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Background A cluster-Randomised Controlled Trial evaluation of the impact of the Community Health Clubs (CHCs) in the Community Based Environmental Health Promotion Programme in Rwanda in 2015 appeared to find little uptake of 7 hygiene indicators 1 year after the end of the intervention, and low impact on prevention of diarrhoea and stunting. Methods Monitoring data was revisited through detailed community records with all the expected inputs , outputs and external determinants analysed for fidelity to the research protocol. Five household inventory observations were taken over a 40-month period including 2 years after the end of the cRCT in a random selection of the 50 intervention CHCs and data compared to that of the trial. Focus Group Discussion with all Environmental Health Officers of the Ministry of Health provided context to understand the long-term community dynamics of hygiene behaviour change. Results It was found that the intervention had been jeopardised by external determinants with only 54% fidelity to protocol. By the end of the designated intervention period in June 2014, the treatment had reached only 58% of households with 41% average attendance at training sessions by the 4056 registered members and 51% mean completion rate of 20+ sessions. Therefore only 10% of 50 CHCs provided the full so-called ‘Classic’ training as per-protocol. However, sustainability of the CHCs was high, with all 50 being active 2 years after the end of the cRCT and over 80% uptake of recommended practices of the same 7 key indicators as the trial was achieved by 2017. Conclusions The cRCT conclusion that the case study of Rusizi District does not encourage the use of the CHC model for scaling up, raises concerns over the possible misrepresentation of the potential of the holistic CHC model to achieve health impact in a more realistic time frame. It also questions the appropriateness of apparently rigorous quantitative research, such as the cluster-Randomised Controlled Trial as conducted in Rusizi District, to adequately assess community dynamics in complex interventions.

Background Low back pain is highly prevalent and a major source of disability worldwide. Spa therapy is frequently used to treat low back pain, but the associated level of evidence for efficacy is insufficient. To fill this knowledge gap, this protocol proposes an appropriately powered, prospective, evaluator-blinded, multi-centre, two-parallel-arm, randomised (1:1), controlled trial that will compare spa therapy in addition to usual care including home exercise (UCHE) versus UCHE alone for the treatment of chronic low back pain. Methods Eligible patients (anticipated sample size of 358) will have had low back pain for more than 3 months and scores for pain greater than 40 mm on a visual analogue scale (VAS). Following initial consent for UCHE and baseline evaluations, patients are randomised (1:1) to UCHE alone, or UCHE plus spa therapy (18 days of mud packs, underwater massages, showers and water exercises under medical supervision). Patients in the latter arm will be requested to sign an additional consent form as per Zelen randomisation. Follow-up visits will occur at approximately months 1, 6 and 12 and (along with baseline assessments) will cover changes over time in VAS pain scores, the impact of lower back pain on daily life (the Rolland and Morris Disability Questionnaire (RMDQ)), inappropriate fears and beliefs about lower back pain (the fear, avoidance, belief questionnaire (FABQ)), general quality of life (the Euroqol Group 5 dimension, 5 level questionnaire (EQ-5D-5 L)), Patient Acceptable Symptom State (PASS), consumption of analgesic drugs and nonsteroidal anti-inflammatory drugs (NSAIDs), and overall state of health. Health resource use and days of sick leave (and subsequently the associated costs) will also be recorded. The primary outcome is the presence/absence of a clinically relevant change (improvement of at least 30%) in the VAS score for pain at 6 months. Discussion Despite the fact that previous, rather dated recommendations encourage spa therapy for the treatment of low back pain, the current literary corpus is methodologically poor. This protocol has been designed to provide results spanning a thorough range of outcomes at the highest evidence level possible. Trial registration ClinicalTrials.gov: NCT03910023 . Registered on 10 April 2019.

In line with the Sustainable Development Goals (SDGs) and the target for achieving Universal Health Coverage (UHC), state level initiatives to promote health with \"no-one left behind\" are underway in India. In Kerala, reforms under the flagship Aardram mission include upgradation of Primary Health Centres (PHCs) to Family Health Centres (FHCs, similar to the national model of health and wellness centres (HWCs)), with the proactive provision of a package of primary care services for the population in an administrative area. We report on a component of Aardram's monitoring and evaluation framework for primary health care, where tracer input, output, and outcome indicators were selected using a modified Delphi process and field tested. A conceptual framework and indicator inventory were developed drawing upon literature review and stakeholder consultations, followed by mapping of manual registers currently used in PHCs to identify sources of data and processes of monitoring. The indicator inventory was reduced to a list using a modified Delphi method, followed by facility-level field testing across three districts. The modified Delphi comprised 25 participants in two rounds, who brought the list down to 23 approved and 12 recommended indicators. Three types of challenges in monitoring indicators were identified: appropriateness of indicators relative to local use, lack of clarity or procedural differences among those doing the reporting, and validity of data. Further field-testing of indicators, as well as the revision or removal of some may be required to support ongoing health systems reform, learning, monitoring and evaluation.

In a society that perpetuates the strive for a perfect appearance, a fit body has become synonymous with success, but simultaneously hard to achieve. This represents a fertile ground for the development of Exercise Addiction (EA) alongside other disorders, such as Body Dysmorphic Disorder (BDD). This study aims to explore the diffusion of EA in fitness settings in the United Kingdom, Italy, Netherlands, Hungary and the previously unexplored association with appearance anxiety, BDD, self-esteem and the use of fitness supplements. A large cross-sectional sample (N = 1711) was surveyed in fitness settings using the Exercise Addiction Inventory (EAI), Appearance Anxiety Inventory (AAI) and Rosenberg's Self Esteem Scale (RSE) in addition to questions surrounding the use of fitness supplements. Compulsive exercise, appearance anxiety and low self-esteem were present in this sample according to the psychometric measures used (EAI, AAI, RSE). 11.7% scored over the cut off for EA, with alarming peaks in the Netherlands (20.9%) and the United Kingdom (16.1%). 38.5% were found at risk of BDD, mainly female (47.2%). 39.8% used fitness enhancing supplements without medical consultation (95.5%). This cohort of supplement users scored higher in both EAI and AAI. The logistic regression model revealed a strong association between the consumption of sport products and the level of EA across the sample with an odds ratio (OR) of 3.03. Other co-variable factors among female were appearance anxiety (AAI; OR 1.59) and to a lesser extent self-esteem (RSE) (OR 1.08). This study identified a high risk of EA, appearance anxiety and BDD amongst a cohort of gym users internationally. The previously-unexplored association between these disorders and the unsupervised use of a variety of fitness products, including illicit drugs, highlights the need for informed and integrated responses targeting such vulnerable individuals.

Objectives. Parks provide places for people to experience nature, engage in physical activity, and relax. We studied how residents in low-income, minority communities use public, urban neighborhood parks and how parks contribute to physical activity. Methods. In 8 public parks, we used direct observation to document the number, gender, race/ethnicity, age group, and activity level of park users 4 times per day, 7 days per week. We also interviewed 713 park users and 605 area residents living within 2 miles of each park. Results. On average, over 2000 individuals were counted in each park, and about two thirds were sedentary when observed. More males than females used the parks, and males were twice as likely to be vigorously active. Interviewees identified the park as the most common place they exercised. Both park use and exercise levels of individuals were predicted by proximity of their residence to the park. Conclusions. Public parks are critical resources for physical activity in minority communities. Because residential proximity is strongly associated with physical activity and park use, the number and location of parks are currently insufficient to serve local populations well.

To evaluate the attrition rate of members of a fitness center in the city of Rio de Janeiro and the potential explanatory variables for the phenomenon. An exploratory, observational study using a retrospective longitudinal frame. The records of 5240 individuals, members of the fitness center between January-2005 and June-2014, were monitored for 12 months or until cancellation of membership, whichever occurred first. A Cox proportional hazard regression model was adjusted to identify variables associated to higher risk of ‘abandonment’ of activities. This study was approved by Southern Cross University's Human Research Ethics Committee (approval number: ECN-15-176). The general survival curve shows that 63% of new members will abandon activities before the third month, and less than 4% will remain for more than 12 months of continuous activity. The regression model showed that age, previous level of physical activity, initial body mass index and motivations related to weight loss, hypertrophy, health, and aesthetics are related to risk of abandonment. Combined, those variables represent an important difference in the probability to abandon the gym between individuals with the best and worse combination of variables. Even individuals presenting the best combination of variables still present a high risk of abandonment before completion of 12 months of fitness center membership. Findings can assist in the identification of high risk individuals and therefore help in the development of strategies to prevent abandonment of physical activity practice.

aim: There is growing international evidence that outdoor gym equipment in parks can provide health and fitness benefits to the population. As little is known concerning the availability and usage of such equipment in the Aotearoa New Zealand setting, we aimed to study this topic further. methods: An internet survey identified outdoor gym equipment in parks in the 10 most populated territorial authorities (TAs). A field survey of 22 selected parks examined the actual equipment. Observational data were obtained on equipment usage in one large urban park over 3 summer months. results: The internet survey identified 122 parks with outdoor gym equipment in the 10 TAs. The prevalence ranged from zero (in three TAs) up to 5.6 parks per 100,000 population in Christchurch City (i.e., one such park per 18,000 people). The field survey of 22 parks indicated that all the equipment worked as intended and none was vandalised. Observations from one large urban park indicated that the eight pieces of equipment averaged 16 uses per hour overall. This was extrapolated to estimate around 18,000 episodes of use over the 3 summer months for this park. Usage of the different items of gym equipment varied sixfold (p<0.0001). conclusions: There is a need for further research on the relationship between outdoor gym equipment provision and population health and fitness in the New Zealand context. Nevertheless, this study provides preliminary data that such equipment can be extensively used by the public in some settings.

Adolescents’ physical activity patterns appear to be changing, with indications of a shift from nature-based activities toward more structured, indoor forms of exercise. However, it remains unclear how participation in outdoor recreation and fitness center use has developed in parallel over time, and whether these trends vary by degree of urbanization. The aim of the present study was to examine the trends in adolescents’ engagement in outdoor recreation and use of fitness centers across Norwegian municipalities between 2010 and 2019 and to assess how these patterns relate to individual and contextual factors. Repeated cross-sectional data were drawn from the Ungdata survey (N = 67,554), and multilevel linear models were applied to estimate time trends and test interactions with municipal population density. Analyses were adjusted for depressive symptoms, gender, school grade, and vegetation density (NDVI). The results indicated a significant decline in outdoor recreation during the period, particularly in more urban municipalities, alongside a marked increase in fitness center use. The two activity types were positively associated but not mutually exclusive. The findings point to a broader shift in adolescent activity preferences that may reflect changing environmental and sociocultural conditions. These patterns underline the need for public health approaches that recognize diverse forms of youth engagement in physical activity.

The Mediterranean diet (MD) is based on the traditional cuisine of south European countries, and it is considered one of the healthiest dietary patterns worldwide. The promotion of combined MD and physical activity has shown major benefits. However, the association between physical activity and the MD in regular fitness center users is still insufficiently investigated. This cross-sectional survey-based study was conducted on 1220 fitness center users in Croatia. The survey consisted of three parts: general information, the Mediterranean Diet Serving Score (MDSS) and the International Physical Activity Questionnaire Short Form (IPAQ-SF). The results showed that 18.6% of fitness center users were adherent to the MD, and there was a significant positive correlation between the level of physical activity and the MDSS score (r = 0.302, p < 0.001). Moreover, after dividing the sample into tertiles based on the IPAQ-SF score, the third tertile (MET > 3150 min/wk) had the most fitness center users (34.4%) adherent to the MD, while the first tertile (MET < 1750 min/wk) had the least (6.1%). These outcomes emphasize the importance of physical activity as they imply that, with higher levels of physical activity, people are also possibly more aware of the importance that a healthy and balanced diet has on their well-being.

Substantial cross-sectional evidence and limited longitudinal research indicates that the availability of recreational facilities (e.g., parks, fitness centres) is associated with physical activity participation. However, few intervention trials have investigated how recreational infrastructure can be used to reduce inactivity levels in communities. The MOVE Frankston study aimed to assess the impact of low intensity strategies to promote use of a multi-purpose leisure and aquatic centre in a socioeconomically diverse, metropolitan community. This randomised controlled trial of two years’ duration compared public awareness raising (control condition) with two interventions: mailed information about the centre and a free entry pass (I-O); and this minimal intervention supplemented by customer relations management support through telephone contact, mailed promotional materials and additional incentives (I+S). Participants (n = 1320) were inactive adults living in the City of Frankston, Melbourne Australia. There were 928 people (70.3%) followed up at 12 months (61.2% female, 52% ≥55 yrs). Compared with controls, attendance at the Centre once or more was higher in both the I-O (OR 1.79, 95% CI 1.28–2.50) and I+S groups (OR 1.46, 95% CI 1.03–2.07). The proportion of people using the centre weekly did not differ by group. The odds of being in contemplation or preparation to use the Centre were higher in both the I-O (OR 1.76, 95% CI 1.28–2.42) and I+S groups (OR 1.48, 95% CI 1.07–2.06). Total physical activity and related social and cognitive factors did not differ between the groups. The findings show that the low intensity promotional strategies prompted occasional attendance and increased readiness to use this recreational facility, a level of behaviour change unlikely to reduce non-communicable disease risk. It is recommended that more frequent customer relations contact, and involvement of healthcare providers, be tested as strategies to encourage inactive adults to take up physical activity opportunities at recreational facilities of this type.