Short-term effects of a health promotion program targeting healthy nutrition, physical activity and social network enhancement among low-income multi-problem households in the Netherlands


  • Latifa Abidi Department of Health Promotion, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
  • Math Candel Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
  • Hein de Vries Department of Health Promotion, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
  • Natalie Spaans Stimenz, Apeldoorn, Netherlands
  • Gera E. Nagelhout Department of Health Promotion, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands IVO Research Institute, The Hague, The Netherlands



Multi-problem households, Lifestyle intervention, Social contacts, Low SEP


Background: Multi-problem households (MPHs) are less physically active, eat less healthy, have higher perceived stress and worse self-reported health. A health promotion program was developed for MPHs targeting self-reported health, physical activity, healthy nutrition and engagement in social networks. This paper described the effectiveness of this program.

Methods: A quasi-experimental study was conducted in the city Apeldoorn in the Netherlands with assessments at baseline and after six months. The primary outcome was self-reported health. Secondary outcomes were physical activity, fruit and vegetable consumption, social contacts, loneliness, mental health, BMI and lifestyle index. Data were analyzed with multilevel linear regression analyses.

Results: A total of 116 respondents signed up for participation, of which 90 respondents (77.6%) completed the follow-up questionnaire. No differences were found between the control and intervention group on self-reported health (p=0.84). No differences were found between the groups on fruit consumption (p=0.34), but a significant interaction of group×time×health literacy was found (p=0.02). Follow-up analyses showed that only for participants with high health literacy significant differences in fruit consumption were found between control and intervention group at post-test (ß=8.059, p=0.02). No significant differences were found on other outcomes.

Conclusions: Recruiting sufficient participants was a challenge. Significant differences in fruit consumption were found among individuals with a relatively high health literacy and none for the other primary and secondary outcome measures. Our outcomes indicate that health promotion programs, as well as their reachability, need to be further tailored to the needs of MPH.


Giskes K, Avendaňo M, Brug J, Kunst AE. A systematic review of studies on socioeconomic inequalities in dietary intakes associated with weight gain and overweight/obesity conducted among European adults. Obesity Rev. 2010;11(6):413-29.

Sweet E, Nandi A, Adam EK, McDade TW. The high price of debt: Household financial debt and its impact on mental and physical health. Soc Sci Med. 2013;91:94-100.

Nagelhout GE, Abidi L, deVries H. How do health and social networks compare between low-income multiproblem households and the general population? Int J Environment Res Pub Health. 2019;16(24):4967.

Uphoff EP, Pickett KE, Cabieses B, Small N, Wright J. A systematic review of the relationships between social capital and socioeconomic inequalities in health: a contribution to understanding the psychosocial pathway of health inequalities. Int J Equity Health. 2013;12(1):54.

Stringhini S, Berkman L, Dugravot A, Ferrie JE, Marmot M, Kivimaki M, et al. Socioeconomic status, structural and functional measures of social support, and mortality: British Whitehall II Cohort Study, 1985–2009. Am J Epidemiol. 2012;175(12):1275-83.

Bakx P, O'Donnell O, VanDoorslaer E. Spending on health care in the Netherlands: not going so Dutch. Fiscal Stud. 2016;37(3-4):593-625.

Kann-Weedage D, Zoon M, Addink A, vanBoven J, Berger M, deWilde EJ. Aantal en kosten van multiprobleemgezinnen in Almelo. Utrecht Nederlands Jeugdinstituut. 2017.

Vilhelmsson A, Östergren PO. Reducing health inequalities with interventions targeting behavioral factors among individuals with low levels of education-a rapid review. PloS One. 2018;13(4).

Hayba N, Partridge SR, Nour MM, Grech A, Farinelli M. Effectiveness of lifestyle interventions for preventing harmful weight gain among young adults from lower socioeconomic status and ethnically diverse backgrounds: a systematic review. Obesity Rev. 2018;19(3):333-46.

Hornbuckle LM, Kingsley JD, Kushnick MR, Moffatt RJ, Haymes EM, Miles R, et al. Effects of a 12-month pedometer-based walking intervention in women of low socioeconomic status: supplementary issue: health disparities in women. Clin Med Insight Women Health. 2016;9:39636.

Garcia AL, Reardon R, McDonald M, Vargas-Garcia EJ. Community interventions to improve cooking skills and their effects on confidence and eating behaviour. Curr Nutrit Rep. 2016;5(4):315-22.

Sousa L, Rodrigues S. Linking formal and informal support in multiproblem low‐income families: the role of the family manager. J Commun Psychol. 2009;37(5):649-62.

Nagelhout GE, Abidi L, Jansen, T. Leefstijlverandering en netwerkversterking bij multiproblematiek. Vakblad Sociaal Werk. 2019;20(1):27-9.

VanStappen V, Latomme J, Cardon G, DeBourdeaudhuij I, Lateva M, Chakarova N, et al. Barriers from multiple perspectives towards physical activity, sedentary behaviour, physical activity and dietary habits when living in low socio-economic areas in Europe. The feel4Diabetes study. Int J Environment Res Pub Health. 2018;15(12):2840.

Díez J, Gullón P, Vázquez M, Álvarez B, Martín MDP, Urtasun M, et al. A community-driven approach to generate urban policy recommendations for obesity prevention. Int J Environment Res Pub Health. 2018;15(4):635.

Abidi L, Nagelhout GE, Spruijt R, Schutte H, DeVries H. Quasi-experimental study evaluating a health promotion program targeting health nutrition, physical activity and social network enhancement for low-income multi-problem households: Study protocol. Int J Clin Trial. 2018;5:132-41.

Reason P, Bradbury H. Handbook of action research: Participative inquiry and practice. Thousand Oaks, Californiaa: Sage; 2001.

MacLeod J, Nelson G. Programs for the promotion of family wellness and the prevention of child maltreatment: A meta-analytic review. Child Abuse Neglect. 2000;24(9):1127-49.

Al CM, Stams GJJ, Bek MS, Damen EM, Asscher JJ, Laan PH. A meta-analysis of intensive family preservation programs: Placement prevention and improvement of family functioning. Children Youth Service Rev. 2012;34(8):1472-9.

Balkrishnan R, Anderson RT, Bowton D. Self-reported health status predictors of healthcare services utilization and charges in elderly asthmatic patients. J Asthma. 2000;7(5):415-23.

Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health Social Behavior. 1997:21-37.

Craig CL, Marshall AL, Sjöström M, Bauman AE, Booth ML, Ainsworth BE, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exercise. 2003;35(8):1381-95.

RIVM. Indicatoren voor de Monitor Volksgezondheid, 2022. Available at: Accessed on 15 May 2022.

Cuijpers P, Smits N, Donker T, Have M, Graaf R. Screening for mood and anxiety disorders with the five-item, the three-item, and the two-item Mental Health Inventory. Psychiatr Res. 2009;168(3):250-5.

Gierveld JDJ, Tilburg TV. A 6-item scale for overall, emotional, and social loneliness: Confirmatory tests on survey data. Res Aging. 2006;28(5):582-98.

Mantwill S, Monestel-Umaña S, Schulz PJ. The relationship between health literacy and health disparities: a systematic review. PLoS One. 2015;10(12).

WHO. WHO Commission on the Social Determinants of Health. Achieving health equity: from root causes to fair outcomes. Geneva: WHO; 2007.

Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Health. 2004;11:12.

Fransen MP, Schaik TM, Twickler TB, Essink-Bot ML. Applicability of internationally available health literacy measures in the Netherlands. J Health Communicat. 2011;16(3):134-49.

Beunckens C, Molenberghs G, Kenward MG. Direct likelihood analysis versus simple forms of imputation for missing data in randomized clinical trials. Clin Trial. 2005;2(5):379-86.

Everson-Hock ES, Johnson M, Jones R, Woods HB, Goyder E, Payne N. Community-based dietary and physical activity interventions in low socioeconomic groups in the UK: a mixed methods systematic review. Prevent Med. 2013;56(5):265-72.

Lorenc T, Oliver K. Adverse effects of public health interventions: a conceptual framework. J Epidemiol Commun Health. 2014;68(3):288-90.

Hill S, Amos A, Clifford D, Platt S. Impact of tobacco control interventions on socioeconomic inequalities in smoking: review of the evidence. Tobacco Control. 2014;23(2):89-97.

Lorenc T, Petticrew M, Welch V, Tugwell P. What types of interventions generate inequalities? Evidence from systematic reviews. J Epidemiol Commun Health. 2013;67(2):190-3.

Veinot TC, Mitchell H, Ancker JS. Good intentions are not enough: how informatics interventions can worsen inequality. J Am Med Informatic Assoc. 2018;25(8):1080-8.

Holwerda A, Reijneveld S, Jansen D. The effectiveness of care for multiproblem families: An overview. Univer Med Centre Groningen. 2014.

Nagelhout GE, Hogeling L, Spruijt R, Postma N, DeVries H. Barriers and facilitators for health behavior change among adults from multi-problem households: a qualitative study. Int J Environment Res Pub Health. 2017;14(10):1229.

Nagelhout GE, Verhagen D, Loos V, deVries H. Belangrijke randvoorwaarden bij de ontwikkeling van leefstijlinterventies voor mensen met een lage sociaaleconomische status. Tijdschrift Voor Gezondheidswetenschappen. 2018;96(1):37-45.

Mantwill S, Allam A, Camerini AL, Schulz PJ. Validity of three brief health literacy screeners to measure functional health literacy-evidence from five different countries. J Health Commun. 2018;23(2):153-61.






Original Research Articles