One Website to Gather them All: Usability Testing of the New German SKin Cancer INFOrmation (SKINFO) Website-A Mixed-methods Approach.

Skin cancer patients increasingly search the internet to acquire disease-related information. However, information on the internet may be misleading. Recently, SKINFO has been launched, a website exclusively created for German-speaking skin cancer patients providing information as well as additional resources of verified quality. Here, we describe the results of the first usability test of SKINFO using a mixed-methods approach. Ten adult patients with skin cancer were recruited for usability testing in the skin cancer units of the University Hospitals of Erlangen and Dresden, Germany. Testing consisted of three different scenarios where patients were asked to find specific information on the SKINFO website guided by the think-aloud method. Descriptive analysis and content analyses were performed. All patients would recommend SKINFO and appreciated its content, design, and structure. Think-aloud analysis identified the topics layout, navigation, and content and structure which would benefit from refinement. Major criticism included the navigation through the website, and the desire for more specific information addressing patients' relatives and the latest, up-to-date information. Overall, usability testing showed that the unique web-based information platform has the potential to support patients coping with skin cancer and thus strengthen informed decision-making.

Quality, Readability, and Understandability of German Booklets Addressing Melanoma Patients.

Booklets are the preferably used form among patient education materials and are often handed out during medical consultations in dermatological oncology settings. However, little is known about how beneficial they are and whether they correspond to essential quality characteristics. To assess the quality, readability, and understandability of currently freely available booklets written in German addressing melanoma patients (MP). Melanoma booklets in accordance with predefined criteria were searched and analyzed. Three reviewers independently assessed their quality and understandability by applying the DISCERN tool and PEMAT-P. The Flesch Reading Ease Score (FRES) was calculated to determine readability. Nine booklets addressing MP were analyzed. The overall median DISCERN score was 3.6 (interquartile range (IQR) 2.9-4.1), median PEMAT-P score was 91% (IQR 83-94.5), and median FRES was 43 (IQR 33.5-47.5), indicating a medium quality, a high application of understandability elements, but low readability in at least half of the booklets. Incomplete reporting on treatments and insufficient meta-information caused the main quality deficits. There is a need of content and didactic revision of German booklets for MP to raise their quality and to make them beneficial and understandable for more patients. An adaption in accordance with evidence-based criteria and an even stronger involvement of MP in assessment and development of patient education material are considered to be the best approaches.

Information-seeking and use of information resources among melanoma patients of German skin cancer centers.

BACKGROUND: This study aimed to explore the information-seeking behavior (ISB) of melanoma patients (MPs) and MP subgroups, in order to provide data for needs-based adaptation of information provision. METHODS: In a cross-sectional survey in 27 German skin cancer centers, we explored characteristics of the ISB of MPs with the aid of a standardized questionnaire. Sub-group differences were determined with the chi-squared test and predictors of media preferences with logistic regression. RESULTS: 67 % of the 529 participating MPs had clinical stage III or IV melanoma. Most of the participants (81 %) reported medical consultations as their regularly or frequently used information resource (IR). 58 % wished to have more advice about IRs from their physician. Only 8 % of MPs used the services of self-help groups and 12 % of MPs took advantage of the services of cancer counseling centers. The internet (63 %) and booklets (58 %) were reported to be the preferred media. Age, educational level, general need for information and lack of awareness of their own condition proved to be predictors for media preferences. CONCLUSIONS: Most MPs expected their physician to advise them about IRs they could use in addition to medical consultations. Peer support services were quite underused by MPs. The various preferences of media by MPs should be considered when deve-loping and providing IRs.

Developing a data-driven spatial approach to assessment of neighbourhood influences on the spatial distribution of myocardial infarction.

BACKGROUND: There is a growing understanding of the role played by 'neighbourhood' in influencing health status. Various neighbourhood characteristics-such as socioeconomic environment, availability of amenities, and social cohesion, may be combined-and this could contribute to rising health inequalities. This study aims to combine a data-driven approach with clustering analysis techniques, to investigate neighbourhood characteristics that may explain the geographical distribution of the onset of myocardial infarction (MI) risk. METHODS: All MI events in patients aged 35-74 years occurring in the Strasbourg metropolitan area (SMA), from January 1, 2000 to December 31, 2007 were obtained from the Bas-Rhin coronary heart disease register. All cases were geocoded to the census block for the residential address. Each areal unit, characterized by contextual neighbourhood profile, included socioeconomic environment, availability of amenities (including leisure centres, libraries and parks, and transport) and psychosocial environment as well as specific annual rates standardized (per 100,000 inhabitants). A spatial scan statistic implemented in SaTScan was then used to identify statistically significant spatial clusters of high and low risk of MI. RESULT: MI incidence was non-randomly spatially distributed, with a cluster of high risk of MI in the northern part of the SMA [relative risk (RR) = 1.70, p = 0.001] and a cluster of low risk of MI located in the first and second periphery of SMA (RR 0.04, p value  =  0.001). Our findings suggest that the location of low MI risk is characterized by a high socioeconomic level and a low level of access to various amenities; conversely, the location of high MI risk is characterized by a high level of socioeconomic deprivation-despite the fact that inhabitants have good access to the local recreational and leisure infrastructure. CONCLUSION: Our data-driven approach highlights how the different contextual dimensions were inter-combined in the SMA. Our spatial approach allowed us to identify the neighbourhood characteristics of inhabitants living within a cluster of high versus low MI risk. Therefore, spatial data-driven analyses of routinely-collected data georeferenced by various sources may serve to guide policymakers in defining and promoting targeted actions at fine spatial level.

Neighborhood educational disparities in active commuting among women: the effect of distance between the place of residence and the place of work/study (an ACTI-Cités study).

BACKGROUND: Active transportation has been associated with favorable health outcomes. Previous research highlighted the influence of neighborhood educational level on active transportation. However, little is known regarding the effect of commuting distance on social disparities in active commuting. In this regard, women have been poorly studied. The objective of this paper was to evaluate the relationship between neighborhood educational level and active commuting, and to assess whether the commuting distance modifies this relationship in adult women. METHODS: This cross-sectional study is based on a subsample of women from the Nutrinet-Santé web-cohort (N = 1169). Binomial, log-binomial and negative binomial regressions were used to assess the associations between neighborhood education level and (i) the likelihood of reporting any active commuting time, and (ii) the share of commuting time made by active transportation modes. Potential effect measure modification of distance to work on the previous associations was assessed both on the additive and the multiplicative scales. RESULTS: Neighborhood education level was positively associated with the probability of reporting any active commuting time (relative risk = 1.774; p < 0.05) and the share of commuting time spent active (relative risk = 1.423; p < 0.05). The impact of neighborhood education was greater at long distances to work for both outcomes. CONCLUSIONS: Our results suggest that neighborhood educational disparities in active commuting tend to increase with commuting distance among women. Further research is needed to provide geographically driven guidance for health promotion intervention aiming at reducing disparities in active transportation among socioeconomic groups.

Assessment of sedentary behaviors and transport-related activities by questionnaire: a validation study.

BACKGROUND: Comprehensive assessment of sedentary behavior (SB) and physical activity (PA), including transport-related activities (TRA), is required to design innovative PA promotion strategies. There are few validated instruments that simultaneously assess the different components of human movement according to their context of practice (e.g. work, transport, leisure). We examined test-retest reliability and validity of the Sedentary, Transportation and Activity Questionnaire (STAQ), a newly developed questionnaire dedicated to assessing context-specific SB, TRA and PA. METHODS: Ninety six subjects (51 women) kept a contextualized activity-logbook and wore a hip accelerometer (Actigraph GT3X + (TM)) for a 7-day or 14-day period, at the end of which they completed the STAQ. Activity-energy expenditure was measured in a subgroup of 45 subjects using the double labeled water (DLW) method. Test-retest reliability was assessed using intra-class-coefficients (ICC) in a subgroup of 32 subjects who filled the questionnaire twice one month apart. Accelerometry was annotated using the logbook to obtain total and context-specific objective estimates of SB. Spearman correlations, Bland-Altman plots and ICC were used to analyze validity with logbook, accelerometry and DLW data validity criteria. RESULTS: Test-retest reliability was fair for total sitting time (ICC = 0.52), good to excellent for work sitting time (ICC = 0.71), transport-related walking (ICC = 0.61) and car use (ICC = 0.67), and leisure screen-related SB (ICC = 0.64-0.79), but poor for total sitting time during leisure and transport-related contexts. For validity, compared to accelerometry, significant correlations were found for STAQ estimates of total (r = 0.54) and context-specific sitting times with stronger correlations for work sitting time (r = 0.88), and screen times (TV/DVD viewing: r = 0.46; other screens: r = 0.42) than for transport (r = 0.35) or leisure-related sitting-times (r = 0.19). Compared to contextualized logbook, STAQ estimates of TRA was higher for car (r = 0.65) than for active transport (r = 0.41). The questionnaire generally overestimated work- and leisure-related SB and sitting times, while it underestimated total and transport-related sitting times. CONCLUSIONS: The STAQ showed acceptable reliability and a good ranking validity for assessment of context-specific SB and TRA. This instrument appears as a useful tool to study SB, TRA and PA in context in adults.

Walking and cycling for commuting, leisure and errands: relations with individual characteristics and leisure-time physical activity in a cross-sectional survey (the ACTI-Cités project).

BACKGROUND: Increasing active transport behavior (walking, cycling) throughout the life-course is a key element of physical activity promotion for health. There is, however, a need to better understand the correlates of specific domains of walking and cycling to identify more precisely at-risk populations for public health interventions. In addition, current knowledge of interactions between domains of walking and cycling remains limited. METHODS: We assessed past-month self-reported time spent walking and cycling in three specific domains (commuting, leisure and errands) in 39,295 French adult participants (76.5% women) of the on-going NutriNet Santé web-cohort. Multivariate logistic regression models were used to investigate the associations with socio-demographic and physical activity correlates. RESULTS: Having a transit pass was strongly positively associated with walking for commuting and for errands but was unrelated to walking for leisure or to all domains of cycling. Having a parking space at work was strongly negatively associated with walking for commuting and cycling for commuting. BMI was negatively associated with both walking for leisure and errands, and with the three domains of cycling. Leisure-time physical activity was negatively associated with walking for commuting but was positively associated with the two other domains of walking and with cycling (three domains). Walking for commuting was positively associated with the other domains of walking; cycling for commuting was also positively associated with the other domains of cycling. Walking for commuting was not associated with cycling for commuting. CONCLUSIONS: In adults walking and cycling socio-demographic and physical activity correlates differ by domain (commuting, leisure and errands). Better knowledge of relationships between domains should help to develop interventions focusing not only the right population, but also the right behavior.

Spatial heterogeneity of the relationships between environmental characteristics and active commuting: towards a locally varying social ecological model.

BACKGROUND: According to the social ecological model of health-related behaviors, it is now well accepted that environmental factors influence habitual physical activity. Most previous studies on physical activity determinants have assumed spatial homogeneity across the study area, i.e. that the association between the environment and physical activity is the same whatever the location. The main novelty of our study was to explore geographical variation in the relationships between active commuting (walking and cycling to/from work) and residential environmental characteristics. METHODS: 4,164 adults from the ongoing Nutrinet-Santé web-cohort, residing in and around Paris, France, were studied using a geographically weighted Poisson regression (GWPR) model. Objective environmental variables, including both the built and the socio-economic characteristics around the place of residence of individuals, were assessed by GIS-based measures. Perceived environmental factors (index including safety, aesthetics, and pollution) were reported by questionnaires. RESULTS: Our results show that the influence of the overall neighborhood environment appeared to be more pronounced in the suburban southern part of the study area (Val-de-Marne) compared to Paris inner city, whereas more complex patterns were found elsewhere. Active commuting was positively associated with the built environment only in the southern and northeastern parts of the study area, whereas positive associations with the socio-economic environment were found only in some specific locations in the southern and northern parts of the study area. Similar local variations were observed for the perceived environmental variables. CONCLUSIONS: These results suggest that: (i) when applied to active commuting, the social ecological conceptual framework should be locally nuanced, and (ii) local rather than global targeting of public health policies might be more efficient in promoting active commuting.

Descriptive study of sedentary behaviours in 35,444 French working adults: cross-sectional findings from the ACTI-Cités study.

BACKGROUND: Given the unfavourable health outcomes associated with sedentary behaviours, there is a need to better understand the context in which these behaviours take place to better address this public health concern. We explored self-reported sedentary behaviours by type of day (work/non-work), occupation, and perceptions towards physical activity, in a large sample of adults. METHODS: We assessed sedentary behaviours cross-sectionally in 35,444 working adults (mean ± SD age: 44.5 ± 13.0 y) from the French NutriNet-Santé web-based cohort. Participants self-reported sedentary behaviours, assessed as domain-specific sitting time (work, transport, leisure) and time spent in sedentary entertainment (TV/DVD, computer and other screen-based activities, non-screen-based activities) on workdays and non-workdays, along with occupation type (ranging from mainly sitting to heavy manual work) and perceptions towards physical activity. Associations of each type of sedentary behaviour with occupation type and perceptions towards physical activity were analysed by day type in multiple linear regression analyses. RESULTS: On workdays, adults spent a mean (SD) of 4.17 (3.07) h/day in work sitting, 1.10 (1.69) h/day in transport sitting, 2.19 (1.62) h/day in leisure-time sitting, 1.53 (1.24) h/day viewing TV/DVDs, 2.19 (2.62) h/day on other screen time, and 0.97 (1.49) on non-screen time. On non-workdays, this was 0.85 (1.53) h/day in transport sitting, 3.19 (2.05) h/day in leisure-time sitting, 2.24 (1.76) h/day viewing TV/DVDs, 1.85 (1.74) h/day on other screen time, and 1.30 (1.35) on non-screen time. Time spent in sedentary behaviours differed by occupation type, with more sedentary behaviour outside of work (both sitting and entertainment time), in those with sedentary occupations, especially on workdays. Negative perceptions towards physical activity were associated with more sedentary behaviour outside of work (both sitting and entertainment time), irrespective of day type. CONCLUSIONS: A substantial amount of waking hours was spent in different types of sedentary behaviours on workdays and non-workdays. Being sedentary at work was associated with more sedentary behaviour outside of work. Negative perceptions towards physical activity may influence the amount of time spent in sedentary behaviours. These data should help to better identify target groups in public health interventions to reduce sedentary behaviours in working adults.

The environmental correlates of overall and neighborhood based recreational walking (a cross-sectional analysis of the RECORD Study).

BACKGROUND: Preliminary evidence suggests that recreational walking has different environmental determinants than utilitarian walking. However, previous studies are limited in their assessment of environmental exposures and recreational walking and in the applied modeling strategies. Accounting for individual sociodemographic profiles and weather over the walking assessment period, the study examined whether numerous street network-based neighborhood characteristics related to the sociodemographic, physical, service, social-interactional, and symbolic environments were associated with overall recreational walking and recreational walking in one's residential neighborhood and could explain their spatial distribution. METHODS: Based on the RECORD Cohort Study (Paris region, France, n=7105, 2007-2008 data), multilevel-spatial regression analyses were conducted to investigate environmental factors associated with recreational walking (evaluated by questionnaire at baseline). A risk score approach was applied to quantify the overall disparities in recreational walking that were predicted by the environmental determinants. RESULTS: Sixty-nine percent of the participants reported recreational walking over the past 7 days. Their mean reported recreational walking time was 3h 31mn. After individual-level adjustment, a higher neighborhood education, a higher density of destinations, green and open spaces of quality, and the absence of exposure to air traffic were associated with higher odds of recreational walking and/or a higher recreational walking time in one's residential neighborhood. As the overall disparities that were predicted by these environmental factors, the odds of reporting recreational walking and the odds of a higher recreational walking time in one's neighborhood were, respectively, 1.59 [95% confidence interval (CI): 1.56, 1.62] times and 1.81 (95% CI: 1.73, 1.87) times higher in the most vs. the least supportive environments (based on the quartiles). CONCLUSIONS: Providing green/open spaces of quality, building communities with services accessible from the residence, and addressing environmental nuisances such as those related to air traffic may foster recreational walking in one's environment.

Identifying built environmental patterns using cluster analysis and GIS: relationships with walking, cycling and body mass index in French adults.

BACKGROUND: Socio-ecological models suggest that both individual and neighborhood characteristics contribute to facilitating health-enhancing behaviors such as physical activity. Few European studies have explored relationships between local built environmental characteristics, recreational walking and cycling and weight status in adults. The aim of this study was to identify built environmental patterns in a French urban context and to assess associations with recreational walking and cycling behaviors as performed by middle-aged adult residents. METHODS: We used a two-step procedure based on cluster analysis to identify built environmental patterns in the region surrounding Paris, France, using measures derived from Geographic Information Systems databases on green spaces, proximity facilities (destinations) and cycle paths. Individual data were obtained from participants in the SU.VI.MAX cohort; 1,309 participants residing in the Ile-de-France in 2007 were included in this analysis. Associations between built environment patterns, leisure walking/cycling data (h/week) and measured weight status were assessed using multinomial logistic regression with adjustment for individual and neighborhood characteristics. RESULTS: Based on accessibility to green spaces, proximity facilities and availability of cycle paths, seven built environmental patterns were identified. The geographic distribution of built environmental patterns in the Ile-de-France showed that a pattern characterized by poor spatial accessibility to green spaces and proximity facilities and an absence of cycle paths was found only in neighborhoods in the outer suburbs, whereas patterns characterized by better spatial accessibility to green spaces, proximity facilities and cycle paths were more evenly distributed across the region. Compared to the reference pattern (poor accessibility to green areas and facilities, absence of cycle paths), subjects residing in neighborhoods characterized by high accessibility to green areas and local facilities and by a high density of cycle paths were more likely to walk/cycle, after adjustment for individual and neighborhood sociodemographic characteristics (OR = 2.5 95%CI 1.4-4.6). Body mass index did not differ across patterns. CONCLUSIONS: Built environmental patterns were associated with walking and cycling among French adults. These analyses may be useful in determining urban and public health policies aimed at promoting a healthy lifestyle.

Analysing the influence of different street vegetation on traffic-induced particle dispersion using microscale simulations.

Urban vegetation can be viewed as compensation to the environmental drawbacks of urbanisation. However, its ecosystem function is not well-known and, for urban planning, vegetation is mainly considered as an element of urban design. This article argues that planning practice needs to re-examine the impact of vegetation cover in the urban fabric given our evaluation of vegetation's effects on air quality, including the dispersion of traffic-induced particles at street level. Using the three-dimensional microclimate model ENVI-met®, we evaluate these effects regarding the height-to-width ratio of streets flanked by buildings and the vertical and horizontal density of street vegetation. Our results reveal vegetation's effect on particle dispersion through its influence on street ventilation. In general, vegetation was found to reduce wind speed, causing inhibition of canyon ventilation and, consequently, an increase in particle concentrations. Vegetation was also found to reduce wind speed at crown-height and to disrupt the flow field in close vicinity to the canopy. With increasing height-to-width ratio of street canyons, wind speed reduction increases and the disturbance of the flow impacts across a canyon's entire width. We also found that the effect is more pronounced in configurations with poor ventilation, such as the low wind speed, perpendicular inflow direction, and in deep canyons cases.

Associations between dietary patterns, physical activity (leisure-time and occupational) and television viewing in middle-aged French adults.

Diet and physical activity are considered to be major components of a healthy lifestyle. However, few studies have examined in detail the relationships between specific types of physical activity, sedentary behaviour and diet in adults. The objective of the present study was to assess differential relationships between dietary patterns, leisure-time and occupational physical activities and time spent watching television (TV), as an indicator of sedentary behaviour, in middle-aged French subjects. We performed a cross-sectional analysis using data from 1359 participants in the SUpplémentation en VItamines et Minéraux AntioXydants study, who completed a detailed physical activity questionnaire and at least six 24 h dietary records. Sex-specific dietary patterns were derived using factor analysis; their relationships with leisure-time and occupational physical activities and TV viewing were assessed using ANCOVA, after adjustment for age, educational level and smoking status. Three dietary patterns were identified in each sex. After adjustment for potential confounders, leisure-time physical activity was positively associated with a 'healthy' food pattern in both men (P for trend < 0·01) and women (P for trend < 0·03) and negatively associated with an 'alcohol/meat' pattern in men (P for trend < 0·01). TV viewing was positively associated with a 'convenience' pattern in men and with a 'alcohol-appetiser' pattern in women. In conclusion, identification of relationships between dietary patterns, physical activity and sedentary behaviour can enable identification of different types of lifestyle and should help to target at-risk groups in nutrition prevention programmes.

Estimating spatial accessibility to facilities on the regional scale: an extended commuting-based interaction potential model.

BACKGROUND: There is growing interest in the study of the relationships between individual health-related behaviours (e.g. food intake and physical activity) and measurements of spatial accessibility to the associated facilities (e.g. food outlets and sport facilities). The aim of this study is to propose measurements of spatial accessibility to facilities on the regional scale, using aggregated data. We first used a potential accessibility model that partly makes it possible to overcome the limitations of the most frequently used indices such as the count of opportunities within a given neighbourhood. We then propose an extended model in order to take into account both home and work-based accessibility for a commuting population. RESULTS: Potential accessibility estimation provides a very different picture of the accessibility levels experienced by the population than the more classical "number of opportunities per census tract" index. The extended model for commuters increases the overall accessibility levels but this increase differs according to the urbanisation level. Strongest increases are observed in some rural municipalities with initial low accessibility levels. Distance to major urban poles seems to play an essential role. CONCLUSIONS: Accessibility is a multi-dimensional concept that should integrate some aspects of travel behaviour. Our work supports the evidence that the choice of appropriate accessibility indices including both residential and non-residential environmental features is necessary. Such models have potential implications for providing relevant information to policy-makers in the field of public health.