Just-in-Time Prompts for Running, Walking, and Performing Strength Exercises in the Built Environment: 4-Week Randomized Feasibility Study.

BACKGROUND: App-based mobile health exercise interventions can motivate individuals to engage in more physical activity (PA). According to the Fogg Behavior Model, it is important that the individual receive prompts at the right time to be successfully persuaded into PA. These are referred to as just-in-time (JIT) interventions. The Playful Active Urban Living (PAUL) app is among the first to include 2 types of JIT prompts: JIT adaptive reminder messages to initiate a run or walk and JIT strength exercise prompts during a walk or run (containing location-based instruction videos). This paper reports on the feasibility of the PAUL app and its JIT prompts. OBJECTIVE: The main objective of this study was to examine user experience, app engagement, and users' perceptions and opinions regarding the PAUL app and its JIT prompts and to explore changes in the PA behavior, intrinsic motivation, and the perceived capability of the PA behavior of the participants. METHODS: In total, 2 versions of the closed-beta version of the PAUL app were evaluated: a basic version (Basic PAUL) and a JIT adaptive version (Smart PAUL). Both apps send JIT exercise prompts, but the versions differ in that the Smart PAUL app sends JIT adaptive reminder messages to initiate running or walking behavior, whereas the Basic PAUL app sends reminder messages at randomized times. A total of 23 participants were randomized into 1 of the 2 intervention arms. PA behavior (accelerometer-measured), intrinsic motivation, and the perceived capability of PA behavior were measured before and after the intervention. After the intervention, participants were also asked to complete a questionnaire on user experience, and they were invited for an exit interview to assess user perceptions and opinions of the app in depth. RESULTS: No differences in PA behavior were observed (Z=-1.433; P=.08), but intrinsic motivation for running and walking and for performing strength exercises significantly increased (Z=-3.342; P<.001 and Z=-1.821; P=.04, respectively). Furthermore, participants increased their perceived capability to perform strength exercises (Z=2.231; P=.01) but not to walk or run (Z=-1.221; P=.12). The interviews indicated that the participants were enthusiastic about the strength exercise prompts. These were perceived as personal, fun, and relevant to their health. The reminders were perceived as important initiators for PA, but participants from both app groups explained that the reminder messages were often not sent at times they could exercise. Although the participants were enthusiastic about the functionalities of the app, technical issues resulted in a low user experience. CONCLUSIONS: The preliminary findings suggest that the PAUL apps are promising and innovative interventions for promoting PA. Users perceived the strength exercise prompts as a valuable addition to exercise apps. However, to be a feasible intervention, the app must be more stable.

Mobile App (WHEELS) to Promote a Healthy Lifestyle in Wheelchair Users With Spinal Cord Injury or Lower Limb Amputation: Usability and Feasibility Study.

BACKGROUND: Maintaining a healthy lifestyle is important for wheelchair users' well-being, as it can have a major impact on their daily functioning. Mobile health (mHealth) apps can support a healthy lifestyle; however, these apps are not necessarily suitable for wheelchair users with spinal cord injury or lower limb amputation. Therefore, a new mHealth app (WHEELS) was developed to promote a healthy lifestyle for this population. OBJECTIVE: The objectives of this study were to develop the WHEELS mHealth app, and explore its usability, feasibility, and effectiveness. METHODS: The WHEELS app was developed using the intervention mapping framework. Intervention goals were determined based on a needs assessment, after which behavior change strategies were selected to achieve these goals. These were applied in an app that was pretested on ease of use and satisfaction, followed by minor adjustments. Subsequently, a 12-week pre-post pilot study was performed to explore usability, feasibility, and effectiveness of the app. Participants received either a remote-guided or stand-alone intervention. Responses to semistructured interviews were analyzed using content analysis, and questionnaires (System Usability Score [SUS], and Usefulness, Satisfaction, and Ease) were administered to investigate usability and feasibility. Effectiveness was determined by measuring outcomes on physical activity, nutrition, sleep quality (Pittsburgh Sleep Quality Index), body composition, and other secondary outcomes pre and post intervention, and by calculating effect sizes (Hedges g). RESULTS: Sixteen behavior change strategies were built into an app to change the physical activity, dietary, sleep, and relaxation behaviors of wheelchair users. Of the 21 participants included in the pilot study, 14 participants completed the study. The interviews and questionnaires showed a varied user experience. Participants scored a mean of 58.6 (SD 25.2) on the SUS questionnaire, 5.4 (SD 3.1) on ease of use, 5.2 (SD 3.1) on satisfaction, and 5.9 (3.7) on ease of learning. Positive developments in body composition were found on waist circumference (P=.02, g=0.76), fat mass percentage (P=.004, g=0.97), and fat-free mass percentage (P=.004, g=0.97). Positive trends were found in body mass (P=.09, g=0.49), BMI (P=.07, g=0.53), daily grams of fat consumed (P=.07, g=0.56), and sleep quality score (P=.06, g=0.57). CONCLUSIONS: The WHEELS mHealth app was successfully developed. The interview outcomes and usability scores are reasonable. Although there is room for improvement, the current app showed promising results and seems feasible to deploy on a larger scale.

A Focus Group Study Among Inactive Adults Regarding the Perceptions of a Theory-Based Physical Activity App.

Background: Despite the increasing attention for the positive effects of physical activity (PA), nearly half of the Dutch citizens do not meet the national PA guidelines. A promising method for increasing PA are mobile exercise applications (apps), especially if they are embedded with theoretically supported persuasive strategies (e.g., goal setting and feedback) that align with the needs and wishes of the user. In addition, it is argued that the operationalization of the persuasive strategies could increase the effectiveness of the app, such as the actual content or visualization of feedback. Although much research has been done to examine the preferences for persuasive strategies, little is known about the needs, wishes, and preferences for the design and operationalization of persuasive strategies. Objective: The purpose of this study was to get insight in the needs, wishes, and preferences regarding the practical operationalization of persuasive strategies in a mobile application aimed at promoting PA in healthy inactive adults. Methods: Five semistructured focus groups were performed. During the focus groups, the participants were led into a discussion about the design and operationalization of six predefined theory-based persuasive strategies (e.g., self-monitoring, feedback, goal setting, reminders, rewards, and social support) directed by two moderators. The audio-recorded focus groups were transcribed verbatim and analyzed following the framework approach. Results: Eight men and 17 women between 35 and 55 years (mean age, 49.2) participated in the study. Outcomes demonstrated diverse preferences for implementation types and design characteristics of persuasive strategies in mobile applications. Basic statistics (such as distance, time and calories), positive feedback based on easy-to-achieve goals that relate to health guidelines, and motivating reminders on a relevant moment were preferred. Participants had mixed preferences regarding rewards and a social platform to invite other users to join PA. Conclusions: Findings indicated that in mHealth applications for healthy but inactive adults, persuasive strategies should be designed and implemented in a way that they relate to health guidelines. Moreover, there is a need for an app that can be adapted or can learn based on personal preferences as, for example, preferences with regard to timing of feedback and reminders differed between people.

Reinforcement Learning to Send Reminders at Right Moments in Smartphone Exercise Application: A Feasibility Study.

Just-in-time adaptive intervention (JITAI) has gained attention recently and previous studies have indicated that it is an effective strategy in the field of mobile healthcare intervention. Identifying the right moment for the intervention is a crucial component. In this paper the reinforcement learning (RL) technique has been used in a smartphone exercise application to promote physical activity. This RL model determines the 'right' time to deliver a restricted number of notifications adaptively, with respect to users' temporary context information (i.e., time and calendar). A four-week trial study was conducted to examine the feasibility of our model with real target users. JITAI reminders were sent by the RL model in the fourth week of the intervention, while the participants could only access the app's other functionalities during the first 3 weeks. Eleven target users registered for this study, and the data from 7 participants using the application for 4 weeks and receiving the intervening reminders were analyzed. Not only were the reaction behaviors of users after receiving the reminders analyzed from the application data, but the user experience with the reminders was also explored in a questionnaire and exit interviews. The results show that 83.3% reminders sent at adaptive moments were able to elicit user reaction within 50 min, and 66.7% of physical activities in the intervention week were performed within 5 h of the delivery of a reminder. Our findings indicated the usability of the RL model, while the timing of the moments to deliver reminders can be further improved based on lessons learned.

Predictors of Walking App Users With Comparison of Current Users, Previous Users, and Informed Nonusers in a Sample of Dutch Adults: Questionnaire Study.

BACKGROUND: The last decade has seen a substantial increase in the use of mobile health apps and research into the effects of those apps on health and health behaviors. In parallel, research has aimed at identifying population subgroups that are more likely to use those health apps. Current evidence is limited by two issues. First, research has focused on broad health apps, and little is known about app usage for a specific health behavior. Second, research has focused on comparing current users and current nonusers, without considering subgroups of nonusers. OBJECTIVE: We aimed to provide profile distributions of current users, previous users, and informed nonusers, and to identify predictor variables relevant for profile classification. METHODS: Data were available from 1683 people who participated in a Dutch walking event in Amsterdam that was held in September 2017. They provided information on demographics, self-reported walking behavior, and walking app usage, as well as items from User Acceptance of Information Technology, in an online survey. Data were analyzed using discriminant function analysis and multinomial logistic regression analysis. RESULTS: Most participants were current walking app users (899/1683, 53.4%), while fewer participants were informed nonusers (663/1683, 39.4%) and very few were previous walking app users (121/1683, 7.2%). Current walking app users were more likely to report walking at least 5 days per week and for at least 30 minutes per bout (odds ratio [OR] 1.44, 95% CI 1.11-1.85; P=.005) and more likely to be overweight (OR 1.72, 95% CI 1.24-2.37; P=.001) or obese (OR 1.49, 95% CI 1.08-2.08; P=.005) as compared with informed nonusers. Further, current walking app users perceived their walking apps to be less boring, easy to use and retrieve information, and more helpful to achieve their goals. Effect sizes ranged from 0.10 (95% CI 0.08-0.30) to 1.58 (95% CI 1.47-1.70). CONCLUSIONS: The distributions for walking app usage appeared different from the distributions for more general health app usage. Further, the inclusion of two specific subgroups of nonusers (previous users and informed nonusers) provides important information for health practitioners and app developers to stimulate continued walking app usage, including making information in those apps easy to understand and making it easy to obtain information from the apps, as well as preventing apps from becoming boring and difficult to use for goal attainment.

Tailoring digital apps to support active ageing in a low income community.

Despite physical activity being one of the determinants of healthy aging, older people tend to become less active over the years. Maintaining physical activity levels during the life course is a motivational challenge. Digital tools have been used to change this pattern, such as smartphone applications to support physical activity; but there is a lack of in-depth research on the diversity of user's experiences, especially considering older users or non-users of information and communication technologies. OBJECTIVE: Our goal was to identify requirements for designing a mobile app to encourage physical activity in a low-income community population of older people in Brazil (i.e. over 40 years old). METHOD: We conducted a qualitative focus group study, involving by co-design of a physical activity application (Pacer)®. Seventeen volunteers were divided into 2 focus groups of physical active and insufficiently active, and 2 further 4 subgroups in each characterised by digital engagement. The following procedures were performed: (i) baseline assessments; (ii) a focus group with physically active older people and a focus group with insufficiently active older people (iii) design activities with both groups to re-design Pacer. RESULTS: Developing physical activity apps for older people should consider the following features: free application, simple interface, motivational messages using audio and visual information, sharing information among users, multimedia input and sharing and user customisation. In particular, we recommend that exercise apps in low-income communities be tailored to our four categories of users differing in baseline physical activity and digital engagement, to match the social and behavioural preferences we discovered.

Determinants of dietary behaviour in wheelchair users with spinal cord injury or lower limb amputation: Perspectives of rehabilitation professionals and wheelchair users.

OBJECTIVE: This study aims to identify determinants of dietary behaviour in wheelchair users with spinal cord injury or lower limb amputation, from the perspectives of both wheelchair users and rehabilitation professionals. The findings should contribute to the field of health promotion programs for wheelchair users. METHODS: Five focus groups were held with wheelchair users (n = 25), and two with rehabilitation professionals (n = 11). A thematic approach was used for data analysis in which the determinants were categorized using an integrated International Classification of Functioning, Disability and Health and Attitude, Social influence and self-Efficacy model. RESULTS: Reported personal factors influencing dietary behaviour in wheelchair users were knowledge, boredom, fatigue, stage of life, habits, appetite, self-control, multiple lifestyle problems, intrinsic motivation, goal setting, monitoring, risk perception, positive experiences, suffering, action planning, health condition, function impairments, attitude and self-efficacy. Reported environmental factors influencing dietary behaviour in wheelchair users were unadjusted kitchens, monitoring difficulties, eating out, costs, unfavourable food supply, nutrition education/counselling, access to simple healthy recipes, eating together, cooking for others, and awareness and support of family and friends. CONCLUSIONS: Important modifiable determinants of dietary behaviour in wheelchair users that might be influenced in lifestyle interventions are knowledge, fatigue, habits, self-control, intrinsic motivation, risk perception, attitude and self-efficacy. It is recommended to involve relatives, since they appear to significantly influence dietary behaviour.

What Are Good Situations for Running? A Machine Learning Study Using Mobile and Geographical Data.

Running is a popular form of physical activity. Personal, social, and environmental determinants influence the engagement of the individual. To get insight in the relation between running behavior and external situations for different types of users, we carried out an extensive data mining study on large-scale datasets. We combined 4 years of historical running data (collected by a mobile exercise application from over 10K participants) with weather, topographical and demographical datasets. We introduce weighted frequent item mining for the analysis of the data. In this way, we capture temporal and environmental situations that frequently associate with different running performances. The results show that specific temporal and environmental situations (hour in a day, day in a week, temperature, distance to residential areas, and population density) influence the running performance of users more than other situational features. Hierarchical agglomerative clustering on the running data is used to split runners in two clusters (with sustained and less sustained running behavior). We compared the two groups of runners and found that runners with less sustained behavior are more sensitive to the environmental situations (especially several weather and location related features, such as temperature, weather type, distance to the nearest park) than regular runners. Further analysis focused on the situational features for the less sustained runners. Results show that specific feature values correspond to a better or worse running distance. Not only the influence of individual features was examined but also the interplay between features. Our findings provide important empirical evidence that the role of external situations in the running behavior of individuals can be derived from analysis of the combined historical datasets. This opens up a large potential to take those situations specifically into consideration when supporting individuals which show less sustained behavior.

The Design and Development of a Personalized Leisure Time Physical Activity Application Based on Behavior Change Theories, End-User Perceptions, and Principles From Empirical Data Mining.

Introduction: Many adults do not reach the recommended physical activity (PA) guidelines, which can lead to serious health problems. A promising method to increase PA is the use of smartphone PA applications. However, despite the development and evaluation of multiple PA apps, it remains unclear how to develop and design engaging and effective PA apps. Furthermore, little is known on ways to harness the potential of artificial intelligence for developing personalized apps. In this paper, we describe the design and development of the Playful data-driven Active Urban Living (PAUL): a personalized PA application. Methods: The two-phased development process of the PAUL apps rests on principles from the behavior change model; the Integrate, Design, Assess, and Share (IDEAS) framework; and the behavioral intervention technology (BIT) model. During the first phase, we explored whether location-specific information on performing PA in the built environment is an enhancement to a PA app. During the second phase, the other modules of the app were developed. To this end, we first build the theoretical foundation for the PAUL intervention by performing a literature study. Next, a focus group study was performed to translate the theoretical foundations and the needs and wishes in a set of user requirements. Since the participants indicated the need for reminders at a for-them-relevant moment, we developed a self-learning module for the timing of the reminders. To initialize this module, a data-mining study was performed with historical running data to determine good situations for running. Results: The results of these studies informed the design of a personalized mobile health (mHealth) application for running, walking, and performing strength exercises. The app is implemented as a set of modules based on the persuasive strategies "monitoring of behavior," "feedback," "goal setting," "reminders," "rewards," and "providing instruction." An architecture was set up consisting of a smartphone app for the user, a back-end server for storage and adaptivity, and a research portal to provide access to the research team. Conclusions: The interdisciplinary research encompassing psychology, human movement sciences, computer science, and artificial intelligence has led to a theoretically and empirically driven leisure time PA application. In the current phase, the feasibility of the PAUL app is being assessed.

Determinants of physical activity in wheelchair users with spinal cord injury or lower limb amputation: perspectives of rehabilitation professionals and wheelchair users.

Purpose: To gain insight into determinants of physical activity in wheelchair users with spinal cord injury or lower limb amputation, from the perspective of both wheelchair users and rehabilitation professionals.Methods: Seven focus groups were conducted: five with wheelchair users (n = 25) and two with rehabilitation professionals (n = 11). The transcripts were analysed using a sequential coding strategy, in which the reported determinants of physical activity were categorized using the Physical Activity for people with a Disability (PAD) model.Results: Reported personal determinants of physical activity were age, general health status, stage of life, demotivation due to difficulty burning calories, available time and energy, balance in daily life, attitude, and history of a physically active lifestyle. Reported environmental determinants were professional guidance, inconvenient exercise times, accessibility of facilities, costs, transportation difficulties, equipment difficulties, and social support.Conclusions: Important, changeable determinants of physical activity that might be influenced in future lifestyle interventions for wheelchair users are: balance in daily life leading to more time and energy to exercise, attitude towards physical activity, professional guidance, accessibility of facilities (providing information on how and where to find accessible facilities), and social support (learning how to get this).Implications for rehabilitationA physically active lifestyle improves everyday functioning, and decreases disability and the risk of secondary health problems in wheelchair users with spinal cord injury or lower limb amputation.After inpatient rehabilitation, it is difficult for wheelchair users to maintain or further enhance their physical activity, a lifestyle intervention can help them in this.To be effective, lifestyle interventions should address important, changeable determinants of physical activity.Important, changeable determinants of physical activity reported by wheelchair users and rehabilitation professionals are: balance in daily life leading to more time and energy to exercise, attitude towards physical activity, professional guidance, accessibility of facilities, and social support.

Injury incidence and risk factors: a cohort study of 706 8-km or 16-km recreational runners.

OBJECTIVES: To report (1) the injury incidence in recreational runners in preparation for a 8-km or 16-km running event and (2) which factors were associated with an increased injury risk. METHODS: Prospective cohort study in Amsterdam, the Netherlands. Participants (n=5327) received a baseline survey to determine event distance (8 km or 16 km), main sport, running experience, previous injuries, recent overuse injuries and personal characteristics. Three days after the race, they received a follow-up survey to determine duration of training period, running distance per week, training hours, injuries during preparation and use of technology. Univariate and multivariate regression models were applied to examine potential risk factors for injuries. RESULTS: 1304 (24.5%) participants completed both surveys. After excluding participants with current health problems, no signed informed consent, missing or incorrect data, we included 706 (13.3%) participants. In total, 142 participants (20.1%) reported an injury during preparation for the event. Univariate analyses (OR: 1.7, 95% CI 1.1 to 2.4) and multivariate analyses (OR: 1.7, 95% CI 1.1 to 2.5) showed that injury history was a significant risk factor for running injuries (Nagelkerke R-square=0.06). CONCLUSION: An injury incidence for recreational runners in preparation for a running event was 20%. A previous injury was the only significant risk factor for running-related injuries.

Analysis of the Features Important for the Effectiveness of Physical Activity-Related Apps for Recreational Sports: Expert Panel Approach.

BACKGROUND: A large number of people participate in individual or unorganized sports on a recreational level. Furthermore, many participants drop out because of injury or lowered motivation. Potentially, physical activity-related apps could motivate people during sport participation and help them to follow and maintain a healthy active lifestyle. It remains unclear what the quality of running, cycling, and walking apps is and how it can be assessed. Quality of these apps was defined as having a positive influence on participation in recreational sports. This information will show which features need to be assessed when rating physical activity-related app quality. OBJECTIVE: The aim of this study was to identify expert perception on which features are important for the effectiveness of physical activity-related apps for participation in individual, recreational sports. METHODS: Data were gathered via an expert panel approach using the nominal group technique. Two expert panels were organized to identify and rank app features relevant for sport participation. Experts were researchers or professionals in the field of industrial design and information technology (technology expert panel) and in the field of behavior change, health, and human movement sciences who had affinity with physical activity-related apps (health science expert panel). Of the 24 experts who were approached, 11 (46%) agreed to participate. Each panel session consisted of three consultation rounds. The 10 most important features per expert were collected. We calculated the frequency of the top 10 features and the mean importance score per feature (0-100). The sessions were taped and transcribed verbatim; a thematic analysis was conducted on the qualitative data. RESULTS: In the technology expert panel, applied feedback and feedforward (91.3) and fun (91.3) were found most important (scale 0-100). Together with flexibility and look and feel, these features were mentioned most often (all n=4 [number of experts]; importance scores=41.3 and 43.8, respectively). The experts in the health science expert panels a and b found instructional feedback (95.0), motivating or challenging (95.0), peer rating and use (92.0), motivating feedback (91.3), and monitoring or statistics (91.0) most important. Most often ranked features were monitoring or statistics, motivating feedback, works good technically, tailoring starting point, fun, usability anticipating or context awareness, and privacy (all n=3-4 [number of experts]; importance scores=16.7-95.0). The qualitative analysis resulted in four overarching themes: (1) combination behavior change, technical, and design features needed; (2) extended feedback and tailoring is advised; (3) theoretical or evidence base as standard; and (4) entry requirements related to app use. CONCLUSIONS: The results show that a variety of features, including design, technical, and behavior change, are considered important for the effectiveness of physical activity-related apps by experts from different fields of expertise. These insights may assist in the development of an improved app rating scale.

App use, physical activity and healthy lifestyle: a cross sectional study.

BACKGROUND: Physical inactivity is a growing public health concern. Use of mobile applications (apps) may be a powerful tool to encourage physical activity and a healthy lifestyle. For instance, apps may be used in the preparation of a running event. However, there is little evidence for the relationship between app use and change in physical activity and health in recreational runners. The aim of this study was to determine the relationship between the use of apps and changes in physical activity, health and lifestyle behaviour, and self-image of short and long distance runners. METHODS: A cross sectional study was designed. A random selection of 15,000 runners (of 54,000 participants) of a 16 and 6.4 km recreational run (Dam tot Damloop) in the Netherlands was invited to participate in an online survey two days after the run. Anthropometrics, app use, activity level, preparation for running event, running physical activity (RPA), health and lifestyle, and self-image were addressed. A chi-squared test was conducted to analyse differences between app users and non-app users in baseline characteristics as well as in RPA, healthy lifestyle and perceived health. In addition, a multivariate logistic regression analysis was performed to determine if app use could predict RPA, perceived health and lifestyle, and self-image. RESULTS: Of the 15,000 invited runners, 28% responded. For both distances, app use was positively related to RPA and feeling healthier (p < 0.05). Also, app use was positively related to feeling better about themselves, feeling like an athlete, motivating others to participate in running, and losing weight (p < 0.01). Furthermore, for 16 km runners app use was positively related to eating healthier, feeling more energetic and reporting a higher chance to maintain sport behaviour (p < 0.05). CONCLUSIONS: These results suggest that use of mobile apps has a beneficial role in the preparation of a running event, as it promotes health and physical activity. Further research is now needed to determine a causal relationship between app use and physical and health related behaviour.

Plugs for containing faecal incontinence.

BACKGROUND: Faecal incontinence is a distressing disorder with high social stigma. Not all people with faecal incontinence can be cured with conservative or surgical treatment and they may need to rely on containment products, such as anal plugs. OBJECTIVES: To assess the performance of different types of anal plugs for containment of faecal incontinence. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, ClinicalTrials.gov, World Health Organization (WHO) ICTRP and handsearching of journals and conference proceedings (searched 26 May 2015). Reference lists of identified trials were searched and plug manufacturers were contacted for trials. No language or other limitations were imposed. SELECTION CRITERIA: Types of studies: this review was limited to randomised and quasi-randomised controlled trials (including crossovers) of anal plug use for the management of faecal incontinence. TYPES OF PARTICIPANTS: children and adults with faecal incontinence.Types of interventions: any type of anal plug. Comparison interventions might include no treatment, conservative (physical) treatments, nutritional interventions, surgery, pads and other types or sizes of plugs. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed methodological quality and extracted data from the included trials. Authors of all included trials were contacted for clarification concerning methodological issues. MAIN RESULTS: Four studies with a total of 136 participants were included. Two studies compared the use of plugs versus no plugs, one study compared two sizes of the same brand of plug, and one study compared two brands of plugs. In all included studies there was considerable dropout (in total 48 (35%) dropped out before the end of the study) for varying reasons. Data presented are thus subject to potential bias. 'Pseudo-continence' was, however, achieved by some of those who continued to use plugs, at least in the short-term. In a comparison of two different types of plug, plug loss was less often reported and overall satisfaction was greater during use of polyurethane plugs than polyvinyl-alcohol plugs. AUTHORS' CONCLUSIONS: The available data were limited and incomplete, and not all pre-specified outcomes could be evaluated. Consequently, only tentative conclusions are possible. The available data suggest that anal plugs can be difficult to tolerate. However, if they are tolerated they can be helpful in preventing incontinence. Plugs could then be useful in a selected group of people either as a substitute for other forms of management or as an adjuvant treatment option. Plugs come in different designs and sizes; the review showed that the selection of the type of plug can impact on its performance.

Most participate in faecal immunochemical test-based colorectal cancer screening out of curiosity about their chances of developing cancer.

Several clinical trials have shown that colorectal cancer (CRC) screening can reduce cancer deaths. Its effectiveness is affected by the participation level. To develop targeted invitations, we need to understand why individual persons decide to participate. To evaluate reasons for participation among persons invited for faecal immunochemical test-based CRC screening, a total of 10,265 asymptomatic persons aged 50-75 years were invited to a Dutch CRC screening pilot (2008-2009). Reasons for participation were elicited by a questionnaire. A total of 3554 (66%) participants returned the questionnaire. Obtaining more certainty about the chances of developing cancer (ticked by 88%) and the occurrence of cancer in the family or the circle of acquaintances (18%) were the most frequently selected reasons for participation. We also explored reasons for nonparticipation among nonparticipants. In this subgroup, comorbidity and the absence of symptoms were the most frequently reported reasons for declining to participate, but the response rate was low. The vast majority of the participants decided to take up the screening because they wanted to know more about their chances of developing cancer.

Assessing knowledge and attitudes towards screening among users of Faecal Immunochemical Test (FIT).

BACKGROUND: Informed decision making is recognized as important in screening. Invitees should be provided with relevant information, enabling them to make an informed decision. This may be more difficult in ethnic minority and low socio-economic status groups. We aimed to assess the proportion of informed decisions to participate in a faecal immunochemical test (FIT)-based colorectal cancer (CRC) screening pilot and to explore differences in knowledge and attitude across various subgroups. METHODS: Asymptomatic persons aged 50-74 were invited to a second round of a Dutch FIT-based pilot screening programme for CRC. An information leaflet containing all information relevant to enable informed decision making accompanied the invitation. Informed choice was assessed by a mailed questionnaire. Knowledge was elicited through 18 items and attitude towards screening through four items. Main outcome measure was the proportion of informed decision makers among participants. Differences between subgroups were evaluated using logistic regression. RESULTS: Of 5367 screening participants, 2774 (52%) completed the questionnaire. Knowledge was adequate in 2554 (92%); 2736 (99%) showed a positive attitude towards screening. A total of 2525 persons had made an informed choice (91%); male gender, low education level, non-Dutch ethnicity and not speaking Dutch at home were negatively associated with having adequate knowledge in multivariable analysis. CONCLUSION: In FIT-based screening for CRC, the majority of responders made an informed decision to participate. However, we did not succeed in equally providing all population subgroups with sufficient information. Future initiatives should be aimed at reaching these groups to further enable informed decision making.

A poor association was found between self-reported physical activity and estimated maximal oxygen uptake of sedentary multiethnic women.

OBJECTIVES: In health evaluations, physical activity (PA) and cardiorespiratory fitness (maximal oxygen uptake [VO2max]) are important variables. It is not always possible to assess both of them. If the association between self-reported PA and VO2max was strong, it would be possible to use the information on PA to make assumptions about VO2max and vice versa. However, little is known about this relation, in particular among women at high risk for cardiovascular disease. Our aim was to study the association between self-reported PA (Short QUestionnaire to ASses Health enhancing PA) and fitness (determined using the Siconolfi step test) among sedentary women in a multiethnic population. STUDY DESIGN AND SETTING: Participants were sampled from an exercise program for sedentary women (The Netherlands, 2008-09). Linear regression was performed with VO2max (dependent variable) and self-reported PA (independent variable); covariates were age and body mass index. RESULTS: One hundred ninety-seven women from different ethnic backgrounds were included. No significant association was found between VO2max and PA (R(2) = 0.60). CONCLUSION: A poor association was found between self-reported PA and estimated VO2max. Hence, PA and VO2max represent two different aspects of health in sedentary women and cannot be used interchangeably. This should be taken into account when evaluating health promotion interventions or when making health risks statements in sedentary women in a multiethnic population.

Patients' perception of colonoscopy: patients with inflammatory bowel disease and irritable bowel syndrome experience the largest burden.

BACKGROUND: Colonoscopy is a frequently performed procedure worldwide with a negative perception, leading to reluctance to undergo the procedure. Perceptions could differ depending on the specific indication for the colonoscopy. AIMS: To compare patient satisfaction with the colonoscopy procedure between five different patient groups: inflammatory bowel disease (IBD), familial predisposition for cancer, adenoma/carcinoma surveillance, symptoms suggestive of cancer, and irritable bowel syndrome (IBS). METHODS: A prospective questionnaire study was carried out in two regional hospitals and two tertiary teaching hospitals in the Netherlands. A total of 797 consecutive patients scheduled for colonoscopy between October 2009 and June 2010, 146 (18%) IBD, 153 (19%) adenoma or carcinoma surveillance, 104 (13%) familial predisposition, 280 (35%) symptoms suggestive of cancer, and 114 (14%) IBS-like symptoms, were included. Two questionnaires were administered: one on the day of the procedure and another 6 weeks after the procedure. The main outcome measurements were embarrassment, pain, burden, most burdensome aspect, and overall level of satisfaction. RESULTS: Patients with IBD and IBS reported significantly more embarrassment and burden from the bowel preparation phase (P=0.040 and 0.018, respectively) and more pain during the colonoscopy procedure (P=0.018). This difference in pain was also observed when adjusting for volume of sedation administered, familiarity with the endoscopist, duration of the colonoscopy, or whether or not an intervention was performed. All patient groups were less satisfied with the procedure at 6 weeks than directly after the colonoscopy; they recalled more embarrassment and burden, but less pain. CONCLUSION: Patient groups, defined by indication for colonoscopy, experience the colonoscopy procedure differently.

A feces collection paper does not enhance participation in a fecal immunochemical test-based colorectal cancer screening program: randomized clinical trial.

Discomfort with the collection of a stool sample is a frequently cited barrier for participation in fecal test-based colorectal cancer screening. The objective was to evaluate whether a feces collection paper enhances participation in a fecal immunochemical test (FIT)-based colorectal cancer screening program. Randomized clinical trial. Second round of a biannual Dutch FIT-based colorectal cancer screening program pilot. A random sample of 10 265 individuals from the general population, men and women aged 50-75 years at an average risk for colorectal cancer, was eligible for participation. Invitees were randomized to an FIT-only group (n=5136) or an FIT in combination with a feces collection paper group (n=5129). The main outcome measure was participation in screening. Overall, 5367 tests of 10 265 were returned (52%). In the FIT-only group, 2694 tests were returned [52%; 95% confidence interval (CI): 51-54%] versus 2673 tests in the collection paper group (52%; 95% CI: 51-54%). This difference in the participation rate was not significant (relative risk: 0.99; 95% CI: 0.97-1.04). A feces collection paper does not increase participation rates in FIT-based colorectal cancer screening. Future studies should explore other ways of facilitating participation in colorectal cancer screening programs.

Inappropriate use of the faecal occult blood test in a university hospital in the Netherlands.

OBJECTIVES: Although all international guidelines state that there is no indication to perform a faecal occult blood test (FOBT) in symptomatic patients, we believe the test is frequently used as a diagnostic test. The objective of this study was to investigate whether the current guidelines for FOBT use are being followed in the Netherlands. METHODS: The frequency of reasons for ordering a FOBT in 15 hospitals over a time period of 1 year was determined and the consequences of the test result on the diagnostic workup were determined by a retrospective search of electronic hospital charts. RESULTS: In 14 of the 15 hospitals a FOBT was available and totally 2993 FOBTs were performed in 1 year. A total of 201 electronic charts were retrieved. The FOBTs were ordered because of anaemia (41%), suspicion of rectal bleeding (17%), abdominal pain (14%), changed bowel habits (10%) or others (18%). A positive test result was found in 66 (33%) patients and a negative in 133 (66%). Respectively, 38% (25/66) of the patients with a positive and 41% (55/133) of the patients with a negative test result received a gastrointestinal follow-up investigation. In 25/80 investigations, a possible cause of rectal blood loss was detected, of which 13 had a positive FOBT result. CONCLUSION: This study demonstrates that current guidelines on FOBT use are not followed in the Netherlands and that a FOBT is often used as a diagnostic tool instead of a screening tool, thereby causing confusion and unnecessary delays in the diagnostic workup of patients.