Effects and moderators of exercise on sleep in adults with cancer: Individual patient data and aggregated meta-analyses.

OBJECTIVES: To evaluate the effects of exercise interventions on sleep disturbances and sleep quality in patients with mixed cancer diagnoses, and identify demographic, clinical, and intervention-related moderators of these effects. METHODS: Individual patient data (IPD) and aggregated meta-analyses of randomized controlled trials (RCTs). Using data from the Predicting OptimaL cAncer RehabIlitation and Supportive care project, IPD of 2173 adults (mean age = 54.8) with cancer from 17 RCTs were analyzed. A complementary systematic search was conducted (until November 2018) to study the overall effects and test the representativeness of analyzed IPD. Effect sizes of exercise effects on self-reported sleep outcomes were calculated for all included RCTs. Linear mixed-effect models were used to evaluate the effects of exercise on post-intervention outcome values, adjusting for baseline values. Moderator effects were studied by testing interactions for demographic, clinical and intervention-related characteristics. RESULTS: For all 27 eligible RCTs from the updated search, exercise interventions significantly decreased sleep disturbances in adults with cancer (g = -0.09, 95% CI [-0.16; -0.02]). No significant effect was obtained for sleep quality. RCTs included in IPD analyses constituted a representative sample of the published literature. The intervention effects on sleep disturbances were not significantly moderated by any demographic, clinical, or intervention-related factor, nor by sleep disturbances. CONCLUSIONS: This meta-analysis provides some evidence that, compared to control conditions, exercise interventions may improve sleep disturbances, but not sleep quality, in cancer patients, although this effect is of a small magnitude. Among the investigated variables, none was found to significantly moderate the effect of exercise interventions on sleep disturbances.

Psychometric properties of the Dutch extended Cancer Survivors' Unmet Needs measure (CaSUN-NL).

Information and support needs increase emotional distress and can impede cancer survivors' adjustment. To investigate the information and support needs of Dutch cancer survivors, the Cancer Survivors' Unmet Needs measure (CaSUN) was translated into Dutch and applied in two Dutch studies with cancer survivors (N = 255; N = 467). The CaSUN-NL entailed the original five CaSUN scales, extended with respectively a returning to work and lifestyle scale. This study aimed to determine the psychometric properties of the CaSUN-NL. To assess validity, a maximum likelihood factor analysis was employed. Construct validity was analysed using Pearson's and Spearman's correlation coefficients. To assess reliability, test-retest (Kappa coefficient) and internal consistency (Cronbach's alpha) values were determined. Factor analysis revealed the original five factors. Test-retest reliability was low (r ≤ .15, 93% retest response). Internal consistency values were high (Cronbach's alpha = 0.92-0.94), except for lifestyle. Significant correlations were found between total number of unmet needs with anxiety (r = .55), depression (r = .49), negative adjustment (r = .50), quality of life (r = -.52) and age (r = -.24). The CaSUN-NL is valid and reliable to investigate the unmet information and support needs of Dutch cancer survivors.

Mediators of physical exercise for improvement in cancer survivors' quality of life.

OBJECTIVE: Mediating mechanisms of a 12-week group-based exercise intervention on cancer survivors' quality of life (QoL) were examined to inform future exercise intervention development. METHODS: Two hundred nine cancer survivors ≥ 3 months posttreatment (57% breast cancer) aged 49.5 (± 10.4) years were assigned to physical exercise (n = 147) or wait-list control (n = 62). QoL, fatigue, emotional distress, physical activity, general self-efficacy and mastery were assessed at baseline and post-intervention using questionnaires. Path analysis was conducted using Mplus to explore whether improved physical activity, general self-efficacy and mastery mediated the effects of exercise on fatigue and distress and consequently QoL. RESULTS: The intervention was associated with increased physical activity (ß = 0.46, 95% confidence interval (CI) = 0.14;0.59), general self-efficacy (ß = 2.41, 95%CI = 0.35;4.73), and mastery (ß = 1.75, 95%CI = 0.36;2.78). Further, the intervention had both a direct effect on fatigue (ß = -1.09, 95%CI = -2.12;0.01), and an indirect effect (ß = -0.54, 95%CI = -1.00;-0.21) via physical activity (ß = -0.29, 95%CI = -0.64;-0.07) and general self-efficacy (ß = -0.25, 95%CI = -0.61;-0.05). The intervention had a borderline significant direct effect on reduced distress (ß = -1.32, 95%CI = -2.68;0.11), and a significant indirect effect via increased general self-efficacy and mastery (ß = -1.06, 95%CI = -1.89;-0.38). Reductions in fatigue (ß = -1.33, 95%CI =-1.85;-0.83) and distress (ß = -0.86, 95%CI = -1.25;-0.52) were associated with improved QoL. Further, increased physical activity was directly associated with improved QoL (ß = 3.37, 95%CI = 1.01;5.54). CONCLUSION: The beneficial effect of group-based physical exercise on QoL was mediated by increased physical activity, general self-efficacy and mastery, and subsequent reductions in fatigue and distress. In addition to physical activity, future interventions should target self-efficacy and mastery. This may lead to reduced distress and fatigue, and consequently improved QoL of cancer survivors.

Why do Romanian junior high school students start to smoke?

BACKGROUND: Adolescence is a crucial period in the development of smoking behaviour. To develop efficient prevention programmes for teenagers, it is essential to understand why adolescents start to smoke. The objective of this study was to assess the predictors of smoking onset among Romanian junior high school students aged 13-14. METHODS: The data were obtained from a two-wave, 9-month longitudinal study carried out among 504 junior high school non-smokers from Cluj-Napoca, Romania. Questionnaires assessed smoking behaviour, attitudes, social influence, self-efficacy and intention regarding smoking (motivational variables), as well as different sociodemographic features. RESULTS: The results from the logistic regression analysis revealed that baseline lower self-efficacy in refraining from smoking in several social situations, baseline pressures from peers to smoke and baseline intentions to smoke significantly increased the risk of non-smokers to become smokers at follow-up 9 months later. CONCLUSIONS: These findings underline that reinforcing social self-efficacy to refuse smoking, resisting peer pressures and maintaining negative intentions regarding smoking are essential ingredients for smoking prevention programmes among Romanian junior high school students.

Patient adherence to prescribed medication instructions for dyspepsia: the DIAMOND-study.

BACKGROUND: Insight into patient adherence is needed to enable an effect evaluation of medication for dyspepsia. OBJECTIVES: Adherence was explored by investigating two adherence outcome measures (completeness and intake fidelity) using data from the DIAMOND-study. METHODS: The DIAMOND-study is a pragmatic RCT comparing a 'step-up' with a 'step-down' treatment strategy. In step 1 participants (n =653) were instructed to use five pills/day for maximally 30 days: an antacid 4dd plus a placebo 1dd ('step-up') or a proton pump inhibitor 1dd plus a placebo 4dd ('step-down'). If the complaints persisted, step 2 was started (H(2)-receptor antagonist 2dd), and subsequently step 3 (five pills/day, placebo and verum vice versa from step 1). Completeness was assessed by pill counts, intake fidelity by patient questionnaires measuring the degree to which patients adhered to specific instructions concerning timing, frequency, dose and way of intake. RESULTS: In step 1, patients used on average 3.9 pills/day (78% of the prescribed doses), in step 2, 1.7 pills/day (85%) and in step 3, 3.6 pills/day (72%). For the four times daily pills, half of the patients used less than 80% of the prescribed pills per day. This was one third of the patients for the twice daily pills and one quarter for the once daily pills. There were no completeness differences between active or placebo medication and no differences between the study arms. As regards intake fidelity, 70% of the patients made one or more errors in the medication intake. CONCLUSION: There is room for improvement in adherence rates for dyspepsia medication.

Participation in colorectal cancer screening trials after first-time invitation: a systematic review.

BACKGROUND AND STUDY AIM: Colorectal cancer (CRC) screening is implemented by an increasing number of countries. Participation rates of screening programs influence the health benefit and cost-effectiveness of the applied method. The aim was to systematically review participation rate after first-time invitation for CRC screening with fecal occult blood test (FOBT), sigmoidoscopy, colonoscopy, and/or computed tomography (CT) colonography. METHODS: A systematic literature search was performed prior to October 1 2009. Prospective CRC screening studies of unselected populations reporting participation rates were included. RESULTS: After meta-analyses, overall participation rates were found to be 47 % for FOBT, 42 % for fecal immunologic tests (FITs), 35 % for sigmoidoscopy, 41 % for sigmoidoscopy combined with FIT/FOBT, 28 % for colonoscopy, and 22 % for CT colonography. Studies comparing screening methods showed higher participation rates for less invasive methods. Studies comparing invitation methods showed higher participation rates with general practitioner involvement, a more personalized recruitment approach, and reduction of barriers that discourage participation. CONCLUSIONS: Knowledge of identified factors affecting CRC screening participation can be used to improve screening programs.

Applying a theory-based framework to understand public knowledge of genetic risk factors: a case for the distinction between how-to knowledge and principles knowledge.

OBJECTIVE: Using E.M. Rogers's knowledge framework as presented in his seminal innovation-decision process, this paper aims to present an overview of the general public's knowledge of genetics. It also makes a first attempt to examine the statistical validity of this framework. METHODS: A sample of 2,500 members of the Dutch general population was presented with a questionnaire containing measures of 3 increasingly complex forms of knowledge: awareness knowledge, (practical) how-to knowledge and (theoretical) principles knowledge. RESULTS: The general public seems to be moderately aware of genetic risk factors for multifactorial diseases. In general, how-to knowledge seems fair, whereas principles knowledge is limited and superficial. Additional analyses provided empirical evidence for the distinction between awareness knowledge, how-to knowledge and principles knowledge. CONCLUSION: The innovation-decision process, and specifically Rogers's knowledge framework, provides a useful tool for public education in genetics. Future research may build upon and extend our findings by examining the persuasion, decision, implementation, and possibly the confirmation stages of the innovation-decision process concerning genetic education.

Factors underlying smoking relapse prevention: results of an international Delphi study.

No definitive picture of the factors determining smoking relapse exists, and many smoking relapse prevention programmes have only modest behavioural effects. This study aims to identify the level of consensus among and compare the opinions of two groups of experts (researchers and coaches who provide smoking cessation courses) regarding factors already studied in relation to smoking relapse, factors that have not yet been addressed and ideas on how to improve prevention programmes. A three-round Delphi method was employed. In the first round, 15 researchers completed an electronic questionnaire on factors associated with relapse. The results were used to develop a structured questionnaire for the second round, which was completed by 47 researchers and 61 coaches. The second-round results were then presented to the same experts in the third round, enabling them to re-rate their answers. Results revealed high consensus on some factors already identified as predicting relapse (e.g. self-efficacy), new factors (e.g. action planning) and several methods to improve prevention programmes. Generally speaking, the researchers and coaches provided similar suggestions. The results paint a picture of the current state of knowledge on relapse-related factors and point the way to areas for further research.

Evaluation of a peer-led smoking prevention programme for Romanian adolescents.

The goal of this study was to assess the effects of a school-based smoking prevention programme that used both a video and peer-led discussion groups among Romanian junior high school students aged 13-14 years. The programme embraced the social influence approach and concentrated on enhancing self-efficacy and the acquisition of cigarette refusal skills. Twenty schools were randomly assigned to the control and experimental conditions, resulting in 55 participating classes from the seventh grade (28 in the control group and 27 in the experimental group). Pretest and 9 months follow-up data on weekly smoking initiation and psychosocial variables were collected from 1071 students. Multilevel logistic regression analyses demonstrated a significant effect of the programme on adolescents' smoking behaviour after 9 months. At post-test, weekly smoking onset was 4.5% in the experimental group versus 9.5% in the control group. Furthermore, the programme had significant effects on smoking-related beliefs. In the experimental group, this resulted in a more negative attitude towards smoking, increased social self-efficacy levels and a more negative intention towards smoking. These findings show that short-term effects of the smoking prevention programme can be realized in Romania. More studies are needed to analyse how to maintain these effects over time.

Smoking among Dutch elementary schoolchildren: gender-specific predictors.

Higher rates of smoking initiation and continuation by female compared with male adolescents, as found in many developed countries, may call for gender-specific prevention programs. Risk factors of smoking initiation and continuation were examined prospectively (1997-2002) among 3205 Dutch elementary schoolchildren (mean age 11.64) in an intervention trial using written questionnaires and multilevel logistic regression. At baseline, smoking prevalence was lower among girls than among boys; at follow-up, smoking initiation was lower among girls than among boys. Concerning smoking initiation, girls and boys shared the following risk factors: age, modeling from parents and siblings ('modeling nuclear'), modeling from other members in the social circle ('modeling diffuse') and perceived pro-tobacco pressure to smoke. The only gender-specific predictor of smoking initiation was parent origin; girls with non-Dutch parents could be targeted for prevention programs. Concerning continuation, girls and boys shared the following risk factors: older age, more modeling nuclear and diffuse, fewer smoking disadvantages and lower self-efficacy to refrain from smoking. This study confirms that social modeling, smoking attitude and self-efficacy information to refrain from smoking deserve a prominent place in smoking prevention programs for schoolchildren. Besides booster sessions, family-directed programs are suggested. No gender-specific predictors of later smoking initiation were found, apart from parent origin, which is not amenable to intervention.

Which patient-related factors determine self-perceived patient adherence to prescribed dyspepsia medication?

Patient adherence to medical treatment for dyspepsia is disappointing, whereas adherence is crucial for a proper evaluation of treatment. This prospective study used elements of the Integrated Change Model and Weiner's Attribution Theory to describe patients' important cognitions and their interrelationships regarding self-perceived adherence to short-term medical treatment for dyspepsia. Patient questionnaires measured the predictors before treatment and self-perceived adherence after treatment. Approximately one-quarter of the patients indicated that they were non-adherent (n = 347). Univariate and multiple linear regression analyses revealed several significant predictors that explained 44% of the variance in self-perceived adherence. Patients with a low educational level, patients who claimed to regularly forget their medication in general, patients with a low self-efficacy or a low intention were less likely to be adherent. These results may indicate targets for interventions designed to improve adherence to medical treatment for dyspepsia. For instance, asking about expected difficulties in taking acid suppressants (e.g. forgetfulness or medication use at weekends) and making action plans to overcome these difficulties (e.g. using reminders) may result in improved adherence rates. Such an approach may reach a substantial number of patients since one in five patients in our study experienced some difficulties in taking medication.

Cancer patients' view on rehabilitation and quality of life: a programme audit.

An existing 12-week cancer rehabilitation group programme, combining physical training and psychosocial sessions, was recently tested in a quantitative longitudinal cohort study (n = 658) among adult patients who have problems coping with cancer. Results showed improvements in all quality of life domains. The objective of the present study was to explore patients' perspectives on how and to what extent the rehabilitation programme had met their needs in order to optimize the programme. Patients who participated in the programme no longer than 5 years ago were interviewed in three focus groups (n = 23). Participants saw rehabilitation as provided by the programme as an important steppingstone in their ongoing recovery process and identified the integrated physical training, psychosocial sessions and patient-to-patient contacts as a powerful and supportive combination. Recommendations for improvements to the programme mainly concerned the psychosocial module. Information needs varied strongly among participants and, in this respect, it was hard to satisfy all of them. Participants suggested that the programme should focus more on developing skills to cope with cancer, its consequences and emerging problems after rehabilitation. In conclusion, participants valued the group-based multi-modal cancer rehabilitation programme and recommended to focus more on developing coping skills.

Measuring the severity of upper gastrointestinal complaints: does GP assessment correspond with patients' self-assessment?

BACKGROUND: Questionnaires are frequently used to measure the severity of gastrointestinal (GI) complaints. These questionnaires can either be filled out by the physicians or by the patients, but it is not clear whether these scores correspond. This study aimed to investigate the interrater agreement between physician-reported severity and patient-reported severity concerning the patients' upper GI complaints. METHODS: In a prospective observational study, the severity of eight GI complaints was registered by both patients and GPs independently on a seven-point scale (n = 316) before and after treatment with esomeprazole. Weighted kappa values for the agreement on the severity and simple kappa values for the agreement on the absence or presence of symptoms were calculated. RESULTS: The weighted kappa values ranged from 0.14 to 0.68 indicating poor to moderate agreement. The agreement on the presence or absence of symptoms was similar. Several systematic differences in scoring were found: the GPs tended to underestimate the severity of belching, nausea, early satiety, vomiting and upper and lower abdominal pain. Furthermore, the treatment effect for belching and lower abdominal pain was more often overestimated, while the treatment effect for nausea was more often underestimated by the GP. CONCLUSION: The agreement between GP and patient is low. The differences in scoring should be kept in mind when comparing physician-reported outcomes with patient-reported outcomes.

General public's knowledge, interest and information needs related to genetic cancer: an exploratory study.

Single-group interviews were conducted with 49 people to get an idea of what and how the general public thinks about genetic cancer. Understanding what people think and need is crucial for adequate public health communication about genetic issues. Group discussions revealed that people believed that the vulnerability for cancer was largely dependent on their lifestyle, and that they were at risk if cancer ran in their family. Participants found it difficult to distinguish cancer from genetic cancer since in both cases the cause was related to cell problems. People felt that they lacked adequate knowledge of genetic cancer, which was also confirmed by the misconceptions revealed during the discussions. Participants mentioned both advantages (knowing one's risk, performing preventive actions, more openness, less taboo, and more knowledge) and disadvantages (fear arousal, difficult to time, undirected, tenability) of receiving genetic information. Although people felt ambivalent about wanting to receive genetic cancer information, as yet the general tendency seemed to be to postpone opening up to such information until there was a relevant case in the family. Subsequently, preferred information sources were family members and health professionals. According to the participants mass media should provide information on relevant features of genetic cancer to look out for. As yet, people showed little interest in biological genetic information.

Measuring information needs among cancer patients.

A scale for assessing information needs of cancer patients was constructed and validated. Two studies were conducted. Study 1 was designed to test the factor structure of the measurement instrument. A total of 498 patients with breast cancer and Hodgkin disease were interviewed. In study 2, 133 patients with head and neck cancer were measured just before treatment as well as 6, 13 and 52 weeks after treatment. Study 2 aimed to confirm the factor structure established in study 1, and to test for construct validity in a new population, the psychometric properties of the information needs scales, and the scales' sensitivity to change. In study 1 a two-factor structure (an action and a disease-oriented scale) including 17 items was revealed. The second study confirmed the factor structure from study 1. As hypothesized, greater information needs related to higher levels of state-anxiety, more depression, and more psychological complaints. Although, correlations over time per information need scale indicate some stability of scores, findings suggested that the need for information about disease and treatment is less stable over time than need for information about access to help and solutions. Further validation of the instrument is required.

Predictors of intention to adhere to physiotherapy among women with urinary incontinence.

During the last decade, pelvic floor muscle exercise (PFME) therapy has proved its short-term efficacy among women with urinary incontinence. Long-term success with PFME therapy is hampered by non-adherence. So far, specific knowledge on determinants of adherence behavior has been scarce. A cross-sectional study was conducted to elucidate the relative importance of determinants of the intention to adhere to PFME therapy in women with urinary incontinence. Based on behavioral theories, literature research and interviews, a questionnaire measuring determinants of the intention to adhere to PFME therapy was developed. In total, 129 women, aged 17 years or over, with symptoms of urinary incontinence, completed this questionnaire. Multiple regression analysis with backward elimination was carried out to identify determinants that predict intention. Significant predictors of the intention to adhere to PFME therapy were the amount to urinary loss per wet episode and women's perception of their ability to do the exercises as recommended under various circumstances. Building self-efficacy might be a good starting point for health education interventions aiming to promote adherence to PFME therapy, which can be used by physiotherapists and general practitioners.

Participation in a sigmoidoscopic colorectal cancer screening program: a pilot study.

At present, very little is known about the determinants of endoscopic screening participation. This study presents an analysis of the psychosocial associations of participation and nonparticipation in a sigmoidoscopic colorectal cancer screening program. The present pilot study was executed among members of a Dutch target group, ages 50-60 years, who visited an internal medicine outpatient clinic. Individuals who were asked to participate in the program (n = 200) received general information with regard to the screening procedure. The participation rate was 45%. Persons who participated in the screening program as well as those who wanted to participate in the study but did not want to participate in the screening program were asked to fill out a questionnaire. Self-efficacy, i.e., the individual's perception of the difficulty of participating in the screening program, appeared to be the most important association of participation. Furthermore, response efficacy, i.e., the individual's beliefs about the outcome of participation, and social support proved to be concepts that were associated with participation.

Effectiveness of a social influence approach and boosters to smoking prevention.

This paper presents the short-term and long-term results of a randomized smoking prevention trial. The purpose was to evaluate two smoking prevention programs, a social influence (SI) program and a SI program with an additional decision-making component (SI(DM)). Moreover, the contribution of boosters was assessed as well. Fifty-two schools were randomly assigned to the SI program, the SI(DM) program or a control group. Half of the treatment schools were randomly assigned to the booster condition; the other half did not receive boosters. Both programs consisted of five lessons, each lasting 45 min, and were given in weekly sessions in grades 8 and 9 of high schools in the Netherlands. The most successful program was the SI program with boosters which resulted in a significantly lower increase in smoking rates (5.6 and 9.7%, respectively) compared to the control group (12.6 and 14.9%, respectively) at both 12 and 18 months follow-up. The results suggest that boosters can be an effective tool for maintaining or increasing the effectiveness of smoking prevention programs. It is recommended that the SI program with the booster be implemented at the national level, since this intervention showed the greatest behavioral effects.

Monitoring the dissemination of an educational protocol on pediatric asthma in family practice: a test of associations between dissemination variables.

Many asthma education programs aim at reducing morbidity. Now that effective programs are available, the next step is the nationwide dissemination to achieve morbidity reduction. A dissemination of a tested program has been undertaken in Dutch primary care, guided by the Diffusion of Innovation theory. It was hypothesized that greater awareness and concern and/or receptivity about asthma self-management would make it more likely that family physicians would adopt the program. Family physicians were considered more likely to adopt the program if they saw it as an improvement on their current way of providing education, as easy to use, and as having observable outcomes. It was expected that once the program had been adopted, and as it was being implemented, it would increasingly be perceived by its users as successful. Finally, more perceived success of performance was expected to be related to continued use. Both longitudinal and cross-sectional data largely confirmed the hypotheses.