Perceived barriers and facilitators of the implementation of a combined lifestyle intervention with a financial incentive for chronically ill patients.

BACKGROUND: This study aims to describe barriers and facilitators of the implementation of a combined lifestyle intervention (CLI) in primary care for patients with chronic disease. The aim of CLI to help patients to create a healthy lifestyle and to maintain this healthy lifestyle. During a CLI a patient receives advice and counselling to improve health-related behavior such as physical activity and diet. Special attention was given to the influence of adding a health promoting financial incentive (HPFI) for the participants to the CLI. METHODS: Twenty-four semi-structured interviews within six care groups were performed between July and October 2017. The interviews were transcribed verbatim and coded by two researchers independently. RESULTS: Respondents mentioned several preferred characteristics of the CLI such as easy accessibility of the intervention site and the presence of health care professionals during exercise sessions. Moreover, factors that could influence implementation (such as attitude of the health care professionals) and preconditions for a successful implementation of a CLI (such as structural funding and good infrastructure) were identified. Overall, positive HPFIs (e.g. a reward) were preferred over negative HPFIs (e.g. a fine). According to the respondents, HPFIs could positively influence the degree of participation, and break down barriers for participating in and finishing the CLI. CONCLUSIONS: Multiple barriers and facilitators for successful implementation of a CLI were identified. For successful implementing CLIs, a positive attitude of all stakeholders is essential and specific preconditions should be fulfilled. With regard to adding a HPFI, more research is needed to identify the attitude of specific target groups towards an HPFI.

Perceived health status associated with transport choice for short distance trips.

BACKGROUND: This study examines the association between active transport and perceived general health, perceived psychological wellbeing and a healthy body weight in the Netherlands. METHODS: Data were collected by an online questionnaire (N = 3663) in the Netherlands. Data collection was conducted over a period of one calendar year starting July 2012. Logistic regression analyses were used to investigate the association between choice of transport mode (bicycling vs car use and walking vs car use) and perceived general health, perceived psychological wellbeing and having a healthy weight respectively. The presented OR's may be interpreted as the likelihood of an average person in our dataset to have a better perceived health or body weight when choosing active transport (either bicycling or walking) over using the car for trips up to 7.5 km. RESULTS: Cycling was found to be significantly associated with a better perceived general health (OR = 1.35, 95%CI:1.07-1.70) and having a healthy body weight (OR = 1.52, 95%CI:1.28-1.79), but not with a better perceived psychological wellbeing (OR = 1.12, 95%CI:0.93-1.34). Walking was found to be significantly associated with having a healthy body weight (OR = 1.35, 95%CI:1.09-1.69), but not with a better perceived general (OR = 1.12, 95%CI:0.84-1.51) or psychological wellbeing (OR = 0.85, 95%CI:0.67-1.08). CONCLUSION: Our results suggest that active transport use has been associated with a better perceived general health and a healthy body weight. However, more research is needed to be able to elucidate which factors cause this better health. No associations were observed between transport choice and perceived psychological wellbeing.

Concurrent validity of the PAM accelerometer relative to the MTI Actigraph using oxygen consumption as a reference.

The purpose of this study was to examine the concurrent validity of the Personal Activity Monitor (PAM) accelerometer relative to the Actigraph accelerometer using oxygen consumption as a reference, and to assess the test-retest reliability of the PAM. Thirty-two fit, normal weight adults (aged 21-54) performed two activities, treadmill walking and stair walking, while wearing the PAM, the Actigraph and the Cosmed K4b(2). Correlation coefficients and agreement in absolute energy expenditure (EE) levels between PAM, Actigraph and Cosmed were calculated. The test-retest reliability was examined among 296 PAM's using a laboratory shaker. Intraclass correlation coefficients (ICC) and coefficient of variation (CV) were determined. Correlations for treadmill walking and stair walking, respectively, were r(2)=0.95 and r(2)=0.65 for PAM with Actigraph, r(2)=0.82 and r(2)=0.93 for PAM with VO(2) and r(2)=0.64 and 0.74 for Actigraph with VO(2). Both the PAM and Actigraph underestimated EE during treadmill and stair walking by a substantial amount. The test-retest reliability of the PAM was high [ICC=0.80; 95% confidence interval (CI) (0.28;0.92) and intra-CV=1.5%]. The PAM and Actigraph accelerometer are comparable in assessing bodily movement during treadmill and stair walking. The PAM is a valid device to rank subjects in EE and can be useful in collecting objective data to monitor habitual physical activity.

[Cost-effectiveness of prevention: opportunities for public health policy in the Netherlands]. / Kosteneffectiviteit van preventie: kansen voor het Nederlandse volksgezondheidsbeleid.

OBJECTIVE: To gain insight into the cost-effectiveness of new preventive interventions. DESIGN: Systematic review and interviews. METHOD: Based on literature search, a search of the project database of ZonMw and interviews with experts, the National Institute for Public Health and the Environment drew up a long list of preventive interventions that are potentially cost-effective but are not yet systematically carried out in the Netherlands. From this long list, 21 interventions were selected for each of which, at least 3 economic evaluations were available that indicate favourable cost-effectiveness (< Euro 20,000,--per QALY gained). RESULTS: The majority of the interventions concerned vaccination and screening programmes (7 and 5 respectively). Only a small minority concerned health promotion or health protection (1 respectively 3). There was strong evidence that 5 interventions were both cost-effective, and feasible. These were: screening for Chlamydia, screening for diabetic retinopathy in type 2 diabetes, screening for neonatal group beta streptococcal infections through a combination strategy, prevention of recurrent myocardial infarction through heart habilitation, and prevention of head injuries by wearing of bicycle helmets by children. CONCLUSION: Before implementation of preventive interventions, it is necessary to investigate whether these interventions are also cost-effective in the Dutch context.

Exposure and effectiveness of phytosterol/-stanol-enriched margarines.

BACKGROUND: Studies on effectiveness of phytosterol/-stanol-enriched margarines in the community have received low priority. For postlaunch monitoring purposes including risk-benefit analyses, it is needed to investigate both exposure and effectiveness of these margarines. OBJECTIVE: To study the use and effectiveness of phytosterol/-stanol-enriched margarine. DESIGN, SETTING AND SUBJECTS: The study population consisted of 2379 subjects that participated in a community intervention study ('Hartslag Limburg') aged 28-76 years. In 1998 and 2003, blood samples for total and high-density lipoprotein (HDL) cholesterol were obtained. A general questionnaire and food frequency questionnaire (FFQ) were administered. From 1999 onwards, phytosterol/-stanol-enriched margarines were introduced on the Dutch market. On the basis of 2003 data, subjects were classified in users of (a) phytosterol/-stanol-enriched margarine, (b) cholesterol-lowering drugs, (c) the combination (both enriched margarine and drugs) and (d) neither enriched margarines nor cholesterol-lowering drugs. RESULTS: Mean (+/-s.d.) daily intake of phytosterol-enriched margarine (n=99) and phytostanol-enriched margarine (n=16) was 14+/-9 g. From 1998 to 2003, total serum cholesterol concentration changed significantly different among the four groups: in the combination users -2.04+/-1.50 mmol/l (-29%), in cholesterol-lowering drug users -1.09+/-1.17 mmol/l (-17%), in the enriched margarine users -0.24+/-0.75 mmol/l (-4%) and in non-users +0.10+/-0.72 mmol/l (+2%)(P<0.05). CONCLUSION: Recommended doses are not consumed, but phytosterol/-stanol-enriched margarines can modestly reduce serum total cholesterol in the community. These margarines cannot equal the effect of cholesterol-lowering drugs, but may act additively. Further investigation of the health effects that may occur during simultaneous cholesterol lowering drugs and phytosterol-or -stanol-enriched margarines usage is important, as well as community education about the cholesterol lowering foods and drugs. SPONSORSHIP: Netherlands Organization for Health Research and Development (ZonMW) (data collection of Hartslag Limburg and further data- analyses).

Netherlands research programme weight gain prevention (NHF-NRG): rationale, objectives and strategies.

OBJECTIVE: To outline the rationale, objectives and strategies used in a systematically designed research programmme to study specific weight gain-inducing behaviours, their social-psychological as well as environmental determinants, and the effects of interventions aimed at the prevention of weight gain. DESIGN: The evidence for potential behavioural determinants and strategies to prevent weight gain was reviewed, and the methods applied within the Netherlands Research programme weight gain prevention (NHF-NRG) project were described. The project is designed according to the Intervention Mapping protocol. SETTING: The Netherlands. SUBJECTS: The main target groups are (a) adolescents (12-16 y) in secondary school, (b) young adults (20-40 y) at the workplace and (c) recently retired people (55-65 y) at home. INTERVENTIONS: Each intervention includes an individual component, in which computer-tailored information is provided. Additionally, interventions are aimed at changing environmental components. RESULTS: The short-term results of this project can be expected by the beginning of 2005. Guidelines for nationwide weight gain prevention, based on this research programme, will become available in 2007. CONCLUSIONS: Based on the few interventions that were evaluated to date, no robust conclusions can be drawn regarding the effectiveness of obesity prevention. The systematic and multidisciplinary design of the NHF-NRG programme enables the identification of potentially effective methods and strategies for the prevention of weight gain.

Leisure time physical activity and health-related quality of life: cross-sectional and longitudinal associations.

Studies that relate change in physical activity to change in health-related quality of life in the general population are needed to confirm associations suggested by cross-sectional studies. In the present study, cross-sectional as well as longitudinal associations between leisure time physical activity and health-related quality of life were studied in an apparently healthy population. The present study showed cross-sectional associations between at least moderately intense leisure time physical activity and general health perceptions, vitality, physical functioning and role limitations due to physical health problems. No associations were present for total leisure time physical activity. Change in leisure time physical activity was associated with change in social functioning in men as well as in women, irrespective of the intensity of physical activity. Only in men, change in total leisure time physical activity was associated with change in vitality and general mental health. In our study, cross-sectional associations were not confirmed by longitudinal analyses. Cross-sectional associations were mainly found for physical components of health-related quality of life, whereas longitudinal associations were predominantly observed for mental components of health-related quality of life. Confirmation of our results by those of other studies is needed in order to quantify health promotion messages.

Physical activity and stroke. A meta-analysis of observational data.

BACKGROUND: Based on studies published so far, the protective effect of physical activity on stroke remains controversial. Specifically, there is a lack of insight into the sources of heterogeneity between studies. METHODS: Meta-analysis of observational studies was used to quantify the relationship between physical activity and stroke and to explore sources of heterogeneity. In total, 31 relevant publications were included. Risk estimates and study characteristics were extracted from original studies and converted to a standard format for use in a central database. RESULTS: Moderately intense physical activity compared with inactivity, showed a protective effect on total stroke for both occupational (RR = 0.64, 95% CI: 0.48-0.87) and leisure time physical activity (RR = 0.85, 95% CI: 0.78-0.93). High level occupational physical activity protected against ischaemic stroke compared with both moderate (RR = 0.77, 95% CI: 0.60-0.98) and inactive occupational levels (RR = 0.57, 95% CI: 0.43-0.77). High level compared with low level leisure time physical activity protected against total stroke (RR = 0.78, 95% CI: 0.71-0.85), haemorrhagic stroke (RR = 0.74, 95% CI: 0.57-0.96) as well as ischaemic stroke (RR = 0.79, 95% CI: 0.69-0.91). Studies conducted in Europe showed a stronger protective effect (RR = 0.47, 95% CI: 0.33-0.66) than studies conducted in the US (RR = 0.82, 95% CI: 0.75-0.90). CONCLUSIONS: Lack of physical activity is a modifiable risk factor for both total stroke and stroke subtypes. Moderately intense physical activity is sufficient to achieve risk reduction.

Physical activity of subjects aged 50-64 years involved in the European Prospective Investigation into Cancer and Nutrition (EPIC).

OBJECTIVE: To describe physical activity of participants in the European Prospective Investigation into Cancer and Nutrition (EPIC). DESIGN: A cross-sectional analysis of baseline data of a European prospective cohort study. SUBJECTS: This analysis was restricted to participants in the age group 50-64 years, which was represented in all EPIC centres. It involved 236 386 participants from 25 centres in nine countries. In each EPIC centre, physical activity was assessed by standardised and validated questions. Frequency distribution of type of professional activity and participation in non-professional activities, and age-adjusted means, medians and percentiles of time dedicated to non-professional activities are presented for men and women from each centre. RESULTS: Professional activity was most frequently classified as sedentary or standing in all centres. There was a wide variation regarding participation in different types of non-professional activities and time dedicated to these activities across EPIC centres. Over 80% of all EPIC participants engaged in walking, while less than 50% of the subjects participated in sport. Total time dedicated to recreational activities was highest among the Dutch participants and lowest among men from Malmö (Sweden) and women from Naples (Italy). In all centres, total time dedicated to recreational activity in the summer was higher than in the winter. Women from southern Europe spent the most time on housekeeping. CONCLUSIONS: There is a considerable variation of physical activity across EPIC centres. This variation was especially evident for recreational activities in both men and women.

Physical activity and cognitive decline, the role of the apolipoprotein e4 allele.

PURPOSE: The purpose of this study was to investigate the association between level of physical activity and risk of cognitive decline at older age and its variation across carriers and noncarriers of the apolipoprotein e4 allele. METHODS: The association was studied in a cohort of 347 elderly Dutch men. Mean age of the study subjects was 74.6 +/- 4.3 yr in 1990. Physical activity was categorized in "maximal 1 h per day" versus "more than 1 h per day." Cognitive decline was defined as a drop MMSE score > 3 points between 1990 and 1993. RESULTS: After adjusting for age, education, alcohol consumption, smoking and cognitive functioning at baseline, subjects with maximal 1 h of physical activity per day had a two-fold increased risk of cognitive decline (OR 2.0, 95% CI: 0.9-4.8) as compared with the rest. Risk of cognitive decline was particularly strong in carriers of the APOE*4 allele (adjusted OR 3.7, 95% CI: 1.1-12.6). CONCLUSION: The authors conclude that promotion of physical activity at older age may reduce the risk of cognitive decline. The existence of subgroups with a particularly high risk may have important implications for prevention strategies.

[Physical activity in relation to sociodemographic variables and health status of adult men and women in Amsterdam, Doetinchen and Maastricht]. / Lichamelijke activiteit in samenhang met sociaal-demografische determinanten en gezondheidskenmerken bij volwassen mannen en vrouwen in Amsterdam, Doetinchem en Maastricht.

OBJECTIVE: To gain insight into the physical activity level of a sample of the Dutch population, to identify groups with an increased prevalence of physical inactivity and to investigate if increased moderate activity is associated with a more favourable cardiovascular risk profile and a higher self-rated health. DESIGN: Descriptive. METHOD: In 1993-1997 a monitoring project on risk factors and health has been carried out in a random sample of inhabitants of Doetinchem, Amsterdam and Maastricht. Using a questionnaire, information was obtained from the participants about physical activity, demographic characteristics, smoking behaviour and self-rated health. Also, height, weight and blood pressure were measured and a blood sample was taken. In this sample, the serum concentrations of total and high density lipoproteins were determined. This article concerns the activity in 1997 and the trend in activity in the period 1994-1997. In 1997, 4,029 persons, aged 20-64 years, took part. RESULTS: In 1997 46% (n = 1864) of the study population were, on average, active in moderate activities for less than half an hour per day, and 21% (n = 831) for less than half an hour per week ('inactives'). Inactivity was most common in subjects aged 50-59 years (28%), subjects with a low educational level (38%), widowed subjects (34%) and unemployed (36%) or disabled (42%) subjects. Since 1994, the proportion of inactive subjects increased among individuals with a low level of education. Regular physical activity, whether moderate or strenuous, was associated with a more favourable risk profile and a better self-rated health. CONCLUSION: Almost half of the persons examined were little active, which was associated with a less favourable cardiovascular risk profile and a less good self-rated health.

Exercise training and heart rate variability in older people.

PURPOSE: Heart rate variability (HRV), a characteristic that is potentially increased by physical activity, has been associated with incidence of cardiac events and total mortality. Since the incidence of cardiac events among older people is high and their physical activity levels and HRV are generally low, it is important to investigate whether regular physical activity can modify HRV in this age group. The purpose of the study was to investigate the effect of regular physical activity on HRV in older men and women. METHODS: In a randomized controlled trial, the effect of six months' training on HRV was investigated in a group of 51 older men and women (67.0 +/- 5.1 yr). The training group gathered three times per week for 45 min supervised training. RESULTS: At the end of the intervention period, HRV was higher primarily during the day. During daytime, the SD of all normal intervals (+6%) as well as the low frequency component (+ 15%) and the very low frequency component (+ 10%) of HRV were significantly increased (P < 0.05) as compared with the control group. Effects of training were most pronounced in subjects inactive in sports at baseline. CONCLUSION: This study demonstrates that regular physical activity increases HRV (specifically in the very low and low frequency components) in older subjects. Hence, in older subjects, physical training may be an effective means to modify positively a factor that is associated with increased incidence of cardiac events.

Serum cholesterol decline and depression in the postpartum period.

We examined the relation between total serum cholesterol decline and depression in the postpartum period in a prospective study of 266 Dutch women, who were followed until 34 weeks after delivery. The decline in serum cholesterol between week 32 of pregnancy and week 10 postpartum was similar for women who became depressed (n = 63) in the subsequent period and women who did not (difference, 0.10 mmol/l; 95% confidence interval [CI] -0.16 to 0.37). Adjusting for age, multiparity, education level, smoking status, concurrent illness, and social support, the odds ratio of depression was 1.4 (95% CI, 0.64 to 2.9) for women in the highest tertile of serum cholesterol decline and 0.61 (95% CI, 0.28 to 1.3) for women in the intermediate tertile, as compared with women in the lowest tertile. Our results do not support the hypothesis that rapid serum cholesterol decline increases risk of depression in the postpartum period.

The effect of six months training on weight, body fatness and serum lipids in apparently healthy elderly Dutch men and women.

OBJECTIVE: To investigate the effect of a six-months training program on changes in body weight and lipid concentrations, and their interrelationship in elderly people. DESIGN: Intervention study. The elderly subjects were randomly assigned to a control group or one of two supervised aerobic training groups, either all round activities or ergometer cycling, both exercising 3-4 times a week for six months. SUBJECTS: 229 elderly men and women, aged 60-80 y. MEASUREMENTS: Various fatness parameters by anthropometry, serum lipids and peak power output. RESULTS: During the intervention, no significant changes were observed in weight or body fatness in subjects of the training groups. Serum high density lipoprotein (HDL), low density lipoprotein (LDL) and total cholesterol and triglycerides tended to change in a favourable direction in the elderly of the intervention groups, but only triglyceride concentration in women of the cycle ergometer group (mean difference with controls: -0.24 mmol/L, 95% confidence interval (CI): -0.45, -0.03) and total serum cholesterol and HDL-cholesterol concentrations in subjects of the all-round activity group, (-0.32mmol/L, 95% CI: -0.63, -0.01 and -0.15mmol/L, 95% CI -0.25, -0.05, respectively) were significantly reduced as compared to controls. Regression analysis showed that the intervention-control difference in change of all lipids was independent of changes in weight, body fat and previous engagement in sport activity. CONCLUSION: Regular physical exercise in an elderly population resulted in favourable changes in serum lipid concentrations that were not significant, but no change in body weight or fatness. Change in lipid concentration could not be attributed to change in weight or body fat.

Effect of physical training on QTc interval in elderly people.

In order to assess whether heart rate-adjusted QT duration (QTc) is reduced by physical activity in an elderly population, a randomized, controlled intervention study of the effect of a 6-month intensive training program on QTc was undertaken. The participants were 229 healthy men and women, aged 60-80 years. The subjects of the intervention group trained three to four times a week at a work load of about 70% of their maximum capacity for 6 months, while the control subjects maintained their habitual activities. The main outcome measures were change in QTc and resting heart rate. For women, the mean QTc interval (ms) of the intervention group changed by -6.7 (SE 2.8) versus 0.6 (SE 2.4) in the control group (P = .05), while for men, the change in the intervention group subjects was -2.7 (SE 2.2) versus 0.4 (SE 3.1) in the control subjects (P = .39). Also, resting heart rate (beats/ min) changed in intervention group women by -4.6 (SE 1.7) as against -0.06 (SE 1.1) in the control subjects (P = .02), and in intervention group men it changed by -3.2 (SE 1.2) versus -0.9 (SE 1.5) in the control subjects (P = .25). These data indicate that regular physical activity favorably affects QTc in elderly women. A similar, but not significant, trend was observed in men. The beneficial shift in QTc may be caused by a more favorable autonomic balance through increased parasympathetic activity. The reduced resting heart rate in subjects of the intervention group supports this view. Although the reduction was relatively small, it may represent a favorable effect on cardiovascular risk.

Intensity, duration, and frequency of physical activity and coronary risk factors.

Relationships between coronary risk factors and intensity, duration, and frequency of leisure activity were studied in 5943 men and 6039 women, ages 25-69. Age, smoking, socioeconomics, season, body mass index (BMI), urbanization, occupational activity, and liquid, alcohol, and saturated/total fat intake were adjusted using multivariate regressions. Among men each 100 kcal.kg-1.wk-1 spent on vigorous activities (7.5-9.0 MET) was associated with: significant (P < 0.01) average differences of -0.36 mmol.L-1 total cholesterol, +0.17 mmol.L-1 HDL cholesterol (P < 0.001), +0.05 HDL/total cholesterol (P < 0.001), -0.33 mmol.L-1 triglycerides, -3 mm Hg diastolic blood pressure, -10 beats.min-1 heart rate (P < 0.001), +30 L.min-1 peak flow, and -1.1 kg.m-2 BMI. Among women it was associated with: -7 mm Hg systolic blood pressure, -6 beats.min-1 heart rate (P < 0.001), +50 L.min-1 peak flow (P < 0.001), and -1.4 kg.m-2 BMI (P < 0.05). Moderate activity (either 3.0-4.5 MET or 5.0-7.0 MET) was significantly (P < 0.05) associated with HDL cholesterol, BMI, and, for men, heart rate; for women, it was associated with HDL/total cholesterol, triglycerides, diastolic blood pressure, and peak flow. With duration and intensity constant, increasing frequency by one time per wk was significantly (P < 0.05) associated with -0.014 mmol.L-1 total cholesterol, +0.001 HDL/total cholesterol, -0.36 beats.min-1 heart rate, -0.093 kg.m-2 BMI among men, and +0.009 mmol.L-1 HDL cholesterol, +0.001 HDL/total cholesterol, -0.014 mmol.L-1 triglycerides, -0.31 beats.min-1 heart rate, and -0.098 kg.m-2 BMI among women. Serum lipids and BMI showed stronger associations with frequency than with intensity or duration.

Effect of strenuous exercise on fibrinogen and fibrinolysis in healthy elderly men and women.

The elevated incidence of thrombotic disease in elderly people may be associated with an increase in PAI-1 and fibrinogen with ageing. Cross-sectional studies report an inverse relation of PAI-1 and fibrinogen with physical activity, but training studies show inconsistent results. In a controlled intervention study among elderly subjects (aged 60-80 years) we observed a moderate decrease in PAI-1 antigen (4%, -2.1 +/- 2.4 ng/ml), a significant increase in t-PA activity (11%, 0.07 +/- 0.04 IU/ml) and an unexpected significant increase in fibrinogen (6%, 0.18 +/- 0.07 g/l) in subjects following a 6-month intensive training program as compared to controls. Reduction in PAI-1 antigen was significantly associated with a decrease in triglycerides (beta = 10.3 ng/ml per 1 mM, p <0.01) and insulin (beta = 2.37 ng/ml per 1 mU/l, p = 0.07). Increase in fibrinogen coincided with a rise in C-reactive protein (p <0.001). These data suggest that regular intensive activity may increase fibrinolytic activity in a moderate way, but also may cause chronically elevated plasma levels of acute phase proteins in elderly persons.

Validity of the Physical Activity Scale for the Elderly (PASE): according to energy expenditure assessed by the doubly labeled water method.

The study investigates the validity of the Physical Activity Scale for the Elderly (PASE) in 21 Dutch elderly men and women. The PASE is an easily scored, brief questionnaire for elderly, suitable for large epidemiologic studies. The PASE score was compared with physical activity measured with the doubly labeled water method. The correlation coefficient of the PASE score with the residuals from the regression analysis using total energy expenditure as dependent and resting metabolic rate as independent variate was 0.58 (95% CI = 0.50-0.81). Women had greater engagement in extremely high scoring activities as housework and taking care of others, resulting in higher PASE scores than men (97.9 and 71.9). The higher scores in women were not linked to higher activity levels, which suggests that the mentioned activities may be overvalued. Sex specific correlation coefficients were 0.79 (CI = 0.32-0.95) and 0.68 (CI = 0.15-0.90) for men and women, respectively. In conclusion, the PASE proved to be a reasonable valid method to classify healthy elderly men and women into categories of physical activity. Some possible refinements were suggested, which may improve the accuracy of the PASE questionnaire.