The differentiated effectiveness of a printed versus a Web-based tailored physical activity intervention among adults aged over 50.

This study provides insight in the effectiveness of a print-delivered and a Web-based physical activity (PA) intervention (with or without additional environmental information on local PA possibilities) among people aged over 50. Intervention groups (print-delivered basic [PB; n = 439], print-delivered environmental [PE; n = 435], Web-based basic [WB; n = 423], Web-based environmental [WE; n = 432]) and a control group (n = 411) were studied in a clustered randomized controlled trial. Participants received three times tailored advice within four months, targeting the psychosocial determinants of PA, and additional environmental information (in two conditions). Outcome measures include weekly minutes and days of sufficient PA 6 months after the start, considering age, gender, educational level, body mass index, the presence of a chronic physical limitation and PA intentions as possible effect moderators. The results showed that the PB (B = 192.47; 95% CI = 75.24-309.71; P = 0.003), the PE (B = 229.31; 95% CI = 108.73-349.89; P = 0.001) and the WB-intervention condition (B = 214.25; 95% CI 88.65-339.85; P = 0.002) resulted in significantly increased weekly minutes of PA. Only the printed conditions resulted in increased days of sufficient PA (PB: B = 0.63; 95% CI = 0.35-0.92; P < 0.001; PE: B = 0.55; 95% CI = 0.26-0.85; P = 0.001). Additional environmental information did not increase intervention effects. Differences in effect were found between age and gender subgroups. In conclusion, both printed and Web-based interventions can be effective in increasing PA in adults aged over 50.

[Measuring the handgrip strength of geriatric patients]. / Het meten van handgreepsterkte bij geriatrische patiënten.

The handgrip strength of geriatric patients can be measured when the patient is hospitalized. This article elaborates on the intrinsic and extrinsic factors which have a direct or indirect influence on handgrip strength. For the best results the tests need to be taken in the best circumstances with attention to individual differences and the age of the patient. Handgrip strength as determination of biological vitality is a key concept. Besides the physical characteristics there are many psychological factors (cognition, psyching-up, test attitude…) influencing the results. These are barely mentioned or not mentioned at all in the usual procedures. Research of handgrip strength testing theories is mostly focused on young, healthy adults and less on elderly patients. The main goal of this article is stimulating experimental research on the measurement of handgrip strength with elderly people and involving them more actively with the procedure. It is not enough to acquire insight in function and predicting characteristics of handgrip strength. Next to the aiming for the best test performance is 'working interactively with elderly patients' a goal on itself in the modern vision of health care.

Differences in the use and appreciation of a web-based or printed computer-tailored physical activity intervention for people aged over 50 years.

This study provides insight into the use and appreciation of a tailored physical activity intervention for people aged over 50 years in different intervention conditions (i.e. printed versus web-based and basic versus environmental). Participants (within a clustered randomized controlled trial) received printed or web-based-tailored advice three times within 4 months. Half of the participants also received environmental information. Differences in use and appreciation between both delivery modes and between the basic and environmental condition (similar delivery mode) were assessed at 3 (N = 935) and 6 (N = 649) months after baseline using analyses of variance and chi-square test. The use of the printed intervention (i.e. 92.7-98.2% read, 70.1-76.5% kept and 39.9-56.8% discussed) was significantly higher and printed intervention components were better appreciated than web-based intervention (scores, respectively, 6.06-6.91 versus 5.05-6.11 on a scale of 1-10). In-depth appreciation (e.g. reliability, perceived individualization) was average to high, without differences between intervention conditions. Additional environmental information did not increase appreciation; however, environmental intervention components were more used compared with basic intervention components. Integration of environmental components can stimulate active use of the intervention. To increase the public impact and prevent dropout by participants of web-based physical activity interventions, design modifications are needed for ease of use and improved appreciation.

Determinants of awareness, initiation and maintenance of physical activity among the over-fifties: a Delphi study.

To develop effective interventions to stimulate physical activity (PA), insight into its underlying variables is needed. The aim of this study was to obtain an overview of the most relevant determinants of awareness, initiation and maintenance of PA among the over-fifties by means of a three-round Delphi study. In the first round, 17 key-experts outlined possible relevant determinants into an open-ended electronic questionnaire. In the second round, 118 experts completed a structured electronic questionnaire that was based on the first round results, in which they scored each determinant on its relevance. In the third round, experts were asked to re-rate the relevance of each determinant, after feedback was given about the group median relevance score. After three rounds, the experts agreed on 30 relevant determinants of the three phases of PA. When compared with longitudinal studies, the Delphi study pointed out new concepts, such as several post-motivational and social and environmental determinants as possible relevant determinants, suggesting that this method has the potential to trace new and promising determinants. The results further showed that next to similarities, much dissimilarity in relevant determinants of awareness, initiation and maintenance of PA was found, suggesting that most determinants could be phase specific.

Smoking and the Ø pattern; predictors of transitions through the stages of change.

Pre-contemplators, contemplators and preparers have previously been described by distinct scores on pros, social influence and self-efficacy, the Ø pattern. The objective of this study was to replicate this pattern in a sample of adult smokers (n = 554), to longitudinally observe stage sequence and identify predictors for forward and backward stage transition. Three hypotheses were formulated: (i) forward transition from pre-contemplation will be predicted by a higher perception of pros concerning smoking cessation, (ii) backward transition from contemplation will be predicted by a lower perception of pros of quitting smoking and (iii) forward transition from preparation will be predicted by a higher self-efficacy perception concerning smoking cessation. The Ø pattern was replicated successfully. Smokers appeared to be more likely to transition to an adjacent stage than to skip a stage in the sequence. For prediction of stage transition, separate analyses were conducted for pre-contemplators, contemplators and preparers. Respondents transitioning forward were compared with respondents remaining in the same stage or transitioning backward and vice versa. Hypothesis (i) and (iii) were confirmed. Additionally, self-efficacy predicted forward transition from pre-contemplation. Implications towards improving interventions and research concerning stage transition are discussed.

Predictors of smoking relapse in a sample of Dutch adult smokers; the roles of gender and action plans.

BACKGROUND: The object of this study was to investigate the influence of gender and the additional protective quality of action plans on the occurrence of relapse in smokers after a pharmacy-based minimal intervention strategy. METHODS: Respondents received a written baseline questionnaire, based on the I-Change Model, and were contacted 3 months after baseline by telephone. RESULTS: A total of 223 respondents were included in relapse analyses. Relapse was predicted by intention, the use of pharmacotherapy and action plans. Predictors differed for men and women. CONCLUSIONS: Action plans provide a protective value against smoking relapse. Men and women did not differ in relapse rates, but predictors differed. Developers of relapse prevention activities should consider developing programmes based on gender. These programmes could also benefit from making use of action plans as a method for preventing relapse.

Motivational stages of adolescent smoking initiation: predictive validity and predictors of transitions.

The present study tested the use and validity of a stage model of adolescent smoking initiation. The model aims to identify adolescents who are currently not smoking, but who are cognitively predisposed to start smoking in the future. Research on subtypes within the precontemplation stage of adolescent smoking initiation and the concept of susceptibility to smoking led to the construction of a motivational stage model of four distinct stages: committer, immotive, progressive, and contemplator. Using longitudinal data on a large international sample of European adolescents (n=7117), the model proved to have value in predicting smoking initiation at 12 months follow up. The odds ratio to take up regular smoking behavior appeared to double with each forward stage transition. Although effect sizes were small to moderate, unique predictors of transitions from the various stages were identified. Implications of the findings are discussed.

Smoking initiation among Gambian adolescents: social cognitive influences and the effect of cigarette sampling.

In this study, determinants of tobacco use among Gambian youths were examined. A cross-sectional school-based survey was conducted among 282 students, aged 14-18. The potential determinants were derived from the core constructs of the Theory of Planned Behavior and the ASE model. Moreover, various measures of knowledge and media influence were added to the research model. The results show that free cigarette offers by representatives of tobacco companies were mostly responsible for the difference between smokers and non-smokers. Other variables associated with smoking behavior were greater intention to smoke in the future, lower self-efficacy expectations regarding emotional situations, smoking behavior of the respondent's best friend, the mother having a job and the absence of other family members living in the house. Our study supports current efforts to prohibit tobacco advertising and promotions in The Gambia, especially the distribution of free samples. Additionally, we recommend prevention activities in schools and communities to aim at making children less vulnerable to 'sampling', increasing their self-efficacy expectations regarding emotional situations and making them aware of the influence of their best friend.

Development and longitudinal test of an instrument to measure behavioral stages of smoking initiation.

A dearth of longitudinal research has been observed regarding the measurement of the behavioral process of adolescent smoking initiation. The present study operationalizes the leading model on the process of smoking initiation, including two stages of nonpersistent smoking behavior that were previously unlabelled. An instrument was developed that distinguished six distinct stages of smoking initiation (i.e., never smoker, trier, experimenter, regular smoker, nonsmoking decider, and quitter). Data were gathered longitudinally in 1998 and 1999. The results indicated the applicability of the instrument in a large cross-cultural population of early European adolescents from Finland, Denmark, the United Kingdom, The Netherlands, Spain, and Portugal (n = 7899). Stage transitions had taken place in the expected sequence and progression to daily smoking at 12 months follow-up was successfully predicted. The theory-driven assessment of the process of adolescent smoking initiation may contribute to the development of a generally accepted measure of adolescent smoking initiation.

Model of unplanned smoking initiation of children and adolescents: an integrated stage model of smoking behavior.

BACKGROUND: Two lines of psychological research have attempted to spell out the stages of adolescent smoking initiation. The first has focused on behavioral stages of smoking initiation, while the second line emphasized motivational stages. METHODS: A large international sample of European adolescents (N = 10,170, mean age = 13.3 years) was followed longitudinally. Self-reported motivational and behavioral stages of smoking initiation were integrated, leading to the development of the Model of Unplanned Smoking Initiation of Children and Adolescents (MUSICA). The MUSICA postulates that youngsters experiment with smoking while they are in an unmotivated state as regards their plans for smoking regularly in the future. RESULTS: More than 95% of the total population resided in one of the seven stages distinguished by MUSICA. The probability of starting to smoke regularly during the 12 months follow-up period increased with advanced stage assignment at baseline. Unique social cognitive predictors of stage progression from the various stages were identified, but effect sizes of predictors of transitions were small. CONCLUSIONS: The integration of motivational and behavioral dimensions improves our understanding of the process of smoking initiation. In contrast to current theories of smoking initiation, adolescent uptake of smoking behavior was found to be an unplanned action.

"Kicking the initiation": do adolescent ex-smokers differ from other groups within the initiation continuum?

BACKGROUND: Current research on the continuum of smoking initiation has largely focused on phases of progressing frequency of smoking. To gain more insight into reasons some adolescents do, and others do not, proceed to advanced levels of smoking behavior, a continuum in which two categories of ex-smoking are proposed is examined. METHODS: Standardized scores on psychosocial predictors of smoking among adolescent nonsmoking deciders and quitters were compared cross-sectionally with those of the categories of never smokers, triers, experimenters, and regular smokers (n = 23,317). RESULTS: Never smokers, triers, experimenters, and regular smokers had significantly different characteristics with regard to psychosocial predictors of smoking (P < 0.01), with scores of never smokers indicating that they were least at risk of smoking in the future and those of regular smokers indicating that they were most at risk. Scores of nonsmoking deciders showed that they were less at risk than triers and experimenters and more at risk than never smokers. Quitters seemed to have less risky psychosocial characteristics than experimenters and more risky characteristics than nonsmoking deciders. CONCLUSIONS: Studying transitions of smoking behavior based on six possible phases (i.e., never smoking, nonsmoking deciding, trying, experimenting, regular smoking, and quitting) might lead to more valid insights into predictors of adolescent smoking behavior.

Subtypes within the precontemplation stage of adolescent smoking acquisition.

The present study examined the existence of three possible subtypes within the precontemplation stage of smoking acquisition: committers, immotives, and progressives. The sample of the study included young people from six European countries (mean age = 13 years) who had never smoked regularly (n = 21 535). A cross-sectional design was used to assess cognitive determinants of smoking behavior: attitudes towards smoking, perceived social influences, and self-efficacy to remain a nonsmoker. Adolescents within the various stages of smoking acquisition were compared with regard to standardized T scores on these risk factors. The results showed that adolescents in the three subgroups of precontemplation differed from each other on every cognitive determinant tested, revealing a higher risk to start smoking among progressives than among immotives. Immotives revealed a higher risk to start smoking than committers. It is concluded that the use of subtypes within acquisition precontemplation in research on adolescent smoking may be a promising tool for investigating the initiation continuum and for improving the quality of both the implementation and evaluation of prevention programs.

Effectiveness of a minimal contact smoking cessation program for Dutch general practitioners: a randomized controlled trial.

BACKGROUND: Until recently, Dutch general practitioners contributed little to tobacco control. This is due to several factors, among which is the lack of a feasible intervention program for adult smokers. Such a minimal contact behavioral intervention, using the Stage-of-Change concept, is now available. Effectiveness was tested in a randomized trial. METHOD: Twenty-two general practitioners and their practice assistants were trained in applying the program. In all, 530 smoking patients were enrolled, randomly assigned to either the intervention or the usual treatment condition. Analysis of treatment effects was performed with logistic regression analysis. In a backward stepwise procedure confounding effects of baseline differences were eliminated. RESULTS: At 12-month follow-up, self-reported abstinence rates (including nonrespondents as smokers) differed significantly between intervention subjects and controls: 13.4 vs 7.3% point prevalence (odds ratio 1.51, P < 0.05). An analysis of consecutive abstinence, defined as being abstinent at both 6- and 12-month follow-up, showed that 8.2% of the intervention group compared to 3.1% of the controls had sustained abstinence for more than 6 months (odds ratio 3.04, P < 0.001). CONCLUSIONS: Results indicate that an effective smoking cessation program for use in Dutch general practice, already shown to be feasible, is now available. Outcomes are generally consistent with recent international literature.

The reach and effectiveness of a national mass media-led smoking cessation campaign in The Netherlands.

OBJECTIVES: This study examined the reach, effectiveness, and cost-effectiveness of a mass media-led smoking cessation campaign including television shows, a television clinic, a quit line, local group programs, and a comprehensive publicity campaign. METHODS: A random sample of baseline smokers (n = 1338) was interviewed before and after the campaign and at a 10-month follow-up. A nonpretested control group (n = 508) of baseline smokers was incorporated to control for test effects. RESULTS: Most smokers were aware of the campaign, although active participation rates were low. Dose-response relations between exposure and quitting were found. The follow-up point prevalence abstinence rate attributable to the campaign was estimated to be 4.5% after control for test effects and secular trends. The cost per long-term quitter was about $12. CONCLUSIONS: In spite of a massive rise in tobacco promotion expenditures prior to the campaign and the absence of governmental control over the media, the campaign under study may have increased normal cessation rates substantially.

[How effective are smoking cessation campaigns?]. / Hoe effectief zijn 'Stoppen met roken'-campagnes?

An important risk factor, single as well as combined with other factors, for the development of cancer is tobacco smoking. In the Netherlands 37% of the adult men smoke, and 30% of the women. It is estimated that 20% of the now living population will eventually die from the consequences of smoking. Besides stimulating youngsters not to take up smoking, helping smokers to stop is preventative for the evolution of cancer. However, how effective are the attempts that are currently accomplished in this field? In this contribution, the quit-rates that the different methods produce will be described, over and above the 5% of smokers who yearly succeed in quitting on their own. These rates vary from 5% among the general population resulting from a mass media led campaign. Finally, some critical comments will be given on governmental policies.

Differential beliefs, perceived social influences, and self-efficacy expectations among smokers in various motivational phases.

BACKGROUND: The ASE model, an integration of social psychological models, states that motivational phases and the transition from one phase to another can be predicted by behavioral determinants. The goal of the present study was to replicate the so-called O pattern that was found in earlier Dutch studies. METHODS: In four cross-sectional studies (N = 918, N = 354, N = 225, N = 317), smokers filled in a questionnaire based on the ASE model, while the motivational phase question was based on the stage definitions from the Transtheoretical model. RESULTS: Precontemplating smokers perceived fewer advantages of quitting than contemplators. Precontemplators encountered less support for quitting than contemplators. Contemplators reported lower self-efficacy expectations than those in preparation, while this group had lower self-efficacy expectations than respondents in action. Ex-smokers in maintenance reported fewer disadvantages of quitting than those in action. CONCLUSIONS: Since changes in cognitive determinants are thought to mediate transitions in motivational phases, the results can be used to tailor health education messages to the needs of smokers in the various motivational phases. The results suggest that smokers in precontemplation would benefit most from information about the pros of quitting and from obtaining support for quitting. Smokers in contemplation and preparation may benefit most from self-efficacy-enhancing information.

Assessment of the inhalation technique in outpatients with asthma or chronic obstructive pulmonary disease using a metered-dose inhaler or dry powder device.

Inhaled medication is commonly prescribed for the treatment of asthma and chronic obstructive pulmonary disease (COPD), but is often not properly used by patients. A total of 316 patients suffering from asthma or COPD took part in a study that evaluated how patients utilized their metered-dose inhaler (MDI) or dry powder inhaler, using a standardized inhaler checklist. Two hundred eighty-one patients (88.9%) made at least one mistake in the inhalation technique. The mistakes were classified into skill and nonskill mistakes. Two hundred patients made one or more skill mistakes and 81 patients only made one or more nonskill mistakes. The most common skill error was "not continuing to inhale slowly after activation of the canister" (69.6%). The nonskill item most patients had difficulties with was "exhale before the inhalation" (65.8%). Patients who used an MDI made significantly fewer nonskill mistakes than patients using a dry powder device. Older patients had more difficulty with the correct use of the inhaler than younger patients. There was no difference in errors between men and women. In this patient sample, most patients failed to use their inhaler correctly. Regular instructions and checkups of inhalation technique are the responsibility of the physician and should be a standard and routine procedure.

Cost-effectiveness of smoking cessation modalities: comparing apples with oranges?

BACKGROUND: Although the results of self-help and group treatments for smoking cessation are known, the cost effectiveness and participants' characteristics of these treatments remain mostly undetermined. METHODS: Consecutive samples of 84 self-help manual requesters and 83 group participants in a Dutch community-based smoking cessation program were subjected to telephone interviews before treatment and after a 6-month follow-up. Participants' baseline characteristics were compared and contrasted with a random sample of nonparticipating smokers (N = 924). Cost effectiveness rates were computed from the perspectives of the society, the steering group, and the participants. RESULTS: Participants appeared to be more "hardcore smokers" than nonparticipants. Self-help manual requesters seemed easier quitters than group participants. Self-help was at least three times as cost effective as group treatment from the perspective of the program provider and over four times as cost effective from the viewpoint of the participants. When taking savings through not smoking into account, return on the social investment was positive. CONCLUSIONS: From a social perspective, the project seemed cost effective, compared with medical interventions. Since both modalities attracted different groups of smokers, cost effectiveness comparisons may incorporate the comparison of apples with oranges, and referral to either modality should be based on smokers' characteristics and the societal value placed on health as well.

Evaluation of a Dutch community-based smoking cessation intervention.

BACKGROUND: Until 1990, smoking cessation interventions in the Netherlands were limited. The utility and effectiveness of community-based smoking cessation programs have not been examined. METHODS: In a treatment city (Den Bosch) a multicomponent community-based smoking cessation intervention was implemented in which local mass media and general practitioners draw smokers' attention to a local quit line. Telephone counselors advised applicants on their choice between self-help and group treatment and optional telephone counseling. Another Dutch city (Apeldoorn) served as a control. Population samples of smokers (n = 547 and n = 546) were interviewed three times at approximately 7-month intervals. Self-help manual requesters (n = 84) and group participants (n = 83) were interviewed before and 6 months after treatment. RESULTS: Treatment modalities were successful; 13% of self-help manual requesters and 22% of group participants were abstinent after 6 months. On a population level the intervention resulted in significantly higher recall of self-help manual and group program in the treatment city. A modest intervention effect on prevalence of abstinence was found at the community level. CONCLUSIONS: Treatment modalities were effective within their participants, but the intervention effectiveness on a community level was limited. No significant difference was found between quit rates after 14 months (7% in treatment city and 9% in control city). Several system failures could be identified. However, probably the intervention effect was seriously confounded by two national governmental publicity campaigns introducing and reinforcing a mandatory smoking ban and a series of national campaigns initiated by the united Dutch tobacco producers opposing the ban.