Monday, December 12, 2016

High Sedentary Time and Little Physical Activity in 4 countries in Europe

The objective of a study just published in Sports Medicine -with Anne Loyen as first author- was to pool, harmonise and re-analyse national accelerometer data from adults in four European countries in order to describe population levels of sedentary time and physical inactivity.
ActiGraph accelerometer count data from 9509 participants of five cross-sectional studies -in England, Portugal, Norway and Sweden- were centrally processed using the same algorithms. Multivariable logistic regression analyses were conducted to study the associations of sedentary time and physical inactivity with sex, age, weight status and educational level, in both the pooled sample and the separate study samples.
On average, participants were sedentary for 530 min/day, and accumulated 36 min/day of moderate to vigorous intensity physical activity. Twenty-three percent accumulated more than 10 h of sedentary time/day, and 72% did not meet the physical activity recommendations. Nine percent of all participants were classified as high sedentary and low active. Participants from Norway showed the highest levels of sedentary time, while participants from England were the least physically active. Age and weight status were positively associated with sedentary time and not meeting the physical activity recommendations. Men and higher-educated people were more likely to be highly sedentary, while women and lower-educated people were more likely to be inactive.
In conclusion, w
e found high levels of sedentary time and physical inactivity in four European countries. Older people and obese people were most likely to display these behaviours and thus deserve special attention in interventions and policy planning. In order to monitor these behaviours, accelerometer-based cross-European surveillance is recommended.

Tuesday, December 6, 2016

Effects of exercise on quality of life in patients with cancer: an individual patient data meta-analysis

In a paper just published in Cancer Treatment Reviews -with Dr. Laurien Buffart as first author, as part of the POLARIS study, and together with a large international consortium -, we present the methods and results of a large individual patient data (IPD) meta-analysis to evaluate the effects of exercise on quality of life (QoL) and physical function (PF) in patients with cancer, and to identify moderator effects of demographic (age, sex, marital status, education), clinical (body mass index, cancer type, presence of metastasis), intervention-related (intervention timing, delivery mode and duration, and type of control group), and exercise-related (exercise frequency, intensity, type, time) characteristics.  IPD from 34 randomised controlled trials (n=4,519 patients) that evaluated the effects of exercise compared to a usual care, wait-list or attention control group on QoL and PF in adult patients with cancer were retrieved and pooled. Linear mixed-effect models were used to evaluate the effects of the exercise on post-intervention outcome values (z-score) adjusting for baseline values. Moderator effects were studies by testing interactions. Exercise significantly improved QoL. These effects were not moderated by demographic, clinical or exercise characteristics. Effects on QoL were significantly larger for supervised than unsupervised interventions. In conclusion, exercise, and particularly supervised exercise, effectively improves QoL and PF in patients with cancer with different demographic and clinical characteristics during and following treatment. Although effect sizes are small, there is consistent empirical evidence to support implementation of exercise as part of cancer care.

Thursday, December 1, 2016

New edition of Dutch handbook on health education

This week the new edition of our book 'Gezondheidsvoorlichting en gedragsverandering' (Health education and behavior change) was published. Dr. Patricia van Assema of Maastricht University and Prof. Lilian Lechner of the Dutch Open University were my co-editors. The book provides a comprehensive overview for planning, preparing, conducting and evaluation of health education and health behavior change interventions. The book is structured according to a planning model that includes analyses of health and quality of life, the underlying health behaviors and the determinants of engaging in these behaviors, as well as behavior change strategies tailored to these determinants. The Intervention Mapping approach is presented as a means
to translate the information from these analyses into actual interventions. The book has further chapters on different settings for health education, implementation and dissemination of interventions, and on evaluation of health education interventions. The second part of the book presents real-life examples of intervention development and evaluations.

Thursday, November 3, 2016

Lifestyle correlates of overweight in adults: a hierarchical approach

Obesity-related lifestyle behaviors usually co-exist but few studies have examined their simultaneous relation with body weight. In a study just published in the International Journal of Behavioral Nutrition & Physical Activity as part of the Sustainable prevention of obesity through integrated strategies (SPOTLIGHT) project, we aimed to identify the hierarchy of lifestyle-related behaviors associated with being overweight in adults, and to examine subgroups so identified.
Data were obtained from a cross-sectional survey conducted across 60 urban neighborhoods in 5 European urban regions between February and September 2014. Data on socio-demographics, physical activity, sedentary behaviors, eating habits, smoking, alcohol consumption, and sleep duration were collected by questionnaire. Participants also reported their weight and height. A recursive partitioning tree approach (CART) was applied to identify both main correlates of overweight and lifestyle subgroups.
Among the 5295 adults that participated, the mean body mass index was 25.2 kg/m2, and 46.0 % were overweight as indicated by a BMI ≥25 kg/m2. CART analysis showed that among all lifestyle-related behaviors examined, the first identified correlate was sitting time while watching television, followed by smoking status. Different combinations of lifestyle-related behaviors (prolonged daily television viewing, former smoking, short sleep, lower vegetable consumption, and lower physical activity) were associated with a higher likelihood of being overweight, revealing 10 subgroups. Members of four subgroups with overweight prevalence >50 % were mainly males, older adults, with lower education, and living in greener neighborhoods with low residential density.
Sedentary behavior while watching television was identified as the most important correlate of being overweight. Delineating the hierarchy of correlates provides a better understanding of lifestyle-related behavior combinations which may assist in targeting preventative strategies aimed at tackling obesity.

Tuesday, October 18, 2016

Psychosocial variables moderate the relationship between leisure time physical activity and mortality among myocardial infarction survivors

Leisure time physical activity (LTPA) is inversely related to mortality risk among patients with a history of myocardial infarction (MI). In a paper just published in BMC Cardiovascular Disorders -with Dr. Rony Oosterom-Calo as first author- we explored if heart failure (HF) status and psychosocial variables moderate this association in a prospective cohort study among MI survivors.
LTPA was inversely associated with mortality. HF did not, but psychosocial variables did, moderate the association. Among the higher active patients, patients with a high level of depression had a lower mortality risk in comparison to those with a low level, and patients with a low level of social support had a lower mortality risk in comparison to those with a high level of social support.

Wednesday, September 28, 2016

Social capital, neighborhood income and overweight across Europe

People with lower socio-economic status -lower levels of education, income and/or job status- in general have poorer health and engage more in unhealthy life style behaviors such as unhealthy diets and lack of physical activity. They also tend to have higher body weight and are more likely to be overweight or obese. Neighbourhood income inequality may contribute to such differences in body weight. In a paper just published in the European Journal of Public Health -with Joreintje Mackenbach as first author- we explored whether neighbourhood social capital mediated the association of neighbourhood income inequality with individual body mass index (BMI). For this study data from the SPOTLIGHT project -a study in different urban regions across Europe to explore neighbourhood contextual determinants of overweight and obesity-were used. A total of 4126 adult participants from 48 neighbourhoods in France, Hungary, the Netherlands and the UK provided information on their levels of income, perceptions of neighbourhood social capital and BMI. Higher neighbourhood income inequality was associated with elevated levels of BMI a
nd lower levels of neighbourhood social networks and neighbourhood social cohesion. High levels of neighbourhood social networks were associated with lower BMI. Results stratified by country demonstrated that social networks fully explained the association between income inequality and BMI in France and the Netherlands. Social cohesion was only a significant mediating variable for Dutch participants. In conclusion our results suggest that in some European urban regions, neighbourhood social capital plays a large role in the association between neighbourhood income inequality and individual BMI.

Tuesday, September 13, 2016

Correlates of adherence to a physical exercise program after cancer treatment

In a paper just published in the International Journal of Behavioral Nutrition and Physical Activity we studied demographic, clinical, psychosocial, physical and environmental factors associated with participation in and adherence to a combined resistance and endurance exercise program among cancer survivors, shortly after completion of primary cancer treatment. Data from the randomized controlled Resistance and Endurance exercise After ChemoTherapy (REACT) study were used for this study.
Participants were randomly allocated to either a high intensity (HI) or low-to-moderate intensity (LMI) exercise program. Patients’ participation rate was defined as their decision to participate in the REACT study. Exercise adherence reflected participants’ attendance to the scheduled exercise sessions and their compliance to the prescribed exercises. High session attendance rates were defined as attending at least 80 % of the sessions. High compliance rates were defined as performing at least of 90 % of the prescribed exercise across all sessions. Correlates of exercise adherence were studied separately for HI and LMI exercise. Demographic, clinical, and physical factors were assessed using self-reported questionnaires. Relevant clinical information was extracted from medical records.

Cancer survivors who participated in the exercise program were more likely to have higher education, be non-smokers, have lower psychological distress, higher outcome expectations, and perceive more exercise barriers than non-participants. In HI exercise, higher self-efficacy was significantly associated with high session attendance and high compliance with endurance exercises, and lower psychological distress was significantly associated with high compliance with resistance exercises. In LMI exercise, being a non-smoker was significantly associated with high compliance with resistance exercises and higher BMI was significantly associated with high compliance with resistance and endurance exercises. Furthermore, breast cancer survivors were less likely to report high compliance with resistance and endurance exercises in LMI exercise compared to survivors of other types of cancer.

In conclusion, several demographic, clinical and psychosocial factors were associated with participation in and adherence to exercise among cancer survivors. Psychosocial factors were more strongly associated with adherence in HI than LMI exercise.

Tuesday, September 6, 2016

lack of association of health behaviors and psychosocial characteristics with preterm birth

Preterm birth is the leading pregnancy outcome associated with perinatal morbidity and mortality and remains difficult to prevent. There is evidence that some modifiable maternal health characteristics may influence the risk of preterm birth. The aim of our study just published in Maternal and Child Health Journal was to investigate the relationships of self-reported maternal health behaviour and psychological characteristics in nulliparous women with spontaneous preterm birth in prenatal primary care. We used data from the nationwide DELIVER multicentre cohort study, which was designed to examine perinatal primary care in the Netherlands. In our study, consisting of 2768 nulliparous women, we estimated the relationships of various self-reported health behaviours (smoking, alcohol consumption, folic acid supplementation, daily fruit, daily fresh vegetables, daily hot meal and daily breakfast consumption) and psychological characteristics (anxious/depressed mood and health control beliefs) with spontaneous preterm birth.
Of all variables investigated, low health control beliefs was the sole characteristic significantly associated with spontaneous preterm birth.

Saturday, August 27, 2016

Breakfast, lunch and dinner among school kids across Europe

In a study just published in Preventive Medicine, with Dr. Froydis Vik as first author, we aimed to assess (i) the prevalence of having regular family breakfast, lunch, dinner among 10–12 year olds in Europe, (ii) the association between family meals and child weight status, and (iii) potential differences in having family meals according to country of residence, gender, ethnicity and parental levels of education.
7716 children (mean age: 11.5 ± 0.7 years, 52% girls) in eight European countries (Belgium, Greece, Hungary, The Netherlands, Norway, Slovenia, Spain, Switzerland) participated in a cross-sectional school-based survey in 2010, as part of the ENERGY study. Data on family meals were self-reported by the parents and children's height and weight were objectively measured to determine overweight status.
The prevalence of regular family meals was 35%, 37% and 76% for breakfast, lunch and dinner respectively. Having regular family breakfast, but not lunch or dinner, was inversely associated with overweight. Children of higher educated parents were more likely to have regular family breakfast and less likely to have regular family lunch compared to children of lower educated parents.

Tuesday, July 19, 2016

SOS: systems of sedentary behaviour framework

Ecological models are currently in fashion to study and influence energy balance related behaviours, including sedentary behaviour. However, these ecological models are limited in their ability to capture the complexity of and interplay between determinants. The aim of the project described in a recent publication in the International Journal of Behavioural Nutrition and Physical Activity, with Seb Chasten as first author, was to develop a transdisciplinary dynamic framework, grounded in a system-based approach, for research on determinants of sedentary behaviour across the life span and intervention and policy planning and evaluation. This endeavour was part of the Determinants of Diet and Physical Activity (DEDIPAC) knowledge hub of the Healthy Diet for a Healthy Life joint programming initiative.

We conducted a comprehensive concept mapping approach to develop what we call the Systems Of Sedentary behaviours (SOS) framework, involving four main phases: (1) preparation, (2) generation of statements, (3) structuring (sorting and ranking), and (4) analysis and interpretation.

During the first phase, 550 factors regarding sedentary behaviour were listed across three age groups (i.e., youth, adults and older adults), which were reduced to a final list of 190 life course factors in phase 2 used during the consensus meeting. In total, 69 international delegates, seven invited experts and one concept mapping consultant attended this consensus meeting. The final framework obtained during that meeting consisted of six clusters of determinants: Physical Health and Wellbeing (71 % consensus), Social and Cultural Context (59 % consensus), Built and Natural Environment (65 % consensus), Psychology and Behaviour (80 % consensus), Politics and Economics (78 % consensus), and Institutional and Home Settings (78 % consensus). Conducting studies on Institutional Settings was ranked as the first research priority. The view that this framework captures a system-based map of determinants of sedentary behaviour was expressed by 89 % of the participants.

In summary, through an international transdisciplinary consensus process, the SOS framework was developed for the determinants of sedentary behaviour through the life course. Investigating the influence of Institutional and Home Settings was deemed to be the most important area of research to focus on at present and potentially the most modifiable. The SOS framework can be used as an important tool to prioritise future research and to develop policies to reduce sedentary time.

Sunday, July 3, 2016

Variation in population levels of physical activity in European adults

In a systematic literature review just published in the International Journal of Behavioural Nutrition & Physical Activity, with Anne Loyen as first authors- we aim to provide an overview of all existing cross-European studies that assess physical activity in European adults, describe the variation in population levels according to these studies, and discuss the impact of the assessment methods. The review is registered in the PROSPERO database under registration number CRD42014010334.
All but two of the studies used questionnaires to assess physical activity, with the majority of studies using the IPAQ-short questionnaire. The remaining studies used accelerometers. The percentage of participants who either were or were not meeting the physical activity recommendations was the most commonly reported outcome variable, with the percentage of participants meeting the recommendations ranging from 7 % to 96 % across studies and countries.
The included studies showed substantial variation in the assessment methods, reported outcome variables and, consequently, the presented physical activity levels. Because of this, absolute
population levels of physical activity in European adults are currently unknown. However, when ranking countries, Ireland, Italy, Malta, Portugal, and Spain generally appear to be among the less active countries. Objective data of adults across Europe is currently limited. These findings highlight the need for standardisation of the measurement methods, as well as cross-European monitoring of physical activity levels.

In the same journals we also published similar systematic reviews regarding sedentary time among adults across Europephysical activity among children and adolescents across Europe, and sedentary behaviour in children and adolescents across Europe. These reviews were all part of the DEDIPAC (determinants of diet and physical activity) joint action of the European joint programming initiative 'A Healthy Diet for a Healthy Life'.

Sunday, May 1, 2016

Mediators of exercise effects on quality of life in cancer survivors

There is growing evidence that exercise is beneficial for cancer patients' quality of life. In a study just published on line in the journal Medicine & Science in Sports & Exercise, we explored via which pathways this effect may come about. More specifically we explored if combined resistance and endurance exercise improves cardiorespiratory fitness and muscle strength, thereby reducing fatigue and improving global quality of life (QoL) and physical function among cancer survivors who completed curative treatment including chemotherapy.
One hundred and eighty six cancer survivors were assigned to a 12-week exercise intervention and 91 patients to a wait list control group (WLC).
Compared with WLC, exercise increased cardiorespiratory fitness and reduced general and physical fatigue. The exercise effect on physical fatigue was mediated by change in cardiorespiratory fitness, while higher hand-grip strength was significantly associated with lower physical fatigue, and better lower body muscle function with lower physical and general fatigue. Lower general and physical fatigue were significantly associated with higher global QoL, and physical function.
We concluded that beneficial effects of exercise on global QoL and physical function in cancer survivors were
mediated by increased cardiorespiratory fitness, and subsequent reductions in fatigue.

Wednesday, April 6, 2016

Summary of new Dutch food-based dietary guidelines published

In a paper just published -on behalf of the committee Dutch dietary guidelines 2015 of the Dutch Health Council- in the European Journal of Clinical Nutrition, the methods and results of the committee's work to derive food-based dietary guidelines for the Dutch population is described and discussed. These new dietary guidelines  for the Dutch are based on 29 systematic reviews of English language meta-analyses in PubMed summarizing randomized controlled trials and prospective cohort studies on nutrients, foods and food patterns and the risk of 10 major chronic diseases: coronary heart disease, stroke, heart failure, diabetes, breast cancer, colorectal cancer, lung cancer, chronic obstructive pulmonary disease, dementia and depression. The committee also selected three causal risk factors for cardiovascular diseases or diabetes: systolic blood pressure, low-density lipoprotein cholesterol and body weight. Findings were categorized as strong or weak evidence, inconsistent effects, too little evidence or effect unlikely for experimental and observational data separately. Next, the committee selected only findings with a strong level of evidence for deriving the guidelines. Convincing evidence was based on strong evidence from the experimental data either or not in combination with strong evidence from prospective cohort studies. Plausible evidence was based on strong evidence from prospective cohort studies only. A general guideline to eat a more plant food-based dietary pattern and limit consumption of animal-based food and 15 specific guidelines have been formulated. There are 10 new guidelines on legumes, nuts, meat, dairy produce, cereal products, fats and oils, tea, coffee and sugar-containing beverages. Three guidelines on vegetables, fruits, fish and alcoholic beverages have been sharpened, and the 2006 guideline on salt stayed the same. A separate guideline has been formulated on nutrient supplements. We concluded that completely food-based dietary guidelines can be derived in a systematic and transparent way.

Friday, March 25, 2016

Implementation index and effect of school-based obesity prevention

In a study just published in the journal Health Education Research -with Dr. Femke van Nassau as first author- we investigated if and to what extent the Dutch Obesity Intervention in Teenagers (DOiT) program was implemented as intended and how this affected program effectiveness. We collected data at 20 prevocational education schools in the Netherlands. We assessed seven indicators that may reflect implementation succes: recruitment, reach, dosage, fidelity, satisfaction, effectiveness and continuation. Data collection involved questionnaire research among teachers and pupils, adiposity measures among the pupils. From the data we derived an implementation index scores. The percentage of accomplished activities in the participating s
chools ranged from 9 to 93%. The percentage of lessons delivered decreased from 74 to 18% towards the end of the program. Fidelity to the teacher manual ranged from 85 to 26%. In general, teachers were satisfied with the DOiT lessons and teaching materials. Despite teachers' satisfaction with the DOiT lessons and teaching materials, degree of program implementation was lower than expected, especially towards the end of the program. Further, some evidence was found for an association between a higher implementation index score and program effectiveness.

Tuesday, March 15, 2016

Clinical and behavioural correlates of physical activity among breast cancer survivors

The aim of a study that was published this week in the journal Supportive Care in Cancer  (with Caroline Kampshoff as first author) was to identify demographic, clinical, psychosocial, and environmental correlates of objectively assessed physical activity among breast cancer survivors. Information about such correlates can inform future interventions to promote physical activity in
cancer survivors, which has been shown to improve quality of life and reduce complaints about fatigue among cancer survivors.
For this study we analysed data from 574 female breast cancer survivors who participated in three different intervention studies. Study participants were aged ≥18 years and had completed primary cancer treatment. Physical activity was objectively assessed by accelerometers or pedometers. Participants completed self-reported questionnaires on demographic, psychosocial, and environmental factors. Information regarding clinical factors was obtained from medical records or patient self-report.
Older age, higher body mass index, lower self-efficacy, and less social support were significantly correlated with less physical activity.

Thursday, March 3, 2016

European Sitting Championship

Sedentary behaviour is increasingly recognized as an important health risk, but comparable data across Europe are scarce. The objective of a study we conducted and that was published this week in Plos ONE, was to explore the prevalence and correlates of self-reported sitting time in adults across and within the 28 European Union Member States. This study was linked to the determinants of diet and physical activity (DEDIPAC) joint action of the Healthy Diet for a Healthy Life joint programming initiative.

This study reports data from the Eurobarometer in 2013 with 27,919 randomly selected Europeans (approximately 1000 per Member State).

Median sitting time across Europe was five hours per day. Across Europe, 18.5 percent of the respondents reported to sit more than 7.5 hours per day, with substantial variation between countries (ranging from 8.9 to 32.1 percent). In general, northern European countries reported more sitting than countries in the south of Europe. ‘Current occupation’ and ‘age when stopped education’ were found to be the strongest correlates of sitting time, both across Europe and within most Member States. Compared to manual workers, people with office occupations were 5 times more likely to sit more than 7.5 hours per day. Students were more than 3 times more likely to sit more than 7.5 hours per day than manual workers.

There is thus substantial variation in  sitting time among European adults across countries as well as socio-demographic groups.

Sunday, February 21, 2016

Barriers and facilitators to nationwide dissemination of a school-based obesity prevention program

in a paper just published in the European Journal of Public Health we -with Dr. Femke van Nassau as first author- describe a study on the barriers and facilitating factors to the adoption, implementation and continuation of the Dutch Obesity Intervention in Teenagers (DOiT) programme in the Netherlands.
We evaluated the adoption, implementation and continuation of the programme at 20 prevocational schools, based on interviews with DOiT school coordinators and teachers at the end of the first and second school year of the 2-year implementation period. Identified barriers and facilitating factors were categorized into four groups: (i) organizational factors, (ii) individual factors, (iii) characteristics of the programme and (iv) characteristics of the implementation strategy.
Teachers and DOiT coordinators identified various implementation barriers -such as lack of planning, other urgent unforeseen priorities, no plan to cope with teacher turnover and high teacher workload- as well as facilitating factors (e.g. involvement of DOiT coordinator and support from the DOiT office, sufficient communication and collaboration between teachers, strong teacher motivation and flexibility of the programme). Barriers for successful implementation were mainly at the school and teacher level. The results of our
study can be used for further improvement of the DOiT programme and for the development and improvement of other health promotion programmes in the school setting.

Tuesday, February 16, 2016

A special issue of Obesity Reviews on research into contextual correlates of obesogenic behaviour

Obesity is a main determinants of avoidable burden of disease. Obesity is importantly influenced by eating and physical (in-)activity behaviours. It has been posited that these unhealthy lifestyle behaviours are a normal response to environmental characteristics that may influence an individual's level of physical activity -such as lack of opportunities for being active- and dietary behaviours  -such as too ample opportunities to eat high sugar and fat foods-. Certain environments are thus more ‘obesogenic’ than others – more likely to promote and facilitate unhealthy behaviours, and higher likelihood to become and maintain overweight and obese. Changing the environment may thus offer opportunities to help reduce the obesity epidemic.

In a special issue just published in the journal Obesity Reviews, -introduced by Dr. Jeroen Lakerveld and others-, we present a number of publications that we were able to prepare based on the European Commission-funded SPOTLIGHT project (derived from ‘sustainable prevention of obesity through integrated strategies’).

In this special issue we report on methodological papers, such as pioneering work on assessing self-defined neighbourhood boundaries, providing insights into the neighbourhood limits and size as perceived by study respondents. Additionally Feuillet and colleagues describe a novel way to ascribe neighbourhoods to one of four possible types based on the obesogenic characteristics. The mismatch between perceived and objectively measured environmental obesogenic features is described in the paper by Roda and colleagues, and Mackenbach and colleagues report that  people living in less-well-off neighbourhoods perceive their living quarters as more obesogenic than others. Furthermore, findings of environmental correlates of cycling for transport are reported, and how sleep and sedentary behaviour are associated, as well as a number of other findings.

Educational differences in the validity of self-reported physical activity

The assessment of physical activity for surveillance or population based studies is usually done with self-report questionnaires. We studied if the validity of a much used self-reported physical activity questionnaire -the International Physical Activity Questionnaire (IPAQ) was different according to the level of education of the respondents.
In a paper just published in BMC public health, we compared physical activity as assessed with IPAQ to physical activity assessed with accelerometers (i.e. an objective measure of physical activity) and analysed if the results of these two measurements were better associated in higher than in lower educated people. This was indeed the case. The validity of IPAQ was moderate at best among higher educated respondents, but very poor among lower educated respondents. Our results suggest that questionnaires such as IPAQ should not be used among the lower educated.

Tuesday, February 2, 2016

Tim Lobstein on our SPOTLIGHT project analysis of community-based interventions

This week Dr. Tim Lobstein, director of policy at the World Obesity Federation, wrote a British Medical Journal Blog based on our analyses within the study into obesity and obesogenic environments, a cross-European collaboration (SPOTLIGHT) of community-based interventions for obesity prevention.

Lobstein focusses on the importance of evaluating community-based interventions on Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) to learn from such projects for future endeavours, and to avoid that such projects are being “top-down” by ensuring that all participants (beneficiaries, staff, funders) are involved in the planning process when the project is first mooted. Finally, Lobstein stresses that haste is a waste where community based obesity prevention projects are concerned: "Lastly, complex community-based interventions can experience tensions between delivering a high-quality, effective project in a short period of time on the one side, and achieving engagement in the community and its organisations and leaders on the other. "