Identifying classes of the pain, fatigue, and depression symptom cluster in long-term prostate cancer survivors-results from the multi-regional Prostate Cancer Survivorship Study in Switzerland (PROCAS).

PURPOSE: Aside from urological and sexual problems, long-term (≥5 years after initial diagnosis) prostate cancer (PC) survivors might suffer from pain, fatigue, and depression. These concurrent symptoms can form a cluster. In this study, we aimed to investigate classes of this symptom cluster in long-term PC survivors, to classify PC survivors accordingly, and to explore associations between classes of this cluster and health-related quality of life (HRQoL). METHODS: Six hundred fifty-three stage T1-T3N0M0 survivors were identified from the Prostate Cancer Survivorship in Switzerland (PROCAS) study. Fatigue was assessed with the EORTC QLQ-FA12, depressive symptoms with the MHI-5, and pain with the EORTC QLQ-C30 questionnaire. Latent class analysis was used to derive cluster classes. Factors associated with the derived classes were determined using multinomial logistic regression analysis. RESULTS: Three classes were identified: class 1 (61.4%) - "low pain, low physical and emotional fatigue, moderate depressive symptoms"; class 2 (15.1%) - "low physical fatigue and pain, moderate emotional fatigue, high depressive symptoms"; class 3 (23.5%) - high scores for all symptoms. Survivors in classes 2 and 3 were more likely to be physically inactive, report a history of depression or some other specific comorbidity, be treated with radiation therapy, and have worse HRQoL outcomes compared to class 1. CONCLUSION: Three distinct classes of the pain, fatigue, and depression cluster were identified, which are associated with treatment, comorbidities, lifestyle factors, and HRQoL outcomes. Improving classification of PC survivors according to severity of multiple symptoms could assist in developing interventions tailored to survivors' needs.

Health-related quality of life in long-term prostate cancer survivors after nerve-sparing and non-nerve-sparing radical prostatectomy-Results from the multiregional PROCAS study.

BACKGROUND: Nerve-sparing (NS) surgery was developed to improve postoperative sexual and potentially urological outcomes after radical prostatectomy (RP). However, it is largely unknown how NSRP affects health-related quality of life (HRQoL) including urinary and sexual outcomes in prostate cancer (PC) survivors 5-10 years after diagnosis in comparison with Non-NSRP. METHODS: The study population included 382 stage pT2-T3N0M0 PC survivors 5-10 years post diagnosis, who were identified from the multiregional Prostate Cancer Survivorship in Switzerland (PROCAS) study. Briefly, in 2017/2018, PC survivors were identified via six population-based cancer registries based in both German- and French-speaking Switzerland. HRQoL and PC-specific symptom burden was assessed using the EORTC QLQ-C30 and EORTC QLQ-PR25 questionnaires. Differences in HRQoL outcomes between survivors treated with NSRP (uni- & bilateral) and Non-NSRP were analyzed with multivariable linear regression adjusted for age, years since diagnosis, cancer stage, comorbidities at diagnosis, and further therapies, if appropriate. Multiple imputation was performed to minimize the bias due to missing data. RESULTS: Five to ten years after diagnosis, PC survivors treated with NSRP and Non-NSRP reported similar symptom burden and comparable HRQoL function scores. The only significant differences were reported for sexual activity, whereas PC survivors who underwent NSRP reported statistically significant (P = .031) higher sexual activity than those on Non-NSRP. NSRP and Non-NSRP reported similar scores for urinary symptoms and all other HRQoL outcomes. CONCLUSIONS: Our results support nerve-sparing techniques as an option to improve postoperative sexual, but not urinary outcomes after RP in long-term PC survivors.

Efficacy of motivating short interventions for smokers in primary care (COSMOS trial): study protocol for a cluster-RCT.

BACKGROUND: Tobacco abuse is a frequent issue in general practitioners' (GPs') offices, with doctors playing a key role in promoting smoking cessation to their patients. However, not all smokers are ready and willing to give up smoking. Thus, a GP focusing on smoking cessation alone might waste the opportunity to improve his patient's health by supporting a change in another harmful behaviour pattern. The aim of this study is to determine whether multi-thematic coaching will lead to higher overall health benefits without resulting in a reduced rate of successful smoking cessations, compared with a monothematic smoking cessation approach. METHODS: The study is designed as a two-armed, double-blinded, cluster-randomised trial. GPs will be randomly assigned to the intervention or control group. In the intervention group, GPs will undergo training in patient-centred coaching, shared decision-making and motivational interviewing. The control group will be trained in a state-of-the-art smoking cessation algorithm. GPs will approach adult cigarette-smoking patients and advise those included according to the GP's group affiliation. The primary outcome is the between-group difference in the proportion of participants who achieve a beneficial change in at least one of seven different health-related behavioural dimensions, 12 months post baseline. Secondary outcomes include smoking cessation rates and the patients' self-perceived smoking-related motivation, self-efficacy and planning behaviour. Additionally, covariates describing both GPs and patients will be collected before the start of the intervention, and process outcome measures in compliance with the RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) framework will be recorded during the ongoing study. DISCUSSION: Tobacco consumption is still highly prevalent in the general population and often goes hand in hand with other behaviour patterns with adverse health effects. This study will add to the literature regarding effective strategies available to GPs to address unhealthy behaviour among their smoking patients beyond mere smoking cessation counselling. The study will also establish a basis for decisions about further promotion and dissemination of the coaching under study. TRIAL REGISTRATION: ISRCTN, ISRCTN38129107 . Registered on 2 October 2017.

Validation of the Global Physical Activity Questionnaire for self-administration in a European context.

BACKGROUND/AIM: Little is known about the measurement properties of the self-administered Global Physical Activity Questionnaire (GPAQ) in Europe. The aim was to validate the self-administered GPAQ against accelerometry in Switzerland in German, French and Italian. METHODS: Participants of this cross-sectional study were recruited among members of the Swiss Food Panel (German-speaking and French-speaking samples) and as a convenience sample (Italian-speaking sample). They completed the GPAQ and wore an Actigraph GT3X+ accelerometer during 7 days in 2014/2015. GPAQ and accelerometer data on total physical activity and different intensities, as well as sitting time, were compared using Spearman correlations and Bland-Altman plots. RESULTS: Complete data were available for 354 participants (50.6% women, mean age: 47.0 years) on physical activity, and for 366 on sitting time. Correlations were highest for vigorous physical activity (r=0.46) and sitting time (r=0.47). A significant sex difference was apparent for vigorous physical activity (men: r=0.35 vs women: r=0.55; p=0.02). Some age differences were present especially for total physical activity, with the lowest correlations found for those aged 60+ years. The correlation for sitting time was significantly higher in the youngest age group (r=0.61) compared with the middle (r=0.38, p=0.01) and the oldest age groups (r=0.37, p=0.03). Total physical activity was 2.8 times higher according to the GPAQ than to accelerometer data. CONCLUSIONS: The self-administered version of the GPAQ showed fair-to-moderate validity in the three languages tested, both for men and women and individuals aged ≤60 years. For older individuals, a careful interpretation of total physical activity is required.

Physical Activity, Sensation Seeking, and Aggression as Injury Risk Factors in Young Swiss Men: A Population-Based Cohort Study.

BACKGROUND: This study investigates the relationships between physical activity (PA), sports participation and sensation seeking or aggression and injury risk in young men. METHODS: A representative cohort study was conducted with 4686 conscripts for the Swiss army. Risk factors assessed at baseline were PA, the frequency of sports participation, sensation seeking, and aggression. The number of injuries during the past 12 months was reported 16 months after baseline. Exposure to moderate-tovigorous physical activity (MVPA) was estimated based on baseline PA. RESULTS: Among conscripts, 48.5% reported at least 1 injury for the past 12 months. After accounting for exposure to MVPA, the most inactive individuals (reference group) had the highest injury risk and those with high levels of PA and weekly sports participation the lowest (Poisson regression analysis: incidence rate ratio = 0.14 [0.12-0.16]). Independent of activity level, sensation seeking increased cumulative injury incidence significantly (Logistic regression analysis [injured vs. not injured]: odds ratio = 1.29 [1.02-1.63]) and incidence rates marginally. Aggression was marginally associated only with cumulative injury incidence and only in those participating in daily sports. CONCLUSIONS: When accounting for exposure to PA, being inactive is a strong injury risk factor in young men, whereas the roles of the personality variables are less clear.

Injury risk during different physical activity behaviours in children: a systematic review with bias assessment.

INTRODUCTION: The current focus on a physically active lifestyle in children puts children at increased physical activity-related injury risk. OBJECTIVE: To summarise, in a systematic review, the evidence for the injury risk of several physical activity behaviours in 6- to 12-year-old children. METHODS: An electronic search was performed in three databases (Embase, PubMed and SPORTDiscus). Inclusion criteria were: age 6-12 years; report on injuries related to overall physical activity, active commuting, unorganised leisure time physical activity, physical education and/or organised sports; incidence rates expressed as injuries per hours of physical activity; and published after January 1st 2000. Risk of bias was assessed for all studies included. RESULTS: Eight studies were included. The risk of bias assessment resulted in two studies with a score that was higher than 75 %; risk bias of those two studies was considered low. The medically treated, injury incidence rate was reported to be between 0.15 and 0.27 injuries per 1,000 h of physical activity. The absolute number of injuries related to unorganised leisure time physical activity was higher than the absolute number of injuries reported in organised sports. The respective injury incidence rate expressed per 1,000 h exposure was, however, generally lower during unorganised leisure time than during organised sports. Reported injury incidence rates related to active commuting were comparable to those for unorganised leisure time physical activity. Conflicting injury incidence rates were reported for physical education. Subgroup analysis suggested that girls and children with low habitual levels of physical activity are at increased injury risk. A limitation of the review is that no standard bias assessment was available for this specific context. CONCLUSIONS: Children are at an inherent injury risk while participating in physical activities. Most injury prevention efforts have focussed on the sports setting, but our results suggest that many children sustain an injury during unorganised leisure time physical activities.

Turning the tide: national policy approaches to increasing physical activity in seven European countries.

BACKGROUND: Physical inactivity is one of the four leading behavioural risk factors for non-communicable disease (NCD). Like tobacco control, increasing levels of health-enhancing physical activity (HEPA) will require a national policy framework providing direction and a clear set of actions. Despite frequent calls, there has been insufficient progress on policy development in the majority of countries around the world. This study sought and summarised national HEPA policy in seven European countries (Finland, Italy, the Netherlands, Norway, Portugal, Slovenia and Switzerland). METHODS: Data collection used a policy audit tool (PAT), a 27-item instrument structured into four sections. RESULTS: All countries reported some legislation or policy across the sectors of education, sport and health. Only some countries reported supportive policy in the transport and environment sectors. Five countries reported a stand-alone HEPA policy and six countries reported national recommendations. HEPA prevalence targets varied in magnitude and specificity and the presence of other relevant goals from different sectors highlighted the opportunity for joint action. Evaluation and the use of scientific evidence were endorsed but described as weak in practice. Only two countries reported a national multisector coordinating committee and most countries reported challenges with partnerships on different levels of policy implementation. CONCLUSIONS: Bringing together the key components for success within a national HEPA policy framework is not simple. This in-depth policy audit and country comparison highlighted similarities and differences and revealed new opportunities for consideration by other countries. These examples can inform countries within and beyond Europe and guide the development of national HEPA policy within the NCD prevention agenda.

The combined effect on survival of four main behavioural risk factors for non-communicable diseases.

OBJECTIVE: To quantify and illustrate the combined effects of WHO's four behavioural risk factors for non-communicable diseases (NCDs) on mortality. METHODS: Participants (n=16,721) were part of two Swiss population studies conducted between 1977 and 1993. Smoking status, alcohol consumption, physical activity and diet were assessed at baseline. With record linkage in 2008, up to 31years of follow-up with 3,533 deaths could be recorded. Mortality was assessed with Cox proportional hazard models for each risk factor and their combinations. Ten-year survival probabilities for 65- and 75-year-olds were estimated with Weibull regression models. RESULTS: Hazard ratios for the combination of all four risk factors compared to none were 2.41 (1.99-2.93) in men and 2.46 (1.88-3.22) in women. For 65-year-olds, the probability of surviving the next 10years was 86% for men with no risk factors and 67% for men with four. In women, the respective numbers were 90% and 77%. In 75-year-olds, probabilities were 67% and 35% in men, and 74% and 47% in women. CONCLUSIONS: The combined impact of four behavioural NCD risk factors on survival probability was comparable in size to a 10-year age difference and bigger than the gender effect.

Associations of objectively assessed levels of physical activity, aerobic fitness and motor coordination with injury risk in school children aged 7-9 years: a cross-sectional study.

OBJECTIVES: Physical activity (PA) is important for children's health but entails an inherent risk of injuries. The objective of this study was to assess activity-related correlates of injuries in children of the general population under the age of 10 while accounting for PA behaviour objectively assessed with accelerometers. DESIGN: Cross-sectional. SETTING: Primary schools in Switzerland. PARTICIPANTS: 41 (56.9%) of 72 contacted schools were eligible. 11 (26.9%) of them agreed to participate. 3 more schools were recruited with a snowball system. On the individual level, 83.7% of the parents gave consent. Finally, 249 children with complete data (82.2%) from 20 grade 1-3 classes from 14 schools were analysed (mean age 7.9 years, 49.4% girls). PRIMARY OUTCOME MEASURES: Outcome measures were retrospectively assessed injury incidence rates expressed as the number of injuries per 1000 h of objectively measured moderate-to-vigorous physical activity (MVPA) and injury risk depending on levels of PA, aerobic fitness and motor coordination, derived from logistic regression models. RESULTS: 0.43 injuries/1000 h of MVPA (95% CI 0.28 to 0.58) were reported. After controlling for sociodemographic characteristics and accounting for exposure to PA, children with medium and high levels compared with those with low levels of aerobic fitness assessed with the 20 m shuttle run test were at decreased injury risk (OR=0.37 (95% CI 0.16 to 0.85)/OR=0.29 (0.16 to 0.63)). Children with high motor coordination scores assessed with the "Körperkoordinationstest für Kinder" test were at increased injury risk compared with those in the normal range (2.59 (1.04 to 6.32)). Levels of objectively assessed PA were not associated with injury risk; they were neither expressed as rates nor as cumulative incidence. CONCLUSIONS: This study provides novel data showing that low levels of fitness and high coordinative skills, but not objectively assessed levels of PA, were related to injury risk in children under the age of 10.

Active transport, physical activity, and body weight in adults: a systematic review.

CONTEXT: Physical activity has various health benefits. Active transport can contribute to total physical activity and thus affect body weight because of increased energy expenditure. This review summarizes published evidence on associations of active transport, general physical activity, and body weight in adults. EVIDENCE ACQUISITION: A systematic review of the literature was conducted in October 2010 using eight databases. A total of 14,216 references were screened; full texts were retrieved for 95 articles. Forty-six articles (36 unique studies) were included: 20 (17) from Europe; 18 (13) from North America, Australia, and New Zealand; and eight (six) from other countries. Analyses of the retrieved papers were carried out between November 2010 and March 2011. EVIDENCE SYNTHESIS: Of 15 studies assessing active transport and physical activity, five found associations in the expected direction (more active transport associated with more physical activity) for all or most variables studied, nine found some associations, and one reported no associations. Of 30 studies assessing active transport and body weight, 13 reported associations in the expected direction (more active transport associated with lower body weight) for all or most variables studied, 12 found some associations, two presented some associations in the expected and some in the opposite direction, and three reported no associations. CONCLUSIONS: There is limited evidence that active transport is associated with more physical activity as well as lower body weight in adults. However, study heterogeneity, predominantly cross-sectional designs, and crude measures for active transport and physical activity impede quantitative conclusions.

Allez Hop, a nationwide programme for the promotion of physical activity in Switzerland: what is the evidence for a population impact after one decade of implementation?

OBJECTIVES: To present evidence for a population impact of a national physical activity promotion programme after a decade of implementation. METHODS: The programme Allez Hop offered local physical activity courses (mainly walking and Nordic walking) once a week over 12 weeks. Data from a pretest posttest survey in 2005 course participants (N=2157 at baseline (of 4130, 52.2%), 1587 at first follow-up (73.6%); smaller subsample with second follow-up) and from repeated cross-sectional national surveys have been analysed regarding changes in physical activity behaviour. RESULTS: The total number of Allez Hop courses was 18 684 between 1997 and 2008. 89.2% of participants were women, the mean age was 48.5 years. The proportion meeting the physical activity recommendations was 31.7% at baseline, in participants with first follow-up data it increased from 33.1% to 42.3% (p<0.001). On the population level in the main user group of Allez Hop (middle-aged women) the proportion not engaging in any sport decreased from 50.1% (1997) to 47.2% (2002) and to 43.1% (2007) (p<0.01). Walking/hiking was the second most frequently performed sport (33.7%) in 2007, with the most remarkable increase since 2000 (+11.1%). CONCLUSIONS: Allez Hop was successfully implemented for more than a decade, reached middle-aged women and a high proportion of insufficiently active individuals. Changes in participants' physical activity behaviour must be interpreted cautiously because of low response rates and short follow-up. However, indications for behavioural changes were observed at the population level, even though these data do not allow a causal link to Allez Hop.

Comparison of trial participants and open access users of a web-based physical activity intervention regarding adherence, attrition, and repeated participation.

BACKGROUND: Web-based interventions are popular for promoting healthy lifestyles such as physical activity. However, little is known about user characteristics, adherence, attrition, and predictors of repeated participation on open access physical activity websites. OBJECTIVE: The focus of this study was Active-online, a Web-based individually tailored physical activity intervention. The aims were (1) to assess and compare user characteristics and adherence to the website (a) in the open access context over time from 2003 to 2009, and (b) between trial participants and open access users; and (2) to analyze attrition and predictors of repeated use among participants in a randomized controlled trial compared with registered open access users. METHODS: Data routinely recorded in the Active-online user database were used. Adherence was defined as: the number of pages viewed, the proportion of visits during which a tailored module was begun, the proportion of visits during which tailored feedback was received, and the time spent in the tailored modules. Adherence was analyzed according to six one-year periods (2003-2009) and according to the context (trial or open access) based on first visits and longest visits. Attrition and predictors of repeated participation were compared between trial participants and open access users. RESULTS: The number of recorded visits per year on Active-online decreased from 42,626 in 2003-2004 to 8343 in 2008-2009 (each of six one-year time periods ran from April 23 to April 22 of the following year). The mean age of users was between 38.4 and 43.1 years in all time periods and both contexts. The proportion of women increased from 49.5% in 2003-2004 to 61.3% in 2008-2009 (P< .001). There were differences but no consistent time trends in adherence to Active-online. The mean age of trial participants was 43.1 years, and 74.9% were women. Comparing contexts, adherence was highest for registered open access users. For open access users, adherence was similar during the first and the longest visits; for trial participants, adherence was lower during the first visits and higher during the longest visits. Of registered open access users and trial participants, 25.8% and 67.3% respectively visited Active-online repeatedly (P< .001). Predictors of repeated use were male sex (odds ratio [OR] = 1.2, 95% confidence interval [CI] = 1.04-1.38) and increasing age category in registered open access users, and age 46-60 versus < 30 years (OR = 3.04, 95% CI = 1.25-7.38) and Swiss nationality (OR(nonSwiss)= 0.64, 95% CI = 0.41-1.00) in trial participants. Despite reminder emails, attrition was much higher in registered open access users compared with trial participants, with a median lifetime website usage of 0 days in open access users and 290 days in trial participants. CONCLUSIONS: Adherence, patterns of use, attrition, and repeated participation differed between trial participants and open access users. Reminder emails to encourage repeated participation were effective for trial participants but not for registered open access users. These issues are important when interpreting results of randomized controlled effectiveness trials.

Effectiveness of active-online, an individually tailored physical activity intervention, in a real-life setting: randomized controlled trial.

BACKGROUND: Effective interventions are needed to reduce the chronic disease epidemic. The Internet has the potential to provide large populations with individual advice at relatively low cost. OBJECTIVE: The focus of the study was the Web-based tailored physical activity intervention Active-online. The main research questions were (1) How effective is Active-online, compared to a nontailored website, in increasing self-reported and objectively measured physical activity levels in the general population when delivered in a real-life setting? (2) Do respondents recruited for the randomized study differ from spontaneous users of Active-online, and how does effectiveness differ between these groups? (3) What is the impact of frequency and duration of use of Active-online on changes in physical activity behavior? METHODS: Volunteers recruited via different media channels completed a Web-based baseline survey and were randomized to Active-online (intervention group) or a nontailored website (control group). In addition, spontaneous users were recruited directly from the Active-online website. In a subgroup of participants, physical activity was measured objectively using accelerometers. Follow-up assessments took place 6 weeks (FU1), 6 months (FU2), and 13 months (FU3) after baseline. RESULTS: A total of 1531 respondents completed the baseline questionnaire (intervention group n = 681, control group n = 688, spontaneous users n = 162); 133 individuals had valid accelerometer data at baseline. Mean age of the total sample was 43.7 years, and 1146 (74.9%) were women. Mixed linear models (adjusted for sex, age, BMI category, and stage of change) showed a significant increase in self-reported mean minutes spent in moderate- and vigorous-intensity activity from baseline to FU1 (coefficient = 0.14, P = .001) and to FU3 (coefficient = 0.19, P < .001) in all participants with no significant differences between groups. A significant increase in the proportion of individuals meeting the HEPA recommendations (self-reported) was observed in all participants between baseline and FU3 (OR = 1.47, P = .03), with a higher increase in spontaneous users compared to the randomized groups (interaction between FU3 and spontaneous users, OR = 2.95, P = .02). There were no increases in physical activity over time in any group for objectively measured physical activity. A significant relation was found between time spent on the tailored intervention and changes in self-reported physical activity between baseline and FU3 (coefficient = 1.13, P = .03, intervention group and spontaneous users combined). However, this association was no longer significant when adjusting for stage of change. CONCLUSIONS: In a real-life setting, Active-online was not more effective than a nontailored website in increasing physical activity levels in volunteers from the general population. Further research may investigate ways of integrating Web-based physical activity interventions in a wider context, for example, primary care or workplace health promotion.

Promotion of physical activity in the European region: content analysis of 27 national policy documents.

BACKGROUND: Over the past years there has been increasing interest in physical activity promotion and the development of appropriate policy. So far, there has been no comprehensive overview of the activities taking place in Europe in this area of public health policy. METHODS: Using different search methods, 49 national policy documents on physical activity promotion were identified. An analysis grid covering key features was developed for the analysis of the 27 documents published in English. RESULTS: Analysis showed that many general recommendations for policy developments are being followed, for example: general goals were formulated, an implementation plan was included, a timeframe and a responsible body for the implementation was often specified. However, limited evidence for intersectoral collaboration was found. Quantified goals for physical activity were the exception. Population groups most in need such as people with low levels of physical activity were rarely specifically targeted. Most policies emphasized the importance of an evaluation. However, only about half of them indicated a related intention or requirement. CONCLUSION: In recent years there has been a noticeable development of national policy documents on physical activity promotion. Following principles for policy development more closely could increase the effectiveness of their preparation and implementation further.

Comparison of adult physical activity levels in three Swiss alpine communities with varying access to motorized transportation.

STUDY OBJECTIVE: To compare physical activity levels of residents of three Swiss alpine communities with varying access to motorized transport and to investigate whether socio-demographic factors, the settlement structure or means of transport affect these levels. METHODS: Between January and February 2004 a computer assisted telephone interview was conducted with 901 randomly selected adults aged 18 years or older living in three Swiss alpine communities. In particular, information on moderate and vigorous intensity physical activities and on transport behaviour was collected. Respondents were categorized as 'sufficiently active' or 'insufficiently active' according to self-reported physical activity. MAIN RESULTS: People living in community 1 without access to motorized traffic were significantly more likely to be sufficiently active (Sex- and age-adjusted prevalences of sufficient total physical activity, 43.9% 95% CI: 38.3%-49.8%) compared to individuals living in the other two communities (community 2: 35.9%, 95% CI: 30.6%-41.6%, community 3: 32.7%, 95% CI: 27.5%-38.3%). The differences were due to higher levels of moderate physical activities. Vigorous physical activity levels did not differ between the communities. Community differences were explained by passive means of transport to work and for leisure time activities. CONCLUSIONS: Although the environment encountered in the three alpine communities is generally conducive to physical activity the majority of the participants did not achieve recommended activity levels. Passive mode of transport to work and during leisure time was strongly associated with insufficient total physical activity. Walking and cycling for transportation is thus a promising approach to promote health enhancing physical activity.

The Stages of Change in three stage concepts and two modes of physical activity: a comparison of stage distributions and practical implications.

Stages of Change were assessed for three stage definitions and two modes of health-enhancing physical activity (HEPA) in a representative telephone survey in Switzerland (participation 55.8%; n = 1471). Two five-stage definitions focusing either on intention to change or current behavior were integrated into a seven-stage concept, taking into account both aspects. The two target behaviors were activities with at least moderate intensity and activities with vigorous intensity. According to the two five-stage definitions, at least half of the participants were either in precontemplation (focus on intention) or in preparation (focus on behavior). Upon classification into the seven stages these large stage groups were differentiated. There were differences in the pros for change between the new stages of the seven-stage concept. One in seven participants was regularly active according to the moderate criteria, but not using the vigorous criteria, and one in every eight participants reported the inverse. Results show that an individual can be in different Stages of Change depending on the stage definition and be regularly active or not depending on the target behavior. The practical implications of the seven-stage algorithm and a two-dimensional matrix to classify participants for both moderate and vigorous intensity activities in an Internet-based HEPA program are presented.