual factors influenced the process over time, how and why? Nine specific policies were identified along the pathway as, the policies evolved from user fee exemptions to national health insurance premium exemption. The policy was first introduced in 1963 and has remained on the government agenda over four and over decades in a fluid process of ebbs and flows rather than in a static fixed form. Contextual factors and various policy actors were the major influencers of the ebbs and flows. Contextual factors that influenced the ebbs and flows were: political such as Nkrumah’s ideology of free access to health care and education, changes in government, and presidential election year; economic crises and development partners’ austerity measures; worsening health and demographic indicators; historical events; social unrest; and international agendas such as the MDGs. These contextual factors served as a source of power for policy actors to sustain maternal fee exemption agenda over time. The case study showed that various categories of policy influencers (policy agenda advisers and advocates) and final decision makers (policy agenda directors and approvers) operated within these interrelated contextual factors, which sometimes worked as constraints and sometimes opened opportunities. These contextual factors shaped the timely manner in which policy content was formulated and level of deviation from the intended agenda at each specific decision period. For instance, contextual factors such as declined health budget allocation and high maternal mortality presented the ministry of health bureaucrats with an option to formulate the policy content in a less timely manner and away from the intended agenda of 1997 free maternal care presidential directive. Whilst, within the context of austerity measure and Ghana poverty reduction strategy, maternal fee exemption policy for four deprived regions was formulated in a timely manner and closely linked to the poverty strategy.

Case 2

The case explored how and why maternal health policy and programme agenda items appeared and evolved in the framework of the Ghanaian health sector programme of work agenda between 2002 and 2012. Our specific research questions were: Which maternal health policies were prioritised? How did they evolve on the agenda and why? We examined decision maker’s problem definition and decision making processes, theorizing that a policy or programme’s appearance and fate on the POW agenda is predominantly influenced by how decision makers use their source of power to define problems and frame their policy narratives and accompanying course of actions.

Ministry of health bureaucrats and donors used their power sources as negotiation tools to frame maternal health issues and design maternal health policies and programmes within the framework of the national health sector programme of work. The power sources identified included legal and structural authority; access to authority by way of political influence; control over and access to resources (mainly financial); access to evidence in the form of health sector performance reviews and demographic health surveys; and knowledge of national plans such as Ghana Poverty Reduction Strategy. Bureaucrats and donors used their power sources to define, frame and label issues for attention making some policies such as family planning long term fixtures on the agenda. They used labels such as ‘inadequate obstetric care’, ‘family planning unmet needs’, ‘maternal health a poverty issue’, and ‘poor maternal health a national emergency’ – for actions and to ensure the continuous flow of donor and government funding.

Case 3

The case investigated how and why ‘free family planning as part of the NHIS’ policy attained a position on government agenda in 2012 but has not subsequently moved into formulation and implementation in Ghana. Relying on their power sources such as access to bodies of evidence; bureaucrats, donors, reviewers and reproductive health advocates framed inadequate budgetary allocation and disbursement for family planning and exclusion of family planning services from the national health insurance benefits package - as a major challenge to family planning contribution to maternal health care; and free family planning as potential life and cost saving. Drawing on their legal and structural access to institutionalized public policy processes in Ghana, they proposed the following policy options: include family planning service in the national health insurance benefits package and increase government and donor financial support. The interests of the supporting actors were two fold to eliminate out of pocket payments for family planning service and still sustain the financial needs of the family planning programme through the National Health Insurance Scheme. A window of opportunity opened when a Minister of Health receptive to these problem definitions and policy options publically voiced support for ‘free family planning as part of the NHIS; policy and therefore pushed it high and visibly onto the public policy /government agenda. However, the policy failed to move into formulation and implementation. Factors that influenced this failure included the lack of a stronger, broad based health sector actor support and related inability to agree on and develop policy implementation guidelines; and maintain political access and interest in the issue after it was moved up the agenda.

Case 4

This case explored how and why less than three months into the implementation of a pilot prior to national scale up; primary care maternal services that were part of the basket of services in a primary care per capita national health insurance scheme provider payment system dropped off the agenda. During the agenda setting and policy formulation stages; predominantly technical policy actors within the bureaucratic arena used their expertise and authority for consensus building to get antenatal, normal delivery and postnatal services included in the primary care per capita payment system. Once policy implementation started, policy makers were faced with unanticipated resistance. Service providers, especially the private self- financing used their professional knowledge and skills, access to political and social power and street level bureaucrat power to contest and resist various aspects of the policy and its implementation arrangements – including the inclusion of primary care maternal health services. Arenas of conflict moved from the bureaucratic to the public as opposing actors presented multiple interpretations of the policy intent and implementation and gained the attention of politicians and the public. The context of intense public arena conflicts and controversy in an election year added to the high level political anxiety generated by the contestation. The President and Minister of Health responded and removed antenatal, normal delivery and postnatal care from the per capita package.

Conclusions

The general findings of the thesis are: (1) policy influencers (donors and bureaucrats) and final decision makers (Minister and President) used their power sources and contextual factors to define problems, promote their vested interest and justify actions and inactions; through technical, institutionalised, public and political decision making domains. (2) Policy influencers and final decision makers’ collective actions and inactions through interactions and power relations influenced decisions to their benefit at different levels. They used their control over and access to knowledge, authority and financial, material and human resources to push their interest and influence decisions. Therefore, this thesis concludes that the findings can serve as lessons for policy actors to strategize and make better informed policy decisions. We are in need of a health sector that pays more attention to context, power sources and power relations of final decision makers and influencers and the varied decision making domains in any maternal health policy decision.

The tree under which you sit : district-level management and leadership in maternal and newborn health policy implementation in the Greater Accra Region, Ghana
Kwamie, A. - \ 2016
Wageningen University. Promotor(en): Han van Dijk; I.A. Agyepong. - Wageningen : Wageningen University - ISBN 9789462576742 - 158 p.
health policy - birth - pregnancy - policy - management - administration - ghana - west africa - gezondheidsbeleid - geboorte - zwangerschap - beleid - bedrijfsvoering - bestuur - west-afrika

Health system governance has to do with decision-making – who makes decisions, when, where, how and why. At the district level – the level of care which operationalises health policies – governance is critical, yet remains little understood. Governance has the ability to influence health system performance, and this is essential in maternal and newborn health, where timely decisions are required to support policy implementation. In this regard, district managers are particularly important. They are the link in the middle of the health system, connecting top-end policy formulation to bottom-end implementation. Their abilities to interpret, translate, support and challenge policy will have an effect on what gets operationalised. However, capacity weaknesses in district management and leadership are often cited as a factor in poor health system performance.

This thesis seeks to deepen understandings of district-level management, leadership and decision-making for policy and programme management and implementation for maternal and newborn health. Within this, the thesis also seeks to understand the scope for change that an intervention to strengthen management and leadership capacities can bring.

This thesis contributes to the applied field of health policy and systems research by drawing on policy implementation theory, organisational management theory and complexity theory as its theoretical basis. A realist approach methodology was undertaken to understand the contexts in which district managers are embedded, how this influences their decision-making, and what the effects of a managerial intervention are, given these contexts. The thesis followed an embedded case study flexible design. The first case study was an exploratory qualitative case study to understand how and why district managers make decisions in maternal and newborn health policy implementation. The second case study was an historical case study of district manager decision-space over time. The third case study was an explanatory qualitative case study of the management and leadership intervention. The final validation of our theorising throughout the cases was achieved through the administration of a questionnaire across all district health management teams of the Great Accra Region.

This thesis demonstrates that district managers find themselves in contexts of strong hierarchical authority and resource uncertainty – in particular, lacking financial transparency. This promotes a management and leadership typology which attunes managers towards serving the health system bureaucracy, resulting in reduced district-level responsiveness to maternal and newborn health challenges. The outcome is that district manager decision-space is narrow surrounding resource allocation decisions, and this in turn affects local planning programming and management.

The thesis further demonstrates that broader patterns of centralised governmental decision-making have affected the development of the district health system over time. Particularly, the sequencing of decentralisation processes has ensured that national-level decision-making has remained empowered in contrast to district-level decision-making. System fragmentation – through reduced Government of Ghana funds and increasingly verticalised donor funds – has also been a contributor. This accounts for the observed hierarchical authority and resource uncertainty which affects district managers. As a result of these contexts, this thesis also showed that an intervention to strengthen management and leadership capacities was limited in its sustainability.

This thesis raises the issues of health system organisation as critical to the potential of district management and leadership effectiveness. It provides evidence that weaknesses in district management and leadership arise out of the organisational governance mismatches in autonomy and responsibility. It suggests that in strengthening management and leadership, approaches which seek to address organisational capacities, not only individual capacities, are needed to convey sustainable change. Advancements in this regard have the scope to improve district manager decision-making for maternal and newborn health policy and programme implementation in the future.

Understanding healthful eating from a salutogenic perspective
Swan, E.C. - \ 2016
Wageningen University. Promotor(en): Maria Koelen; Gerrit Jan Hiddink, co-promotor(en): Laura Bouwman; Noelle Aarts. - Wageningen : Wageningen University - ISBN 9789462576957 - 111 p.
extension - foods - health - health education - health foods - health policy - pathogenesis - voorlichting - voedingsmiddelen - gezondheid - gezondheidseducatie - gezondheidsvoedsel - gezondheidsbeleid - pathogenese

The biomedical model of health orients towards pathogenesis, the study of disease origins and causes. The starting point is to understand determinants of ill-health, and health is defined in this model as the absence of disease. When applied to nutrition research, the underlying assumption is that eating is a physiological act, and that eating supports physical health. This risk-oriented, pathogenic view also underlies the search for determinants of unhealthful eating. However, there is such an emphasis on finding risk factors, that the biomedical model overlooks the fact that individuals also possess, or have access to, factors that support healthful eating. As a result, very little is known on factors that enable healthful eating and how these factors can be used to complement current health promotion strategies. The overall aim of this research was to contribute to a better understanding of healthful eating in the context of everyday life. We applied a complementary research framework, the salutogenic model of health, to 1) map factors underlying the development of sense of coherence (SOC); 2) study which of these factors are predictors for healthy eating; 3) unravel how people develop healthful eating practices in everyday life; and 4) integrate this understanding and provide building blocks for nutrition promotion. This research employed a mixed research design, using cross-sectional survey research and in-depth interviews.

Chapter 2 explored the possibilities of applying the salutogenic framework as a complementary approach to biomedical-oriented nutrition research and practice. Nutrition research takes a mostly biomedical-oriented approach to better understand risk factors that determine unhealthful eating. Though relevant for curative medicine, such an approach limits the evidence base for health promotion, which is guided by the principles that personal and social resources are preconditions for health and well-being. Moreover, biomedical-oriented nutrition promotion takes a reductionist approach and studies and enacts upon individual or the external environment separately. Disjointedly studying and enacting upon people and context may be easier, yet it does not do justice to reality and limits the relevance and applicability in everyday eating situations. The salutogenic model of health can provide complementary knowledge on what is already known through biomedical approaches. It guides the study of the dynamics between people and their environment and how health develops from this interaction. Since salutogenesis guides the study of health as an interplay between physical, mental, and social factors, it is more in line with how people experience eating in their everyday lives. In the study described in chapter 3, we examined individual, social, and physical-environmental factors that underlie SOC. Dutch adults (n=781) participated in a cross-sectional study examining the relationship between SOC and a set of individual, social- and physical-environmental factors. The main findings indicate that high SOC was significantly (p<.05) associated with a diverse set of factors including lower doctor oriented multidimensional health locus of control (MHLC); higher satisfaction with weight; higher situational self-efficacy for healthy eating; lower perceived social discouragement for healthy eating; higher perceived levels of neighborhood collective efficacy; and higher perceived neighborhood affordability, accessibility and availability of healthy foods. Non-significant factors (p≥.05) included gender; employment status; education level; cohabitation; BMI; nutrition knowledge; internally oriented MHLC; chance oriented MHLC; and perceived social support for healthy eating. These findings are relevant since they can inform the design of nutrition interventions that target factors that strengthen SOC and provide building blocks for a healthier life orientation. Next, the study in chapter 4 aimed to determine a set of individual, social and physical-environmental factors that predict healthy eating practices in a cross-sectional study of Dutch adults. Data were analyzed from participants (n=703) that completed the study’s survey and logistic regression analysis was performed to test the association of survey factors on the outcome variable high dietary score. In the multivariate logistic regression model, five factors contributed significantly (p<.05) to the predictive ability of the overall model: being female; cohabitation; a strong sense of coherence; flexible restraint of eating; and self-efficacy for healthy eating. Non-significant factors (p≥.05) in the multivariate logistic regression model included age; employment status; net monthly household income; education level; nutrition knowledge; internally oriented MHLC; perceived social support and discouragement for healthy eating; perceived neighborhood collective efficacy and perceived neighborhood affordability, availability and accessibility of healthy foods. Findings complement what is already known of the factors that relate to poor eating practices. This can provide nutrition promotion with a more comprehensive understanding of the factors that both support and hinder healthy eating practices.

Lastly, the qualitative study described in chapter 5 examined a group of healthy eaters and explored life experiences and coping strategies that foster healthful eating through narrative inquiry. The study was undertaken with seventeen Dutch women (aged 36- 54 years) in the highest quartile of dietary quality index scores. The main findings showed that life experiences gave rise to coping strategies that enabled healthful eating. Childhood experiences included: accustomed to non-processed foods and positive child-parent interactions. Adulthood experiences included: regained stability and structure in stressful life events and forged positive experiences with food. Coping strategies included: organizing eating in an uncomplicated manner; creativity in the kitchen; valuing good food with good company; approaching eating with critical self-awareness; and applying craftiness and fortitude during difficult moments. The findings suggest that there is an interplay between life experiences and coping strategies, and this mechanism underpins healthful eating. Findings offer potential entry points for nutrition promotion to foster healthful eating.

When integrating the research findings in chapter 6, we found that healthful eating results from three composite factors: balance and stability, sense of agency, and sensitivity to the dynamics of everyday life. Firstly, healthful eating results from balance and stability in life, represented by a strong SOC, which characterizes a balanced mixture of giving meaning to eating as an integral part of life, comprehending its importance to oneself, and having competencies to manage its organization in the everyday social context. In the life course, healthful eating also results from the ability to regain stability and structure in stressful life events and craftiness and fortitude during difficult moments. Healthful eating is also rooted in a sense of agency (the feeling of being in control of one’s own actions), with regards to the ability to take action related to eating and life in general. This sense of agency is enabled through flexibility, lower doctor oriented MHLC, applying creativity in the kitchen, and approaching eating with critical self-awareness. Thirdly, healthful eating results from a sensitivity to the dynamics of everyday life, with regards to the how people deal with and navigate through everyday challenging situations by applying individual- and context-bound factors including situational self-efficacy, organizing eating in an uncomplicated manner, valuing good food with good company, and perceiving less social discouragement for healthy eating from family and friends.

Few of the factors associated with SOC and healthful eating converged with risk factors for unhealthful eating found in previous studies, including coping, self-efficacy, restraint of eating, and living situation. Our findings show that the set of factors related to the origins of health substantially diverged from the set of factors related to the origins of disease. From this, we conclude that the “origins of health” differ from the “origins of disease”. Hence, factors that foster and support healthful eating are not simply the reversed version of the factors known to increase the risk of unhealthful food choices. This implies that a different set of factors should inform health promoting strategies, in addition to the factors informing strategies targeting the prevention of diet-related illnesses.

The new insights brought forth in this research provide building blocks for salutogenic-oriented nutrition promotion. 1) Strategies should take a more holistic orientation to food and eating, emphasizing a balance between physical, social, and mental health. Similarly, dietary guidelines should emphasis more than what and how much to eat for physical health and also consider the social and mental dimensions.

2) Nutrition promotion should develop strategies to support a healthful orientation to life. Through strengthening SOC, people can become more capable of coping with any situation or challenge, independent of whatever is happening in life. Nutrition promotion should also strengthen more general health promotion factors including mindfulness, critical thinking, and stress management because these skills support adaptive behavior when life circumstances change. 3) Strategies should facilitate health-directed learning processes through positive interactions and experiences with food. For instance, strategies that support health-directed learning processes should improve food-related procedural knowledge such as food literacy and cooking skills. They should also include socially-embedded learning experiences involving the selection, purchase, and preparation of healthful food; encourage positive parent-child interactions at the dinner table; and recommend that people cook regularly with partners, family or friends.

Een gedeelde passie voor gezonder leven. Evaluatieonderzoek naar netwerken rondom de beweegkuur en gecombineerde leefstijl interventies
Hartog-van den Esker, F.G. den; Wagemakers, A. ; Vaandrager, L. ; Koelen, M. - \ 2012
Wageningen : Wageningen University - 69
gezondheidsbevordering - gezondheidsbeleid - levensstijl - lichamelijke activiteit - lichaamsbeweging - voeding en gezondheid - overgewicht - netwerken - health promotion - health policy - lifestyle - physical activity - exercise - nutrition and health - overweight - networks
NISB (Nederlands Instituut voor Sport en Bewegen), projectleider van de BeweegKuur, is in 2010 gestart met het project 'Netwerken bouwen in de BeweegKuur'. In dit project gaat het om het opbouwen van regionale en lokale netwerken voor de afstemming tussen preventie, curatie en sport en voor de borging in gezondheidsbeleid. NISB heeft de Leerstoelgroep Gezondheid en Maatschappij van Wageningen University gevraagd onderzoek te doen naar de netwerkvorming rondom de BeweegKuur. Het doel van het onderzoek is inzicht te krijgen in de factoren van belang voor duurzame netwerken, de resultaten die de netwerken boeken en de wijze waarop netwerken gefaciliteerd kunnen worden. Een tweede doel is het leveren van direct bruikbare kennis voor de netwerken.
EU policy for agriculture, food and rural areas, 2nd rev. ed.
Oskam, A.J. ; Meester, G. ; Silvis, H.J. - \ 2011
Wageningen : Wageningen Academic Publishers - ISBN 9789086861804 - 453
gemeenschappelijk landbouwbeleid - landbouwbeleid - beleid - landbouw - agrarische handel - wereldhandelsorganisatie - voedsel - beleid inzake voedsel - marketingbeleid - diergezondheid - dierenwelzijn - gezondheidsbeleid - plattelandsbeleid - natuurbescherming - milieubeheer - instellingen - besluitvorming - platteland - europese unie - cap - agricultural policy - policy - agriculture - agricultural trade - world trade organization - food - food policy - marketing policy - animal health - animal welfare - health policy - rural policy - nature conservation - environmental management - institutions - decision making - rural areas - european union
The European Union varies widely within its boundaries. Still, there are common policies for agriculture, food and rural areas, although with many differences in relation to specific conditions in Member States. Starting with the Mac Sharry reform in 1992, the EU is on a long-term path to freer and more open markets. Traditional EU market and price measures are now largely replaced by 'decoupled' direct income support, and further steps are being prepared. There is increased attention at both EU and Member-State levels to food quality, food safety and animal welfare, as there is also to the environment and the development of rural areas. The Union is thus becoming a leader in food and rural policies.
Epidemiology in public health practice
Haveman-Nies, A. ; Jansen, S. ; Oers, H. van; Veer, P. van 't - \ 2010
Wageningen : Wageningen Academic Publishers - ISBN 9789086861408 - 384
epidemiologie - volksgezondheid - methodologie - gezondheidsbeleid - epidemiology - public health - methodology - health policy
Over the past decades, epidemiology has made a relevant contribution to public health by identifying health problems and analysing their determinants. However, recent developments call for new and applied methods to support the planning, implementation and evaluation of public health policies and programmes. This book presents an integrated overview of such epidemiological methods, to be used within the joint working process of several public health disciplines. It provides relevant theories, concepts and tools, illustrated with practical examples in order to empower epidemiologists in public health. The first part of this book describes epidemiological history in a nutshell and explains the relationship with the public health domain. It closes with the presentation of a joint work cycle for policy, practice and research: the public health cycle. Part II presents seven steps for epidemiologists to strengthen their contribution to the public health cycle: conduct a needs assessment, support priority setting, formulate aims and objectives, construct a logic model, develop an evaluation plan, perform quality control and analyse processes and outcomes. Part III is dedicated to successful collaboration of epidemiology with other public health disciplines such as health promotion, policy making and primary health care.
Social relationships and healthy ageing : epidemiological evidence for the development of a local intervention programme
Croezen, S. - \ 2010
Wageningen University. Promotor(en): Pieter van 't Veer; Lisette de Groot, co-promotor(en): Annemien Haveman-Nies. - [S.l. : S.n. - ISBN 9789085856917 - 128
gezondheid - verouderen - ouderen - sociale participatie - interventie - gezondheid op regionaal niveau - gemeenschapsprogramma's - gezondheidsbeleid - sociale relaties - health - aging - elderly - social participation - intervention - community health - community programs - health policy - social relations
Introduction
In view of the growing number of older people in our society and the related consequences for health and well-being, research focussing on healthy ageing is essential. Already, the associations between supportive social relationships and healthy ageing have been established. However, there is as yet no consensus about whether or not it is the structure of the social network, its function- ing or a combination that is most important for health, and in addition, about which aspects of structure and function are important.

Aim
The main objective of this thesis was to investigate aspects of the structure and functioning of social relationships and their influence on mental, physical and social health in older people. This was relevant to obtain scientific evidence for practice-based research to support local policy making on healthy ageing.

Methods
Different characteristics and functions of social relationships, such as frequency of contact, different sources of social network ties, satisfaction with relationships, positive and negative perceptions of social support and social engagement have been analysed in cross-sectional and prospective studies. Cross-sectional data are from six community health services in the eastern part of the Netherlands. The overall sample size constituted of 24,936 people aged 65 and over (response 79%). Prospective data are from the Doetinchem Cohort Study. The first examination round (1987-1991) comprised 12,448 men and women aged 20 to 59 years. The overall response rate was 62% for the baseline measurement and 79%, 75% and 78% for rounds 2, 3 and 4 respectively.

Results
Cross-sectional analyses showed that satisfaction with the social contacts was strongly related to physical (OR 2.36; 95% CI 2.11-2.64), mental (OR 4.65; 95% CI 4.20-5.15) and self-perceived health (OR 2.52; 95% CI 2.29-2.78). Longitudinal analyses underlined this finding by showing that unfavourable levels of social support were predictive for health-compromising behaviours and poor health over a 10-year period of follow-up, and for increased mortality risk over a 15- year period of follow-up (HR 1.57; 95% CI 1.03-2.39). Furthermore, neighbours were found to be an important source of the social network ties of older people in relation to physical (OR 1.87; 95% CI 1.68-2.07), mental (OR 1.53; 95% CI 1.39-1.69) and self-perceived health (OR 1.42; 95% CI 1.30-1.54).

Further exploration of the relationship between social support and loneliness using structural equation modelling identified that social support in everyday situations may serve as a good start- ing point for health promotion activities to prevent loneliness. To better target health promotion activities for healthy ageing, analyses were performed to group older people into subgroups with similar social engagement activity patterns. Five clusters were identified: 1) less socially engaged elderly; 2) less socially engaged caregivers; 3) socially engaged caregivers; 4) leisure-engaged elderly; and 5) productive-engaged elderly. Older people who were not engaged in any social activity other than the care for a sick person, were identified as a possible target group, given the relatively high share of unhealthy people among them. In this non-socially engaged target group, the prevalence of loneliness was 48%, compared to 30% in the socially engaged groups; poor self-perceived health: 41% compared to 14%; poor mental health: 25% compared to 9%; poor physical health: 27% compared to 2%.

Conclusion
Well-functioning social relationships were favourably associated with health. By integrating all results, the local data have strengthened the scientific evidence-base for local policy making and have contributed to the development of an evidence-based community intervention supporting social participation among older people.
De kennisinfrastructuur van de Openbare Gezondheidszorg. Vorm en functioneren
Vaandrager, L. ; Driessen Mareeuw, F.A. van den; Naaldenberg, J. ; Klerkx, L.W.A. ; Molleman, G. ; Regt, W. de; Zandvliet, J. - \ 2010
Den Haag : ZonMw - 187
volksgezondheid - gezondheidszorg - gezondheidsbeleid - public health - health care - health policy
Mentale gezondheid en werk : zingeving bevlogenheid motivatie werkplezier : verslag 3e themacongres Gezondheidsmanagement, Bedrijf in Beweging 13 maart 2008
Raaijmakers, T. ; Vaandrager, L. ; Baart, P. ; Cappelleveen, C. van; Hofstee, M. - \ 2008
Amersfoort : WUR/IHMQ/B&R/Lifeguard - 32
gezondheid op het werk - arbeid (werk) - arbeidsvoldoening - arbeidsomstandigheden - gezondheidsbeleid - gezondheid - occupational health - labour - work satisfaction - working conditions - health policy - health
Samenvatting van het congres Gezondheidsmanagement Bedrijf in Beweging. Met per sessie een kort verslag. Hoe zorgt de werkgever ervoor dat de medewerkers gezond blijven en hun werk goed kunnen blijven doen? En wat kunnen medewerkers hier zelf aan doen? Welke rol spelen bevlogenheid, werkplezier, motivatie en zingeving voor werkenden daarin?
Handleiding - Audit Referentiekader Gezondheidsbevordering. Deelrapport 2A, Pilot project Referentiekader Gezondheidsbevordering.
Saan, H. ; Haes, W. de; Hekkink, C. ; Wagemakers, A. - \ 2007
Woerden : NIGZ (NIGZ - Rapport ) - 31
gezondheidsbevordering - volksgezondheid - gezondheidsbeleid - gezondheidsbescherming - health promotion - public health - health policy - health protection
Deze handleiding bij de ontwikkelde audit, die gebaseerd is op het referentiekader volgt het stimulerende spoor: professionals die dat willen kunnen met het Referentiekader in de spiegel kijken en onderzoeken of hun uitgangspunten wel voldoende tot zijn recht komen, of de voorliggende kansen wel benut worden en of goed gebruik gemaakt is van beschikbare professionele inzichten en wetenschappelijke kennis. Het is bedoeld om een beleidsplan of een programma goed door te lichten
Verslag 2e themacongres Gezondheidsmanagement, Bedrijf in Beweging 15 maart 2007
Baart, L. ; Cappelleveen, C. van; Hofstee, M. ; Raaijmakers, T. ; Straaten, I. van; Vaandrager, L. - \ 2007
Amersfoort : WUR/IHMQ/B&R/Lifeguard - 26
arbeid (werk) - gezondheid op het werk - gezondheidsbeleid - gezondheidsbevordering - bedrijfsvoering - levensstijl - gezondheid - labour - occupational health - health policy - health promotion - management - lifestyle - health
Verslag van de discussies, lezingen en presentaties gehouden tijdens het congres Gezondheidsmanagement, Bedrijf in Beweging, over gezondheidsbeleid op het werk
Levensloop en WIA, verslag eerste themacongres Gezondheidsmanagement
Vaandrager, L. ; Baart, L. ; Raaijmakers, T. ; Hofstee, M. - \ 2006
Zeist : Uitgeverij Kerckebosch - 12
gezondheid op het werk - arbeid (werk) - bedrijfsvoering - gezondheidsbeleid - levensloop - arbeidsongeschiktheid - ziekteverlof - occupational health - labour - management - health policy - life course - labour disability - sick leave
Verslag van het eerste themacongres gezondheidsmanagement, dinsdag 7 maart 2006. In deze publicatie wordt teruggekeken op de conferentie, passeren de inleidingen de revue en worden de workshops verslagen. Tijdens de conferentie toonden de initiatiefnemers een aantal voorbeelden van organisaties waar gezondheid goed gemanaged wordt. Ook de manier waarop een organisatie tot gezondheidsmanagement kan komen, kwam uitgebreid aan de orde, waarbij een duidelijke koppeling gemaakt wordt naar de WIA en Levensloopregeling
Voeding is een zaak van de gehele maatschappij
Woerkum, C.M.J. van - \ 2006
VoedingsMagazine 19 (2006)1. - ISSN 0922-8012 - p. 24 - 25.
voedselconsumptie - obesitas - overgewicht - gezondheid - eetpatronen - levensstijl - gezondheidsbeleid - food consumption - obesity - overweight - health - eating patterns - lifestyle - health policy
'Voeding is een topthema op televisie, de politiek bemoeit zich er tegenaan en internet staat er vol mee,' zegt prof. dr. Cees van Woerkum (Wageningen Universiteit). Opvallend vindt hij de koppeling van eetstijlen en identiteit
Gender relations, livelihood security and reproductive health among women refugees in Uganda. The case of Sudanese women in Rhino Camp and Kiryandongo refugee settlements
Mulumba, D. - \ 2005
Wageningen University. Promotor(en): Georg Frerks. - Wageningen : s.n. - ISBN 9085043042 - 353
man-vrouwrelaties - vluchtelingen - vrouwen - voortplantingsgedrag - gezondheidszorg - gezondheidsbeleid - gemeenschappen - uganda - afrika - sudan - oorlog - conflict - huishoudens - migranten - gender relations - refugees - women - reproductive behaviour - health care - health policy - war - households - migrants - communities - africa
Allergiepreventie: een agronomische benadering: workshop 27 maart 2003, Wageningen
Meer, I.M. van der; Gilissen, L.J.W.J. ; Hall, R.D. ; Heteren, G. van - \ 2004
Wageningen : Plant Research International (Rapport / Plant Research International 78) - 30
allergieën - acute overgevoeligheid - allergische reacties - ziektepreventie - kwaliteit van het leven - kosten - immunologie - gezondheidsbeleid - onderzoek - allergies - immediate hypersensitivity - allergic reactions - disease prevention - quality of life - costs - immunology - health policy - research
Allergies, both food and environmentally related, are a continually growing health problem, particularly in the Western World. Exact causes and the additional environmental and social factors which play a role in the onset of these illnesses are still poorly understood. What is already clear is that while allergy sufferers remain a minority in the community, the reduction of the Quality-of-Life of these individuals and the financial consequences to the community as a whole is of major significance. Allergy is an illness where the sufferer is confronted on a daily basis with his or her lifestsyle limitations. The direct and indirect costs, from medical care, sick leave, loss of earnings, reduced productivity etc, already reach well into billions of euros. A complicating factor is that there are many kinds of allergy, with many different causes and several approaches for treatment. There is therefore no single solution. Much social and scientific research is still needed to generate the additional knowledge which is required to determine a suitable multidisciplinary strategy for the long-term tackling of this problem. Input from a wide range of sources, from social scientists to medics and from agriculturalists to immunologists etc, is essential to assess the situation fully and to assist in determining longterm policy decisions at a national level. This multidisciplinarity calls for broad support from different parts of government, industry and societal bodies to achieve the desired goal of reversing the rise in the number of allergy sufferers, preferably through prevention rather than cure.
Landbouw en zorg in de provincie. Inventarisatie van provinciaal beleid landbouw en zorg
Elings, M. ; Hassink, J. ; Ketelaars, T.J.W.M. - \ 2003
Wageningen : Plant Research International (Rapport / Plant Research International 63) - 54
landbouwbeleid - gezondheidsbeleid - sociaal beleid - regionaal beleid - inventarisaties - nederland - provincies - zorgboerderijen - agricultural policy - health policy - social policy - regional policy - inventories - netherlands - provinces - social care farms
Om zicht te krijgen op de verschillende beleidsplannen en stimuleringsregelingen van de provincies en om een indruk te krijgen van het resultaat van die beleidsmatige activiteiten, is een inventarisatie uitgevoerd van de beleidsactiviteiten van alle provincies in Nederland. Per hoofdstuk worden de provincies besproken. In het laatste hoofdstuk worden knelpunten besproken waar meerdere provincies tegen aan lopen en worden modellen en fasen van beleidsontwikkeling beschreven
De Prijs van Overgewicht
Cornelisse-Vermaat, J.R. ; Maassen van den Brink, H. ; Groot, W. de - \ 2003
ESB Economisch Statistische Berichten 88 (2003)4395. - ISSN 0013-0583 - p. 92 - 94.
obesitas - overgewicht - overeten - voedingsstoornissen - kosten van de gezondheidszorg - gezondheidszorg - gezondheidsbeleid - voeding - nederland - obesity - overweight - overeating - nutritional disorders - health care costs - health care - health policy - nutrition - netherlands
In Nederland zijn steeds meer mensen te dik. Mensen met overgewicht lopen grotere gezondheidsrisico's en de kosten voor gezondheidszorg nemen erdoor toe. Tijd voor een 'snack tax'?
Tussenstand praktijkproef dierveiligheidsindex
Mul, M.F. ; Bokma-Bakker, M. - \ 1999
Praktijkonderzoek varkenshouderij 13 (1999)6. - ISSN 1382-0346 - p. 9 - 11.
diergeneeskunde - varkens - diergezondheid - varkensstallen - dierenwelzijn - hygiëne - gezondheidszorg - gezondheidsbeleid - veterinaire hygiëne - veterinary science - pigs - animal health - pig housing - animal welfare - hygiene - health care - health policy - veterinary hygiene
De eerste tussenresultaten van de praktijkproef dierveiligheidsindex (DVI) zijn bekend. Van 104 varkensbedrijven is op dit moment inzicht verkregen in de haalbaarheid van de verschillende DVI-niveaus (DVI- 1, 2 en 3). Gemiddeld blijken de bedrijven aleen aanzienlijk deel van het totale pakket aan voorschriften te realiseren. Voldoen aan alle voorschriften blijkt echter moeilijker.
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