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1.  Feasibility and Effectiveness of Online Physical Activity Advice Based on a Personal Activity Monitor: Randomized Controlled Trial 
Background
Inactive people are often not aware of the fact that they are insufficiently active. Providing insight into their actual physical activity (PA) levels may raise awareness and could, in combination with tailored PA advice, stimulate a physically active lifestyle.
Objective
This study evaluated the feasibility and effectiveness of a 3-month intervention in which Dutch office workers were provided with a personal activity monitor (PAM) coupled to simple and concise Web-based tailored PA advice (PAM COACH).
Method
Participants were randomly assigned to the 3-month PAM intervention (n = 51) or received a single written information brochure with brief general PA recommendations (n = 51). Study outcome measures were changes in PA (recall of minutes per week spent on PA, as measured by the Activity Questionnaire for Adolescents and Adults), determinants of PA, aerobic fitness, and body composition. Follow-up measurements were performed immediately after the 3-month intervention and at 8-months, 5 months after the end of the 3-month intervention period.
Results
A total of 102 workers, 23 to 39 years old, completed the baseline measurement at the worksite. 48 completed the 3-month follow up and 38 the 8-month follow-up in the intervention group, 50 completed the 3-month follow up and 42 the 8-month follow up in the control group. 35 out of 48 (73%) participants in the PAM intervention group reported wearing the PAM regularly, and the PAM COACH was used almost once a week; 24 out of 46 (52%) PAM users set a personal goal, and 33 (72%) entered their favorite activities on the website. Main reasons for not using these items were lack of interest or not being able to find the item on the website. The majority of PAM users (34 out of 46, 74%) read the advice, of whom 14 (39%) found it unappealing. After the 3-month intervention, no significant intervention effect was observed (adjusted difference in min/week) for sedentary behavior (β = 10, 95% CI = −435 to 455), light-intensity PA (β = −129, 95% CI = −337 to 79), moderate-intensity PA (β = −13, 95% CI = −89 to 63), vigorous-intensity PA (β= −6, 95% CI = −75 to 62), and moderate- to vigorous-intensity PA (β = −23, 95% CI = −121 to 76). No significant intervention effect was observed in the PA outcomes at the 8-month follow-up. For the determinants of PA, aerobic fitness, and body composition, no statistically significant intervention effect was observed in the total study population immediately after the 3-month intervention or the 8-month follow-up.
Conclusions
The intervention appeared to be easily applicable to real-life settings. The intervention was ineffective in improving PA behavior or its determinants in healthy office workers. More attention should have been given to the quality and appropriateness of the tailored advice.
Trial Registration
International Standard Randomized Controlled Trial Number (ISRCTN): 93896459; http://www.controlled-trials.com/ISRCTN93896459/ (Archived by WebCite at http://www.webcitation.org/5iR3mf7ex)
doi:10.2196/jmir.1139
PMCID: PMC2763404  PMID: 19674956
2.  Analyzing the contributions of a government-commissioned research project: a case study 
Background
It often remains unclear to investigators how their research contributes to the work of the commissioner. We initiated the ‘Risk Model’ case study to gain insight into how a Dutch National Institute for Public Health and the Environment (RIVM) project and its knowledge products contribute to the commissioner’s work, the commissioner being the Health Care Inspectorate. We aimed to identify the alignment efforts that influenced the research project contributions. Based on the literature, we expected interaction between investigators and key users to be the most determining factor for the contributions of a research project.
Methods
In this qualitative case study, we analyzed the alignment efforts and contributions in the Risk Model project by means of document analysis and interviews according to the evaluation method Contribution Mapping. Furthermore, a map of the research process was drafted and a feedback session was organized. After the feedback session with stakeholders discussing the findings, we completed the case study report.
Results
Both organizations had divergent views on the ownership of the research product and the relationship between RIVM and the Inspectorate, which resulted in different expectations. The RIVM considered the use of the risk models to be problematic, but the inspectors had a positive opinion about its contributions. Investigators, inspectors, and managers were not aware of these remarkably different perceptions. In this research project, we identified six relevant categories of both horizontal alignment efforts (between investigators and key users) as well as vertical alignment efforts (within own organization) that influenced the contributions to the Inspectorate’s work.
Conclusions
Relevant alignment efforts influencing the contributions of the project became manifest at three levels: the first level directly relates to the project, the second to the organizational environment, and the third to the formal and historical relationship between the organizations. Both external and internal alignments influence the contributions of a research project. Based on the findings, we recommend that research institutes invest in a reflective attitude towards the social aspects of research projects at all levels of the organization and develop alignment strategies to enhance the contributions of research.
doi:10.1186/1478-4505-12-8
PMCID: PMC3946030  PMID: 24498894
Alignment effort; Commissioned research; Contributions; Contribution mapping; Horizontal alignment; Interaction; Organizational environment; Public health; Vertical alignment
3.  Design of the SHAPE-2 study: the effect of physical activity, in addition to weight loss, on biomarkers of postmenopausal breast cancer risk 
BMC Cancer  2013;13:395.
Background
Physical inactivity and overweight are two known risk factors for postmenopausal breast cancer. Former exercise intervention studies showed that physical activity influences sex hormone levels, known to be related to postmenopausal breast cancer, mainly when concordant loss of body weight was achieved. The question remains whether there is an additional beneficial effect of physical activity when weight loss is reached.
The aim of this study is to investigate the effect attributable to exercise on postmenopausal breast cancer risk biomarkers, when equivalent weight loss is achieved compared with diet-induced weight loss.
Design
The SHAPE-2 study is a three-armed, multicentre trial. 243 sedentary, postmenopausal women who are overweight or obese (BMI 25–35 kg/m2) are enrolled. After a 4-6 week run-in period, wherein a baseline diet is prescribed, women are randomly allocated to (1) a diet group, (2) an exercise group or (3) a control group. The aim of both intervention groups is to lose an amount of 5–6 kg body weight in 10–14 weeks. The diet group follows an energy restricted diet and maintains the habitual physical activity level. The exercise group participates in a 16-week endurance and strength training programme of 4 hours per week. Furthermore, they are prescribed a moderate caloric restriction. The control group is asked to maintain body weight and continue the run-in baseline diet.
Measurements include blood sampling, questionnaires, anthropometrics (weight, height, waist and hip circumference), maximal cycle exercise test (VO2peak), DEXA-scan (body composition) and abdominal MRI (subcutaneous and visceral fat). Primary outcomes are serum levels of oestradiol, oestrone, testosterone and sex hormone binding globulin (SHBG).
Discussion
This study will give insight in the potential attributable effect of physical activity on breast cancer risk biomarkers and whether this effect is mediated by changes in body composition, in postmenopausal women. Eventually this may lead to the design of specific lifestyle guidelines for prevention of breast cancer.
Trial registration
The SHAPE-2 study is registered in the register of clinicaltrials.gov, Identifier: NCT01511276.
doi:10.1186/1471-2407-13-395
PMCID: PMC3765586  PMID: 23972905
4.  Effects of different discount levels on healthy products coupled with a healthy choice label, special offer label or both: results from a web-based supermarket experiment 
Background
Two strategies commonly recommended to improve population diets include food labels and food taxes/subsidies. The aim of this study was to examine the effects of both strategies separately and in combination.
Findings
An experiment with a 3x3 factorial design was conducted, including: three levels of price reduction (10%; 25%; and 50%) x three labels (‘special offer’, ‘healthy choice’ and ‘special offer & healthy choice’) on healthy foods defined following the Choices front-of-pack nutrition label. N = 109 participants completed the experiment by conducting a typical weekly shop for their household at a three-dimensional web-based supermarket. Data were analysed using analysis of covariance.
Participants receiving a 50% price discount purchased significantly more healthy foods for their household in a typical weekly shop than the 10% discount (+8.7 items; 95%CI = 3.8-13.6) and the 25% discount group (+7.7 items; 95%CI = 2.74 – 12.6). However, the proportion of healthy foods was not significantly higher and the discounts lead to an increased amount of energy purchased. No significant effects of the labels were found.
Conclusion
This study brings some relevant insights into the effects of price discounts on healthier foods coupled with different labels and shows that price effects over shadowed food labels. However, price discounts seem to have ambiguous effects; they do encourage the purchase of healthy products, but also lead to increased energy purchases. More research is needed to examine how pricing strategies can work in directing consumers towards interchanging unhealthier options for healthier alternatives.
doi:10.1186/1479-5868-10-59
PMCID: PMC3668240  PMID: 23680347
Experiment; Food pricing; Food labelling; Price discounts; Supermarket; Intervention; Public health nutrition; Health promotion; Virtual supermarket
5.  School food policy at Dutch primary schools: room for improvement? Cross-sectional findings from the INPACT study 
BMC Public Health  2013;13:339.
Background
Schools can play an important role in the prevention of obesity, e.g. by providing an environment that stimulates healthy eating habits and by developing a food policy to provide such an environment. The effectiveness of a school food policy is affected by the content of the policy, its implementation and its support by parents, teachers and principals. The aim of this study is to detect opportunities to improve the school food policy and/or implementation at Dutch primary schools. Therefore, this study explores the school food policy and investigates schools’ (teachers and principals) and parents’ opinion on the school food policy.
Methods
Data on the schools’ perspective of the food policy was collected from principals and teachers by means of semi-structured interviews. In total 74 principals and 72 teachers from 83 Dutch primary schools were interviewed. Data on parental perceptions about the school food policy were based on a cross-sectional survey among 1,429 parents from the same schools.
Results
Most principals (87.1%) reported that their school had a written food policy; however in most cases the rules were not clearly defined. Most of the principals (87.8%) believed that their school paid sufficient attention to nutrition and health. Teachers and principals felt that parents were primarily responsible to encourage healthy eating habits among children, while 49.8% of the parents believed that it is also a responsibility of the school to foster healthy eating habits among children. Most parents reported that they appreciated the school food policy and comply with the food rules. Parents’ opinion on the enforcement of the school food policy varied: 28.1% believed that the school should enforce the policy more strongly, 32.1% was satisfied, and 39.8% had no opinion on this topic.
Conclusion
Dutch primary schools could play a more important role in fostering healthy eating habits among children. The school food policy could be improved by clearly formulating food rules, simplifying supervision of the food rules, and defining how to enforce the food rules. In addition, the school food policy will only influence children’s dietary behaviour if both the school and the parents support the policy.
doi:10.1186/1471-2458-13-339
PMCID: PMC3637056  PMID: 23587089
Obesity; Children; School food policy; Food rules; Primary school; School health policy
6.  Outdoor play among children in relation to neighborhood characteristics: a cross-sectional neighborhood observation study 
Background
Although environmental characteristics as perceived by parents are known to be related to children’s outdoor play behavior, less is known about the relation between independently measured neighborhood characteristics and outdoor play among children. The purpose of this study was to identify quantitative as well as qualitative neighborhood characteristics related to outdoor play by means of neighborhood observations.
Methods
Questionnaires including questions on outdoor play behavior of the child were distributed among 3,651 parents of primary school children (aged 4–12 years). Furthermore, neighborhood observations were conducted in 33 Dutch neighborhoods to map neighborhood characteristics such as buildings, formal outdoor play facilities, public space, street pattern, traffic safety, social neighborhood characteristics, and general impression. Data of the questionnaires and the neighborhood observations were coupled via postal code of the respondents. Multilevel GEE analyses were performed to quantify the correlation between outdoor play and independently measured neighborhood characteristics.
Results
Parental education was negatively associated with outdoor play among children. Neither the presence nor the overall quality of formal outdoor play facilities were (positively) related to outdoor play among children in this study. Rather, informal play areas such as the presence of sidewalks were related to children’s outdoor play. Also, traffic safety was an important characteristic associated with outdoor play.
Conclusions
This study showed that, apart from individual factors such as parental education level, certain modifiable characteristics in the neighborhood environment (as measured by neighborhood observations) were associated with outdoor play among boys and girls of different age groups in The Netherlands. Local policy makers from different sectors can use these research findings in creating more activity-friendly neighborhoods for children.
doi:10.1186/1479-5868-9-98
PMCID: PMC3478217  PMID: 22901102
Physical activity; Children; Outdoor play; Environment; Neighborhood observations
7.  Contribution mapping: a method for mapping the contribution of research to enhance its impact 
Background
At a time of growing emphasis on both the use of research and accountability, it is important for research funders, researchers and other stakeholders to monitor and evaluate the extent to which research contributes to better action for health, and find ways to enhance the likelihood that beneficial contributions are realized. Past attempts to assess research 'impact' struggle with operationalizing 'impact', identifying the users of research and attributing impact to research projects as source. In this article we describe Contribution Mapping, a novel approach to research monitoring and evaluation that aims to assess contributions instead of impacts. The approach focuses on processes and actors and systematically assesses anticipatory efforts that aim to enhance contributions, so-called alignment efforts. The approach is designed to be useful for both accountability purposes and for assisting in better employing research to contribute to better action for health.
Methods
Contribution Mapping is inspired by a perspective from social studies of science on how research and knowledge utilization processes evolve. For each research project that is assessed, a three-phase process map is developed that includes the main actors, activities and alignment efforts during research formulation, production and knowledge extension (e.g. dissemination and utilization). The approach focuses on the actors involved in, or interacting with, a research project (the linked actors) and the most likely influential users, who are referred to as potential key users. In the first stage, the investigators of the assessed project are interviewed to develop a preliminary version of the process map and first estimation of research-related contributions. In the second stage, potential key-users and other informants are interviewed to trace, explore and triangulate possible contributions. In the third stage, the presence and role of alignment efforts is analyzed and the preliminary results are shared with relevant stakeholders for feedback and validation. After inconsistencies are clarified or described, the results are shared with stakeholders for learning, improvement and accountability purposes.
Conclusion
Contribution Mapping provides an interesting alternative to existing methods that aim to assess research impact. The method is expected to be useful for research monitoring, single case studies, comparing multiple cases and indicating how research can better be employed to contribute to better action for health.
doi:10.1186/1478-4505-10-21
PMCID: PMC3464695  PMID: 22748169
8.  The effects of a 25% discount on fruits and vegetables: results of a randomized trial in a three-dimensional web-based supermarket 
Background
Lowering the price of fruit and vegetables is a promising strategy in stimulating the purchase of those foods. However, the true effects of this strategy are not well studied and it is unclear how the money saved is spent. The aim of this study is to examine the effects of a 25% discount on fruits and vegetables on food purchases in a supermarket environment.
Methods
A randomized controlled trial with two research conditions was conducted: a control condition with regular prices (n = 52) and an experimental condition with a 25% discount on fruits and vegetables (n = 63). The experiment was carried out using a three-dimensional web-based supermarket, which is a software application in the image of a real supermarket. Data were collected in 2010 in the Netherlands. Participants received a fixed budget and were asked to buy weekly household groceries at the web-based supermarket. Differences in fruit and vegetable purchases, differences in expenditures in other food categories and differences in total calories were analyzed using independent samples t-tests and multiple linear regression models accounting for potential effect modifiers and confounders.
Results
The purchased amount of fruit plus vegetables was significantly higher in the experimental condition compared to the control condition (Δ984 g per household per week, p = .03) after appropriate adjustments. This corresponds to a 25% difference compared to the control group. Both groups had similar expenditures in unhealthier food categories, including desserts, soda, crisps, candy and chocolate. Furthermore, both groups purchased an equal number of food items and an equal amount of calories, indicating that participants in the discount condition did not spend the money they saved from the discounts on other foods than fruits and vegetables.
Conclusion
A 25% discount on fruits and vegetables was effective in stimulating purchases of those products and did neither lead to higher expenditures in unhealthier food categories nor to higher total calories purchased. Future studies in real supermarkets need to confirm these findings.
doi:10.1186/1479-5868-9-11
PMCID: PMC3297502  PMID: 22316357
Food prices; Pricing strategies; Randomized controlled trial; Pricing intervention; Fruits and vegetables; Virtual supermarket
9.  The polypill in the primary prevention of cardiovascular disease: cost-effectiveness in the Dutch population 
BMJ Open  2011;1(2):e000363.
Objectives
The aim of the present study was to estimate the cost-effectiveness of the polypill in the primary prevention of cardiovascular disease.
Design
A health economic modelling study.
Setting
Primary healthcare in the Netherlands.
Participants
Simulated individuals from the general Dutch population, aged 45–75 years.
Interventions
Opportunistic screening followed by prescription of the polypill to eligible individuals. Eligibility was defined as having a minimum 10-year risk of cardiovascular death as assessed with the Systematic Coronary Risk Evaluation function of alternatively 5%, 7.5% or 10%. Different versions of the polypill were considered, depending on composition: (1) the Indian polycap, with three different types of blood pressure-lowering drugs, a statin and aspirin; (2) as (1) but without aspirin and (3) as (2) but with a double statin dose. In addition, a scenario of (targeted) separate antihypertensive and/or statin medication was simulated.
Primary outcome measures
Cases of acute myocardial infarction or stroke prevented, quality-adjusted life years (QALYs) gained and the costs per QALY gained. All interventions were compared with usual care.
Results
All scenarios were cost-effective with an incremental cost-effectiveness ratio between €7900 and 12 300 per QALY compared with usual care. Most health gains were achieved with the polypill without aspirin and containing a double dose of statins. With a 10-year risk of 7.5% as the threshold, this pill would prevent approximately 3.5% of all cardiovascular events.
Conclusions
Opportunistic screening based on global cardiovascular risk assessment followed by polypill prescription to those with increased risk offers a cost-effective strategy. Most health gain is achieved by the polypill without aspirin and a double statin dose.
Article summary
Article focus
Cardiovascular diseases continue to be still a major, partly preventable, cause of illness and death.
A polypill that lowers by targeting several risk factors simultaneously is in line with the concept that the aim in primary prevention should be to bring down ‘global’ cardiovascular risk.
The aim of this study was to estimate the potential cost-effectiveness of polypill prescription after opportunistic screening.
Key messages
The results of this study suggest that opportunistic screening and offering a polypill to people with a minimum 10-year risk of cardiovascular mortality of alternatively 5%, 7.5% or 10% is a cost-effective strategy.
A polypill without aspirin but with a double dose of simvastatin leads to most health gains at all risk thresholds considered. At a 10-year risk of cardiovascular death of ≥7.5%, such a strategy would lead to an estimated decrease in the incidence of myocardial infarction and stroke of about 3.5%, at a cost of €8900 per quality-adjusted life year.
Opportunistic screening of the population of ≥40 years to select individuals with a mild to moderately increased risk for cardiovascular diseases, followed by polypill prescription would prevent approximately 3.5% of all cardiovascular events.
Strengths and limitations of this study
Strong point of the study is that different compositions of the polypill have been modelled. Also, realistic estimates for adherence and compliance have been used.
As only preliminary results of a phase II clinical trial on efficacy of the polypill were available, we had to apply mathematical modelling to estimate cost-effectiveness. This provides insight into the range of health benefits that can be expected. Pending results with regard to established clinical endpoints from large-scale phase III trials, the results of this study should not be taken as a precise estimate of the cost-effectiveness of the polypill.
doi:10.1136/bmjopen-2011-000363
PMCID: PMC3278482  PMID: 22189351
10.  Feasibility of multi-sector policy measures that create activity-friendly environments for children: results of a Delphi study 
Background
Although multi-sector policy is a promising strategy to create environments that stimulate physical activity among children, little is known about the feasibility of such a multi-sector policy approach. The aims of this study were: to identify a set of tangible (multi-sector) policy measures at the local level that address environmental characteristics related to physical activity among children; and to assess the feasibility of these measures, as perceived by local policy makers.
Methods
In four Dutch municipalities, a Delphi study was conducted among local policy makers of different policy sectors (public health, sports, youth and education, spatial planning/public space, traffic and transportation, and safety). In the first Delphi round, respondents generated a list of possible policy measures addressing three environmental correlates of physical activity among children (social cohesion, accessibility of facilities, and traffic safety). In the second Delphi round, policy makers weighted different feasibility aspects (political feasibility, cultural/community acceptability, technical feasibility, cost feasibility, and legal feasibility) and assessed the feasibility of the policy measures derived from the first round. The third Delphi round was aimed at reaching consensus by feedback of group results. Finally, one overall feasibility score was calculated for each policy measure.
Results
Cultural/community acceptability, political feasibility, and cost feasibility were considered most important feasibility aspects. The Delphi studies yielded 16 feasible policy measures aimed at physical and social environmental correlates of physical activity among children. Less drastic policy measures were considered more feasible, whereas environmental policy measures were considered less feasible.
Conclusions
This study showed that the Delphi technique can be a useful tool in reaching consensus about feasible multi-sector policy measures. The study yielded several feasible policy measures aimed at physical and social environmental correlates of physical activity among children and can assist local policy makers in designing multi-sector policies aimed at an activity-friendly environment for children.
doi:10.1186/1748-5908-6-128
PMCID: PMC3264503  PMID: 22172049
11.  Willingness to participate in a lifestyle intervention program of patients with type 2 diabetes mellitus: a conjoint analysis 
Background
Several studies suggest that lifestyle interventions can be effective for people with, or at risk for, diabetes. The participation in lifestyle interventions is generally low. Financial incentives may encourage participation in lifestyle intervention programs.
Objective
The main aim of this exploratory analysis is to study empirically potential effects of financial incentives on diabetes patients’ willingness to participate in lifestyle interventions. One financial incentive is negative (“copayment”) and the other incentive is positive (“bonus”). The key part of this research is to contrast both incentives. The second aim is to investigate the factors that influence participation in a lifestyle intervention program.
Methods
Conjoint analysis techniques were used to empirically identify factors that influence willingness to participate in a lifestyle intervention. For this purpose diabetic patients received a questionnaire with descriptions of various forms of hypothetical lifestyle interventions. They were asked if they would be willing to participate in these hypothetical programs.
Results
In total, 174 observations were rated by 46 respondents. Analysis showed that money was an important factor independently associated with respondents’ willingness to participate. Receiving a bonus seemed to be associated with a higher willingness to participate, but having to pay was negatively associated with participation in the lifestyle intervention.
Conclusion
Conjoint analysis results suggest that financial considerations may influence willingness to participate in lifestyle intervention programs. Financial disincentives in the form of copayments might discourage participation. Although the positive impact of bonuses is smaller than the negative impact of copayments, bonuses could still be used to encourage willingness to participate.
doi:10.2147/PPA.S16854
PMCID: PMC3218115  PMID: 22114468
incentives; bonus; copayment; conjoint analysis; willingness to participate
12.  Five-year effect of community-based intervention Hartslag Limburg on quality of life: A longitudinal cohort study 
Background
During the past decade, quality of life (QoL) has become an accepted measure of disease impact, therapeutic outcome, and evaluation of interventions. So far, very little is known about the effects of community-based interventions on people's QoL. Therefore, the effect of an integrative cardiovascular diseases community-based intervention programme 'Hartslag Limburg' on QoL after 5-years of intervention is studied.
Methods
A longitudinal cohort study comparing 5-year mean change in QoL between the intervention (n = 2356) and reference group (n = 758). QoL outcomes were the physical and mental health composite scores (PCS and MCS) measured by the RAND-36. Analyses were stratified for gender and socio-economic status (SES).
Results
After 5-years of intervention we found no difference in mean change in PCS and MCS between the intervention and reference group in both genders and low-SES. However, for the moderate/high SES intervention group, the scales social functioning (-3.6, 95% CI:-6.1 to -1.2), physical role limitations (-5.3, 95% CI:-9.6 to -1.0), general mental health (-3.0, 95% CI:-4.7 to -1.3), vitality (-3.2, 95% CI:-5.1 to -1.3), and MCS (-1.8, 95% CI:-2.9 to -0.6) significantly changed compared with the reference group. These differences were due to a slight decrease of QoL in the intervention group and an increase of QoL in the reference group.
Conclusion
Hartslag Limburg has no beneficial effect on people's physical and mental QoL after 5-years of intervention. In fact, subjects in the intervention group with a moderate/high SES, show a decrease on their mental QoL compared with the reference group.
doi:10.1186/1477-7525-9-11
PMCID: PMC3055802  PMID: 21352575
13.  Perceptions on the use of pricing strategies to stimulate healthy eating among residents of deprived neighbourhoods: a focus group study 
Background
Pricing strategies are mentioned frequently as a potentially effective tool to stimulate healthy eating, mainly for consumers with a low socio-economic status. Still, it is not known how these consumers perceive pricing strategies, which pricing strategies are favoured and what contextual factors are important in achieving the anticipated effects.
Methods
We conducted seven focus groups among 59 residents of deprived neighbourhoods in two large Dutch cities. The focus group topics were based on insights from Rogers' Diffusion of Innovations Theory and consisted of four parts: 1) discussion on factors in food selection; 2) attitudes and perceptions towards food prices; 3) thinking up pricing strategies; 4) attitudes and perceptions regarding nine pricing strategies that were nominated by experts in a former Delphi Study. Analyses were conducted with Atlas.ti 5.2 computer software, using the framework approach.
Results
Qualitative analyses revealed that this group of consumers consider price to be a core factor in food choice and that they experience financial barriers against buying certain foods. Price was also experienced as a proficient tool to stimulate healthier food choices. Yet, consumers indicated that significant effects could only be achieved by combining price with information and promotion techniques. In general, pricing strategies focusing on encouraging healthy eating were valued to be more helpful than pricing strategies which focused on discouraging unhealthy eating. Suggested high reward strategies were: reducing the price of healthier options of comparable products (e.g., whole meal bread) compared to unhealthier options (e.g., white bread); providing a healthy food discount card for low-income groups; and combining price discounts on healthier foods with other marketing techniques such as displaying cheap and healthy foods at the cash desk.
Conclusion
This focus group study provides important new insights regarding the use of pricing strategies to stimulate healthy eating. The observed perceptions and attitudes of residents of deprived neighbourhoods can be integrated into future experimental studies and be used to reveal if and how pricing strategies are effective in stimulating healthy eating.
doi:10.1186/1479-5868-7-44
PMCID: PMC2885313  PMID: 20482857
14.  Effect of an individually tailored one-year energy balance programme on body weight, body composition and lifestyle in recent retirees: a cluster randomised controlled trial 
BMC Public Health  2010;10:110.
Background
The increased prevalence of overweight and obesity warrants preventive actions, particularly among people in transitional stages associated with lifestyle changes, such as occupational retirement. The purpose is to investigate the effect of a one year low-intensity computer-tailored energy balance programme among recent retirees on waist circumference, body weight and body composition, blood pressure, physical activity and dietary intake.
Methods
A randomised controlled trial was conducted among recent retirees (N = 413; mean age 59.5 years). Outcome measures were assessed using anthropometry, bio-impedance, blood pressure measurement and questionnaires.
Results
Waist circumference, body weight and blood pressure decreased significantly in men of the intervention and control group, but no significant between-group-differences were observed at 12 or at 24-months follow-up. A significant effect of the programme was only observed on waist circumference (-1.56 cm (95%CI: -2.91 to -0.21)) at 12 month follow up among men with low education (n = 85). Physical activity and dietary behaviours improved in both the intervention and control group during the intervention period. Although, these behaviours changed more favourably in the intervention group, these between-group-differences were not statistically significant.
Conclusions
The multifaceted computer-tailored programme for recent retirees did not appear to be effective. Apparently the transition to occupational retirement and/or participation in the study had a greater impact than the intervention programme.
Trial registration
Clinical Trials NCT00122213.
doi:10.1186/1471-2458-10-110
PMCID: PMC2845102  PMID: 20205704
15.  Towards translation of environmental determinants of physical activity in children into multi-sector policy measures: study design of a Dutch project 
BMC Public Health  2009;9:396.
Background
Physical inactivity in children is a major health problem in The Netherlands as well as in many other Western countries. In addition to health promotion among parents and children, creating "active" neighbourhoods can contribute to the solution of this health problem. However, changing environmental characteristics is often the responsibility of policy sectors outside the Public Health domain. Therefore this project identifies and evaluates the possibilities of multi-sector policy measures to stimulate physical activity in children.
Methods and design
The project consists of quantitative as well as qualitative research methods and is conducted in four medium sized Dutch cities. To identify perceived environmental determinants of physical activity in children, a large scale health survey was conducted at 42 primary schools. Written questionnaires including topics on the children's physical activity behaviour (i.e. sports participation, outdoor play, active commuting, television watching and computer usage) and physical and social environmental characteristics were completed by 6,601 parents of children aged 3-13 years old and 3449 children aged 9-13 years old. In addition, 33 neighbourhood audits (systematic observations) were conducted to assess objective neighbourhood characteristics. Furthermore, a policy analysis was conducted in the four participating municipalities to provide an overview of the current local policy measures directed at stimulation of physical activity in children. Policy plans of six different policy sectors (Public Health, Sports, Education & Youth, Spatial Planning, Traffic & Transport, and Safety) were screened for their content on physical activity in children. In addition, semi-structured interviews were conducted with policy makers of each of these sectors to identify critical success factors in the development and realization of multi-sector policy plans aimed at stimulating physical activity in children. The results of all these research activities will be discussed with local policy makers during interactive workshop sessions in order to identify clear cut multi-sector policy measures that stimulate physical activity in children.
Discussion
This paper describes the study design of a project that focuses on multi-sector policy measures that stimulate physical activity in children. Next to extensive research into the environmental determinants of physical activity in children, much emphasis is placed on the translation of the research outcomes into concrete and feasible policy plans.
doi:10.1186/1471-2458-9-396
PMCID: PMC2774693  PMID: 19860876
16.  Reliability and validity of the Activity Questionnaire for Adults and Adolescents (AQuAA) 
Background
Accurate measures of physical activity are highly needed. We evaluated the test-retest reliability and construct validity of the self-report Activity Questionnaire for Adults and Adolescents (AQuAA). The AQuAA is a commonly used questionnaire in Dutch youth.
Methods
In the test-retest reliability study, 53 adolescents and 58 adults completed the AQuAA twice, with an interval of two weeks. In the validity study, 33 adolescents and 47 adults wore an accelerometer (Actigraph) during two weeks, and subsequently completed the AQuAA.
Results
In adolescents the test-retest reliability was fair to moderate (intraclass correlations (ICCs) ranging from 0.30 to 0.59). In adults the test-retest reliability was fair to moderate for the time spent on sedentary, light and moderate intensity activities (ICCs ranging from 0.49 to 0.60), but poor for time spent on vigorous activities (ICC = -0.005). The correlations between the AQuAA and Actigraph were low and nonsignificant. Compared with the Actigraph, time spent on all physical activities was significantly higher according to the questionnaire (except for light intensity activities in adolescents), while time spent on sedentary behaviours was significantly lower.
Conclusion
Reliability of the AQuAA is fair to moderate. The validity of the AQuAA compared to an accelerometer is poor. Both adolescents and adults underestimate the time spent on sedentary behaviours and overestimate the time spent on physical activities.
doi:10.1186/1471-2288-9-58
PMCID: PMC3224705  PMID: 19664254
17.  Disagreement in physical activity assessed by accelerometer and self-report in subgroups of age, gender, education and weight status 
Background
The purpose of this study is to compare self-reported time (by questionnaire) and objectively measured time (by accelerometer) spent on physical activity at moderate (MPA) and vigorous intensity (VPA) in subgroups of age, gender, education and weight status.
Methods
In total, 236 adolescents (aged 12–18) and 301 adults (aged 22–40), completed the questionnaire and wore an accelerometer for two weeks.
Results
Adolescents reported exceptionally more time spent on MPA (mean difference 596 ± 704 min/wk) and VPA (mean difference 178 ± 315 min/wk) than was assessed objectively by the accelerometer. Based on the questionnaire, high educated adolescents spent more time on MPA (205 min/wk, p = 0.002) and VPA (120 min/wk, p = 0.01) than low educated adolescents, but according to the accelerometer they spent less time on MPA (149 min/wk, p = 0.001) and VPA (47 min/wk, p = 0.001). Among adults there was moderate agreement between self-reported time and objectively measured time spent on MPA, but in general the reported time spent on MPA (mean difference 107 ± 334 min/wk) and VPA (mean difference 169 ± 250 min/wk) exceeded the time measured with the accelerometer. Overweight adults reported significantly more VPA (57 min/wk, p = 0.04) than normal weight adults, but this was not confirmed by the accelerometer data.
Conclusion
We observed large differences in time spent on MPA and VPA measured by questionnaire and accelerometer in adolescents but reasonably good agreement in adults. Differences between methods varied by gender, education and weight status. This finding raises serious questions about the use of questionnaires to quantify MPA and VPA in adolescents. There is a clear need in advanced valid assessments of PA in adolescents.
Trial number
ISRCTN93896459
doi:10.1186/1479-5868-6-17
PMCID: PMC2670257  PMID: 19320985
18.  The cost-effectiveness of increasing alcohol taxes: a modelling study 
BMC Medicine  2008;6:36.
Background
Excessive alcohol use increases risks of chronic diseases such as coronary heart disease and several types of cancer, with associated losses of quality of life and life-years. Alcohol taxes can be considered as a public health instrument as they are known to be able to decrease alcohol consumption. In this paper, we estimate the cost-effectiveness of an alcohol tax increase for the entire Dutch population from a health-care perspective focusing on health benefits and health-care costs in alcohol users.
Methods
The chronic disease model of the National Institute for Public Health and the Environment was used to extrapolate from decreased alcohol consumption due to tax increases to effects on health-care costs, life-years gained and quality-adjusted life-years gained, A Dutch scenario in which tax increases for beer are planned, and a Swedish scenario representing one of the highest alcohol taxes in Europe, were compared with current practice in the Netherlands. To estimate cost-effectiveness ratios, yearly differences in model outcomes between intervention and current practice scenarios were discounted and added over the time horizon of 100 years to find net present values for incremental life-years gained, quality-adjusted life-years gained, and health-care costs.
Results
In the Swedish scenario, many more quality-adjusted life-years were gained than in the Dutch scenario, but both scenarios had almost equal incremental cost-effectiveness ratios: €5100 per quality-adjusted life-year and €5300 per quality-adjusted life-year, respectively.
Conclusion
Focusing on health-care costs and health consequences for drinkers, an alcohol tax increase is a cost-effective policy instrument.
doi:10.1186/1741-7015-6-36
PMCID: PMC2637894  PMID: 19040717
19.  Validity of the Modified Baecke Questionnaire: comparison with energy expenditure according to the doubly labeled water method 
Background
In epidemiological research, physical activity is usually assessed by questionnaires. Questionnaires are suitable for large study populations since they are relatively inexpensive and not very time consuming. However, questionnaire information is by definition subjective and prone to recall bias, especially among elderly subjects. The Modified Baecke Questionnaire, developed by Voorrips and coworkers, measures habitual physical activity in the elderly. The questionnaire includes questions on household activities, sports, and leisure time activities, over a time period of one year. The Modified Baecke Questionnaire results in a score to classify people as high, moderate, or low in daily physical activity, based on tertiles.
Methods
The validity of the Modified Baecke Questionnaire score was assessed among 21 elderly men and women using the doubly labeled water method as the reference criterion. This method is considered to be the gold standard for measuring energy expenditure in free-living individuals. Energy expenditure on physical activity is estimated by the ratio of total energy expenditure measured by the doubly labeled water method and resting metabolic rate measured by indirect calorimetry. This ratio is called the physical activity ratio.
Results
The Spearman correlation coefficient between the questionnaire score and the physical activity ratio (PAR) was 0.54 (95% CI 0.22–0.66). Correct classification by the questionnaire occurred in 71% of participants who were in the lowest tertile of PAR, in 14% of participants in the middle tertile, and in 43% of participants in the highest tertile. Subjects were not wrongly classified in an opposite tertile.
Conclusion
The validity of the Modified Baecke Questionnaire is fair-to-moderate. This study shows that the questionnaire can correctly classify individuals as low or high active, but does a poor job for moderately active individuals.
doi:10.1186/1479-5868-5-30
PMCID: PMC2426713  PMID: 18505554
20.  Design of the sex hormones and physical exercise (SHAPE) study 
BMC Public Health  2007;7:232.
Background
Physical activity has been associated with a decreased risk for breast cancer. The biological mechanismn(s) underlying the association between physical activity and breast cancer is not clear. Most prominent hypothesis is that physical activity may protect against breast cancer through reduced lifetime exposure to endogenous hormones either direct, or indirect by preventing overweight and abdominal adiposity. In order to get more insight in the causal pathway between physical activity and breast cancer risk, we designed the Sex Hormones and Physical Exercise (SHAPE) study. Purpose of SHAPE study is to examine the effects of a 1-year moderate-to-vigorous intensity exercise programme on endogenous hormone levels associated with breast cancer among sedentary postmenopausal women and whether the amount of total body fat or abdominal fat mediates the effects.
Methods/Design
In the SHAPE study, 189 sedentary postmenopausal women, aged 50–69 years, are randomly allocated to an intervention or a control group. The intervention consists of an 1-year moderate-to-vigorous intensity aerobic and strenght training exercise programme. Partcipants allocated to the control group are requested to retain their habitual exercise pattern. Primary study parameters measured at baseline, at four months and at 12 months are: serum concentrations of endogenous estrogens, endogenous androgens, sex hormone binding globuline and insuline. Other study parameters include: amount of total and abdominal fat, weight, BMI, body fat distribution, physical fitness, blood pressure and lifestyle factors.
Discussion
This study will contribute to the body of evidence relating physical activity and breast cancer risk and will provide insight into possible mechanisms through which physical activity might be associated with reduced risk of breast cancer in postmenopausal women.
Trial registration
NCT00359060
doi:10.1186/1471-2458-7-232
PMCID: PMC2031900  PMID: 17767724
21.  Study protocol of a cluster randomised controlled trial investigating the effectiveness of a tailored energy balance programme for recent retirees 
BMC Public Health  2006;6:293.
Background
People in transitional life stages, such as occupational retirement, are likely to gain weight and accumulate abdominal fat mass caused by changes in physical activity and diet. Hence, retirees are an important target group for weight gain prevention programmes, as described in the present paper.
Methods/Design
A systematic and stepwise approach (Intervention Mapping) is used to develop a low-intensity energy balance intervention programme for recent retirees. This one-year, low-intensity multifaceted programme aims to prevent accumulation of abdominal fat mass and general weight gain by increasing awareness of energy balance and influencing related behaviours of participants' preference. These behaviours are physical activity, fibre intake, portion size and fat consumption. The effectiveness of the intervention programme is tested in a cluster randomised controlled trial. Measurements of anthropometry, physical activity, energy intake, and related psychosocial determinants are performed at baseline and repeated at 6 months for intermediate effect, at 12 months to evaluate short-term intervention effects and at 24 months to test the sustainability of the effects.
Discussion
This intervention programme is unique in its focus on retirees and energy balance. It aims at increasing awareness and takes into account personal preferences of the users by offering several options for behaviour change. Moreover, the intervention programme is evaluated at short-term and long-term and includes consecutive outcome measures (determinants, behaviour and body composition).
doi:10.1186/1471-2458-6-293
PMCID: PMC1698485  PMID: 17147832
22.  Moderately overweight and obese patients in general practice: a population based survey 
BMC Family Practice  2006;7:43.
Background
Obesity is a main threat to public health in the Western world and is associated with diseases such as diabetes mellitus and coronary heart diseases. Up to now a minority of research studied the relation between obesity and the use of primary health care. In the Netherlands the general practitioner (GP) is the main primary health care provider. The objective of this article is to evaluate GP consultation and prescription of drugs in moderate and severely overweight (obese) persons in the Netherlands.
Methods
Data were used from a representative survey of morbidity in Dutch general practice in 2001. Our study sample consisted of 8,944 adult respondents (18+ years) who participated in an extensive health interview. Interview data were linked to morbidity and prescription registration data from 95 general practices where respondents were listed. Body mass index (BMI) was calculated using self-reported height and weight. Analyses were controlled for clustering within practices as well as for socio-demographic and life style characteristics.
Results
Obesity (BMI ≥ 30 kg/m2) was observed in 8.9% of men and 12.4% of women; for moderate overweight (BMI 25-<30 kg/m2) these percentages were 42.2% and 30.4% respectively. Obese men and women were more likely to consult their GP than persons without overweight. This especially holds for diseases of the endocrine system, the cardiovascular system, the musculoskeletal system, the gastro-intestinal system, and skin problems. Related to this, obese men and women were more likely to receive drugs for the cardiovascular system, the musculoskeletal system, alimentary tract and metabolism (including, for example, antidiabetics), and dermatologicals, but also antibiotics and drugs for the respiratory system. For moderately overweight men and women (BMI 25-<30 kg/m2) smaller but significant differences were found for diseases of the endocrine system, the cardiovascular system, and the musculoskeletal system.
Conclusion
Obesity increases the workload of Dutch general practitioners and the use of prescribed medication. The current increase in the prevalence of obesity will further increase the use of health care and related costs. Since a large majority of Dutch persons visit their GP over the course of one year, GPs' potential role in effective prevention strategies cannot be denied.
doi:10.1186/1471-2296-7-43
PMCID: PMC1564048  PMID: 16827937
23.  Promoting physical activity using an activity monitor and a tailored web-based advice: design of a randomized controlled trial [ISRCTN93896459] 
BMC Public Health  2005;5:134.
Background
Ageing is associated with a decrease in physical activity. This decrease particularly occurs during specific transitional life stages. Especially during adolescence and young adulthood a steep decrease in physical activity is observed. Inactive people are often not aware of their inactivity. Providing feedback on the actual physical activity level by an activity monitor can increase awareness and may in combination with an individually tailored physical activity advice stimulate a physically active lifestyle.
Methods
In a randomized controlled trial the effectiveness of providing an activity monitor in combination with a personal physical activity advice through the Internet will be examined. Outcome measures are level of physical activity, determinants of physical activity, quality of life, empowerment, aerobic fitness and body composition. Participants are relatively inactive adolescents and young adults who are measured at baseline, after 3 months intervention and 5 months after the end of the intervention. In addition, facilitating and hindering factors for implementation of the intervention will be investigated.
Discussion
The use of a personal activity monitor in combination with web-based assisted individually tailored health promotion offers a good opportunity to work interactively with large groups of adolescents and young adults and provide them with advice based on their actual activity level. It has great potential to motivate people to change their behaviour and to our knowledge has not been evaluated before.
doi:10.1186/1471-2458-5-134
PMCID: PMC1351198  PMID: 16356182

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