Current research advocates lifestyle factors to manage workers’ health issues, such as obesity, metabolic syndrome, and type II diabetes mellitus, among other things  Obesity: preventing and managing the global epidemic, 2000; World Health Organization (WHO) Obesity and overweight, 2016), though little is known about employees’ lifestyle factors in high-stress, high turnover environments, such as in the long term care (LTC) sector.Drawing on qualitative single-case study in Ontario, Canada, this paper investigates an under-researched area consisting of the health practices of health care workers from high-stress, high turnover environments. In particular, it identifies LTC worker’s mechanisms for maintaining physical, emotional, and social wellbeing.The findings suggest that while particular mechanisms were prevalent, such as through diet and exercise, they were often conducted in group settings or tied to emotional health, suggesting important social and mental health contexts to these behaviors. Furthermore, there were financial barriers that prevented workers from participating in these activities and achieving health benefits, suggesting that structurally, social determinants of health (SDoH), such as income and income distribution, are contextually important.Accordingly, given that workplace health promotion and protection must be addressed at the individual, organizational, and structural levels, this study advocates integrated, total worker health (TWH) initiatives that consider social determinants of health approaches, recognizing the wider socio-economic impacts of workers’ health and wellbeing. Current research advocates lifestyle factors to manage health issues of workers, such as managing obesity, metabolic syndrome, and type II diabetes mellitus, among other things , 51, thoThe findings suggest that LTC workers typically maintained health and wellbeing through self-care measures conducted in group settings or tied to proxies of relaxation and emotional health, however, a few indicated that finances were barriers to practicing healthy behaviors.This study impacts policy such that it advocates integrated, total worker health (TWH) initiatives that consider social determinants of health approaches, recognizing the wider socio-economic impacts of workers’ physical, mental, and social wellbeing.A broad set of public health interventions have been advocated in the occupational health literature. These are generally accepted principles and practices that often include interventions that focus on prevention of accidents and occupational diseases, and also health promotion activities such as enabling workers to become more skilled to improve their lifestyles, quality of diets, sleep, and physical fitness . For exaOther researchers have specifically advocated for the following: smoking cessation, consuming limited or no amount of alcohol, medical surveillance and screening of high risk and vulnerable groups; reducing chemical, physical, ergonomic and emotional exposures; increasing research and development of appropriate drugs and therapeutic products; and advocating interventions that include urban environmental interventions like building safe walkways, bicycle paths, and improving building design to encourage stairwell use , 35, 36.As indicated by Magnavita ; workplaPrevious studies of Canadian LTC have focused on: structural and physical violence , 9; workThis study used a single-case design, and relied on an ethnography, in which the sources of evidence were from direct observations and in-depth, key informant interviews. Observations and interviews were carried out at a LTC site in Toronto, Canada between the hours of 6:30 am am to midnight, which were opportunistic times to observe the workers’ scheduled shift changes that occurred at 7 am, 3 pm, and 11 pm. Observations were conducted in secure, locked and unlocked units/ wings at the site; in public spaces within the facility, and at the reception area. These spaces included: hallways and dining areas on the individual units, the recreation space of the atrium located on the ground floor, the employee break room located at the mezzanine level, and outside the meeting rooms in the basement-level. Forty-two face-to-face, in-depth, semi-structured interviews were conducted with participants, and digitally recorded using Sony ICDPX440 recorders. Fieldnotes were generated during observations, which documented preliminary thoughts, assumptions, and the physical setting. Multiple units of analysis were organized by worker characteristics such as sex, job titles or roles, visible minority (VM) status, full time (F/T) status, and part-time (P/T) work status, among other things  reported self-care measures that included exercise, healthy eating, and so forth. These measures were often conducted in group settings or tied to emotional health, suggesting important social and mental health contexts to these behaviors. Some participants also reported that they had the time and resources to grow their own food, and used consumption as a proxy for relaxation and emotional health. However, there were other workers who said that finances were barriers to practicing healthy behaviors.A: “High blood pressure and I think that was my doctor said it’s probably from the nerve from your job. That’s why I decided to separate my – no longer take my work home with me because I think that’s how I must have gotten it. But yeah, I have a high blood pressure. And I’m borderline diabetic but that runs in the family. Hopefully, I won’t get the disease but I probably will because most of the people in my family have gotten it.”A few key responses summarize the extent to which healthy eating was practiced, along with the rationale for practicing such self-care, such as coping with work because of how it spilled over into domestic life. For example, a female ancillary worker reported that she had hypertension and pre-diabetes. While this worker attributed her medical conditions to family history, more interestingly, her physician suggested they were likely from her “job”, suggesting that employment and working conditions were responsible for this metabolic syndrome component. Accordingly, in order to cope with this type of work-related stress, she reported that she stopped taking her “work home”. She also practiced healthy eating by making her own food from scratch:I: “Do you try to eat healthy?”A: “Oh yeah, I grow my own. I make everything from scratch. I don’t buy any processed food at all because processed food has sugar and it has salt in it. They’re both real bad for you. They have apple ingredients and half of those, they just have funny names for them. But it’s still the same thing. It’s salt and sugar. They just have fancy names for them that’s all. Just call a spade a spade. You don’t have to have 60 trillion names for it. So there’s people who don’t understand what the hell you’re talking about unless you happen to be a professor or a scientist that know all about the stuff. And I’m skinny.” .A: “I usually just go home and just have a cup of tea and just sit down and think about nice things. The work that I have to do at home. I like to cook and I like to garden […] every day I do my cooking. [name of family member] says, ‘Where are you going?’ ‘I’m going to go enjoy myself.’ ‘Oh, you’re going to cook.’The above participant went on to state that she would go home after work and have a cup of tea, possibly alluding to a relaxation strategy. As another health-conscious practice, she also grew her own food:I: “Oh, what about in the winter? If you’re not able to garden, what do you do if you’re not able to?”A: “Oh, I grow all my fruits – all my vegetables all year long. […] Like I have my green peppers, my green pepper tree I brought in from outside. It’s still growing. […] I enjoy it.” .“I’ve always been conditioned-- I guess to like – for exercise and stuff like that. Eating well, sleeping well. That to me is really important. So I make time for that. I sort of shifted my life with it though because now I go to bed super early and I wake up earlier so I get some school work done before I start here because I find it’s just easier for me to do rather than come home to do it because I’m tired.” .Another participant stated that she tried to eat healthy, but she admitted that she also ate junk food sometimes:“I am trying [to eat healthy] technically. I'm trying, because I can see, even me, I've never had any problem until 45, I ate anything I wanted, I did anything. But now, I need to watch [it…], but sometimes we're just eating some junk as well.” One quote demonstrates how some workers practiced self-care because they were conditioned to it, and they considered it to be important. For example a Trainee indicated that she engaged in regular physical activity, adequate sleep, and healthy eating habits because she considered them to be really important and; therefore, prioritized these things to the point where she shifted her life around them:Although the above participants indicated they ate somewhat health-consciously, a few indicated that they had income and budgeting challenges:“So it has extended over to where we live, it’s definitely the cost of living is astronomical, you’re going from – I had [dependents] also live with us, so we’re a family of four and groceries can be expensive, especially if you want to eat healthy, right” “I've tried to like eat like salad and like going to like the store to buy salad in a box. It's like so expensive. So sometimes, it's like, oh, I don't have the money for that right now. So yeah, it's expensive.” .One participant’s response succinctly summarizes how she was sometimes unable to eat healthy exclusively due to costs:A: “[T]he cost of living has gone up, and we haven’t gotten a raise in so many years. I don’t even know. I just -- I don’t even keep track. And it also makes a lot of people mad, because I started six years ago. They’ve worked here 20 years ago, and the pay is the same.” .One PSW attributed the inadequacy of the pay to the stagnation of wages and described the effect of this inadequacy upon the quality and variability in the food she was able to serve to her family. In particular, she gave an example of how junk food, such as a bag of fries, is easier and cheaper to purchase than healthy food, such as salad:A: “The other day, my kids were like, “Oh, mom. Chicken again?” “Well, chicken’s on sale right now. So yeah, that’s what you’re having.“ And I just try and differ it up a little bit. But yeah, for sure. It’s easier to buy a bag of fries than it is a whole salad. Salad’s expensive, but you do what you’ve got to do.” .The same participant went on to state:A: “So I work out with my friends like every three days.”I: “In the gym?”A: “Yeah, in the gym. We do like different [activities on different] days. So like Mondays, we would work on our stomach or something, and then Wednesday, our legs, and then -- and then, like, Friday, we just jog.” .Although a few participants did not participate in physical activity and attributed their thin physique to their metabolism, many routinely reported engaging in physical activity as a form of self-care. This was done in groups or individually. For instance, one worker stated in the interview that she engaged in regular exercise as a social activity with her friends:A: “I’m just going. I like classes. You don’t need to think and you don’t have time to think because it’s the music loud. Everyone jumping and someone, you don’t even… That is why I love classes because you are in, that is, what, 45 minutes, one hour, you are not thinking about anything. If there’s no classes, then treadmills is the other one. Whenever you’re running or you, or just sometimes I’m just listening a book. On my phone, I have books and then I listen and then I’m not thinking about something else [sic].” .Another worker indicated that she engaged in regular, vigorous exercise to clear her mind, and this was done in group sessions, such as in a class:A: “I’m really into music. […] I love music. I’m always listening to music -- when I walk to work, walk home. I swim, too. […] It’s really relaxing.” […] And I go for really long walks. Sometimes I’ll go for a walk for 3 h if I need to just clear my mind. […] I just find walking and listening to music is just a good way to clear your mind.”Another worker said she used walking, listening to music, and swimming as coping strategies to relax and destress herself, despite environmental barriers such as extremely cold weather conditions (which were the conditions in which the interview took place with this worker):I: “Okay. Even in the weather like --?”A: “Yeah. Yeah. […] I don’t mind. As long as I’m warm, I’m good.” .I: “And you’re on your feet all day. Are you able to -- you’re -- I’m guessing you’re very tired. Are you able to do any […] walking moderately or physical activity?”A Personal Support Worker (PSW) reported using exercise after waking up in the morning and before coming in to work:A: “Well, what I do in the morning, I get up and I do exercise. I exercise for 45 minutes. […] I do cardio. I have my exercise tapes, so -- and I do it three to four times a week. […] When I go on my break, I try to walk the stairs. But that’s -- sometimes the feet tired, so I forget that.” .A: “I mean, Monday to Friday I go to the gym. So, like, that’s […] That’s entertainment to me, I guess. That makes it seem like I don’t do anything during the week but it’s, like, my own choosing, right? […] Yeah, I weight train, Monday to Friday.” .One worker described regular exercise as a recreational activity which was pursued during the weekdays, and called it a form of entertainment:The data suggests that the LTC workers in the urban region of study typically reported consumption of healthy diet and participation in physical activity in order to influence their health and wellbeing. This study also supports evidence that physical activity participation also occurred in group or social settings, suggesting they are important factors for behavior modification.The findings reveal that the majority of front line health care workers, many of whom were racialized persons, immigrants, and/or women, relied on particular mechanisms for self-care such as healthy eating and exercise, including walking, yoga, swimming, and going to the gym. While the data suggests that participants routinely engaged in these activities, a few participants reported they did not do so, which was explained by cost-related barriers.The evidence from this study demonstrates several important points. Firstly, the findings shed light on under-researched areas of how workers engage with health-conscious behaviors in order to access their preferred health and wellness practices and maintain emotional health. This study also provides interesting perspectives as to what care workers perceived as healthy or unhealthy. For instance, processed foods, sugar, and salt were considered unhealthy by some participants while salad was considered healthy by others.Thirdly, the findings demonstrate that many of the workers must rely upon their own resources to achieve their optimal health and wellbeing, including costs. This is an important point because behavioral interventions are modulated by social and material circumstances which could otherwise impact morbidity and mortality . OccupatCanadian research suggests that (im)migrants, racialized populations, and women are vulnerable to poverty, illness, and diseases related to low income, psycho-social/ chronic stress, and socioeconomic status disparities , 47, 48), 4847, 4Given the above literature, the findings from this study contribute new information to interdisciplinary occupational health scholarship and contextualize health-conscious behavioral practices from one of the most highly intensive work environments and sectors of employment. The findings are important because the knowledge of personal health practices among workers could reflect resistance and resilience strategies, demonstrate how agency is expressed, as well as illuminating any barriers or limitations. It is increasingly recognized that work influences health and disease in a number of ways, including job-related factors such as income and wages, hours of work, work-load and stress levels, interactions with coworkers, access to paid or unpaid sick leave, and work environments, among other things, all of which impact not only the health and well-being of workers but also their families and communities , 47. ConWhile this study contributes new knowledge, more work can be done. For instance, there are a number of opportunities for further research, such as examining incomes, income distribution, and as well as factors that impact emotional health, such as reporting of workplace violence, or sleep hygiene. The latter two are important given the nature of Canadian LTC work, which is often carried out in shifts, and where exposures to workplace violence have also been reported. Research further suggests that work-related stress and workloads in the LTC sector can be overwhelming ; howeverIn order to improve management of care work, such as in the case of the LTC sector selected for this study, there needs to be commitment to total worker health and wellbeing, which involves the home, family, and community of the workers. While individual, behavioral factors were addressed in this study, it would be beyond the scope and scale of this study to investigate structural factors such as work organization, family, community, and social contexts; although these factors would be good starting points of further investigation for future studies.Furthermore, given the diversity of care workers in the region of study, such approaches would need to be culturally appropriate, and adequate supports must be provided to the workers. This means that not only do services and provisions need to exist, but they also need to be available, affordable, and accessible to the workers who require them. When such services and support systems are made available to workers, they can perform the work better, safely, with less of a personal toll on their health and wellbeing, and with better outcomes for the recipients of care. Additional approaches that would be beneficial if they were to be applied to this and other sectors of employment include: allocating limited resources for provisions of good, stable jobs; decent income; poverty-reduction strategies; and advocating the SDoH .Behaviour modification such as diet and physical activity are embedded in social, political, and economic realities. More research needs to be done to explore health behaviors in highly stressful occupations, while also advocating for holistic approaches that also improve social and material circumstances for workers. While biomedical interventions often reinforce medicalized, positivist solutions, such as diet, physical activity, and screening/surveillance of vulnerable workers, these interventions are limited unless they include integrated approaches. Workplace health promotion interventions should continue to implement occupational risk prevention; however, it is better if the interventions are participatory and inclusive of workers through a bottom-up approach as opposed to exclusively top-down approaches . Accordi


Schools are considered ideal venues to promote physical activity (PA) in children. However, a knowledge gap exists on how to adequately integrate PA into the school day and in particular, on the preferences of children regarding additional PA in school. Therefore, the aim of our qualitative study was to gain comprehensive insight into 10–13-year-old primary schoolchildren’s perspectives on how to increase PA in the school setting. We conducted nine focus groups (32 girls and 20 boys) with children attending the final two grades of primary school in the Netherlands. We used inductive thematic analysis to analyze the data. The results showed that children were enthusiastic about additional PA in school. Children suggested various ways to increase PA, including more time for PA in the existing curriculum, e.g., physical education (PE), recess, and occasional activities, such as field trips or sports days; school playground adaptation; improving the content of PE; and implementing short PA breaks and physically active academic lessons. Children emphasized variation and being given a voice in their PA participation as a prerequisite to keep PA enjoyable and interesting in the long term. Finally, children mentioned the role of the teacher and making efforts to accommodate all children and their different preferences as important. Children have concrete ideas, acknowledging the challenges that accompany integrating additional PA in school. We therefore recommend actively involving children in efforts to increase school-based PA and to make “additional PA in school” a shared project of teachers and students.  Although the numerous physical and mental health benefits of physical activity (PA) for children are scientifically well-documented ,2, many Because of their potential to reach many children, schools have been widely recognized as an ideal setting to contribute to raising children’s PA levels . To thisHowever, several systematic reviews concluded that school-based PA interventions often have only limited or short-term effects on children’s overall PA levels ,14. A poIn the past few years, several qualitative studies have investigated the perspectives of teachers and school administrators regarding primary school-based PA interventions . These studies identified a range of promising PA intervention components that were important according to primary school-aged children, such as providing new and fun activities, the use of technology, using rewards and incentives to encourage participation in PA, and providing opportunities to be active with friends ,30,31,32There is currently a lack of qualitative studies that focus specifically on PA opportunities in the primary school setting, and in particular involving the critical age group of 10–13 years, where, as mentioned above, PA tends to decline ,8. MoreoAdditionally, the sustainability of PA interventions remains a major challenge ,41. TherIn sum, for the development of attractive and effective PA interventions in primary school, more knowledge of the perspectives, needs, and wishes of children is needed. To the best of our knowledge, no qualitative studies have explicitly and comprehensively explored the multi-faceted ideas of 10–13-year-old children regarding increasing PA in the primary school setting. Therefore, the aim of our study was to: (1) explore 10–13-year-old primary schoolchildren’s perspectives on incorporating additional PA into the school day, in particular what practical ideas children have to be more physically active in school and what they think is important to successfully implement these ideas; and (2) to investigate children’s views on how to keep the proposed activities and ideas interesting and fun for a longer period of time. The results of this study can inform both research and practice regarding the development and implementation of future PA interventions aimed at 10–13-year-old children.We conducted a qualitative study, employing focus group interviews with 10–13-year-old children in the last two years of primary school in the Netherlands, i.e., in grades 5, 6, or combined 5/6. Focus groups are an effective method to explore the ideas and perspectives of children ,46. By iIn the Netherlands, children aged 4 to 12 attend primary school (2 years of pre-school followed by grades 1 to 6). On average, children participate in an hour and a half of PE per week. There are no legal provisions issued by the government on the amount of PE that should be provided, but the guideline of the Ministry of Education, Culture and Science prescribes at least two to three lessons of PE per week. PE should either be taught by classroom teachers with a qualification for PE, or a PE specialist . Schoolsn = 9), an overload of research requests (n = 3), or without a specific reason (n = 10). Four schools (9%) agreed to participate.We used a purposive sampling method  to recruAfter a school decided to participate, children in grades 5, 6, and 5/6, and their parents and/or caregivers received an information letter including information on the aim and procedures of the study, and an informed consent form. In order to include perspectives of children with different PA levels in each focus group, we asked parents to fill out a short questionnaire. The questionnaire contained three questions on their child’s PA behavior: (1) sports participation: yes/no; (2) hours of sports participation per week; and (3) hours spent in other PA per week, such as outdoor play and active gaming. We used this information to compose the focus groups (see below). For participation in the focus groups, at least one parent/caregiver and children older than twelve had to sign informed consent. Children received a small present  for their participation afterwards. The Medical Ethical Committee of the VU University Medical Center Amsterdam approved the study protocol (2014.363).Group sizes of four to eight children allow for a manageable, active discussion, and have been recommended in focus group research with children ,55. In aThe focus group interview guide can be found in We developed a protocol and pilot-tested the focus group guide with a group of six boys and a group of six girls from a school that was not included in this study. Based on the feedback of the children and our own experiences, we adapted some instructions and the order of the two warm-up questions. The pilot confirmed that all questions could be answered within 45 to 60 min, which is an optimal duration when conducting focus groups with 10–14-year-olds  would be nice”  4). A few children expressed mixed feelings, stating that, “I think we’re doing enough physical activity in school already” , or that it would depend on the type of extra PA provided. One boy explained that he did not like PA per se, but that he preferred PA over working on school tasks.Generally, children displayed a positive attitude towards additional PA during the school day, stating that it would be “fun” or even “super fun” to be more physically active in school. They also mentioned being dissatisfied with the current amount of PA provided, for example, “physical health benefits. Most children acknowledged that PA is good “for your body, to stay healthy” , in particular with regard to physical fitness, maintaining a healthy body weight and strengthening the muscles. Second, children discussed the emotional benefits of PA. In the majority of focus groups, children reported that being active is fun and can make you feel better: “I feel happier and have more energy” . Likewise, they mentioned that PA can be used as a stress reliever after a test. The children mentioned three important reasons for additional PA in school. First, in all focus groups, children discussed the importance of PA for achieving cognitive benefits, i.e., improving their ability to focus and/or learn in school: “You can concentrate better, so it might also help to improve your grades” . Relatedly, children expressed the need to regularly alternate time spent on academic learning with time being physically active. Children explained that they get distracted, bored, or restless with pent-up energy after long periods of uninterrupted sitting and working on school tasks: “Then, for example, you have arithmetic, languages, and spelling right after each other, and then you get a little impatient and you really want to move” . They believed that PA could serve as a break and recharge opportunity: “You get re-energized” , which helps them to stay motivated and focused during lessons. However, one girl also stated that being active works in a counterproductive manner and distracts her from work.Lastly, in all but three focus groups, children believed that PA could possibly lead to Children had many ideas on how to incorporate additional PA in school, concerning: (1) different PA opportunities, (2) frequency and duration, (3) variation, and (4) location of PA.Different opportunities for additional PA: Children saw opportunities to increase PA time in different parts of the curriculum: during classroom time, recess, physical education (PE), and occasional (outdoor) school activities. In addition, children proposed other ideas, such as the establishment of a child PA committee and possibilities to cut back on academic lesson time in favor of PA. In Frequency and duration of PA: Children did not agree on how long and how often they would like to engage in additional PA opportunities. Concerning the implementation of regular PA breaks, most children agreed on keeping them short, i.e., up to ten minutes. Additionally, in five focus groups children underlined that not too much time should be spent on additional PA, since there has to be enough time left to do school work: “Yeah because the work still needs to get done” .Variation: The majority of children emphasized that providing variation is an effective way to make  PA fun, while it also keeps them motivated to participate in PA throughout the school year. Children suggested implementing variation in different ways. First of all, repeating the same activities too often was deemed boring and could negatively impact participation: “I don’t like tennis or badminton very much and if we have to do that five weeks in a row, I won’t really put much effort in taking part” . Children discussed the idea of alternating different activities , and activity types . In addition, some children indicated that they would enjoy trying out new activities regularly, for example alternating PE classes with workshops or clinics where they are taught a new sport. Second, children highlighted the importance of regularly replacing and/or expanding the supply of playing equipment in PE and at recess, both because of wear and tear and because “after a while, it feels like old news” . Providing variation by purchasing new playing materials and improving the playground facilities  to moving regular indoor activities outdoors .I like it when we get to choose activities ourselves” . According to the children, this could either be achieved by presenting them a range of options to choose from or by letting them think up their own games or activity program, such as preparing a PE class or, in the case of girls, preparing an academic lesson involving PA. Also, girls specifically mentioned that doing self-invented activities can prevent PA from becoming boring in the long run. However, children also expressed concerns about the school being receptive to their ideas, “Yeah, but the school always has the last word anyway, no matter what we think” .Children indicated that they valued having a voice in their PA participation as they emphasized that they would like to have the opportunity to choose the kind of PA that they themselves prefer. For example, one boy said, “I don’t like that because then I won’t know what to do” . Moreover, it might actually hamper variation: “If you’re allowed to choose every time, then I think people will choose the same thing over and over” . In this respect, two girls suggested providing a box of cards with different games and activities to choose from, which could, for example, be used during recess. Furthermore, some children felt that teachers and supervisors could stimulate them being active by helping them think up fun activities and games. Children also discussed some drawbacks of freedom of choice as some found it difficult to come up with activities themselves. For example, one boy did not prefer so-called “free” PE lessons in which children get to choose their own activities: “Yeah, the teacher should encourage you a little bit, so you won’t just sit on the sidelines and do nothing”. #7: “Yeah, like the teacher should say ‘come on, you can do it’” . In some cases, children thought it could be motivating when the teacher joins the activities; however, this depended strongly on whether the teacher is considered “fun.” Children were clear that teachers who are considered grumpy or too strict should not join. Although some children thought that they would not need much guidance from teachers in executing their ideas for additional PA, others deemed supervision necessary to ensure that PA is safe and enjoyable, in particular to prevent rough play and arguments, and to make sure everyone knows and abides by the rules. According to the children, teachers and supervisors should actively and enthusiastically encourage them to engage in PA: #8: “With teacher X, we get to move around every once in a while, but never with teacher Y.” , or “Teacher X is more into gardening and being physically active, while teacher Y focuses more on teaching the subjects” . One boy reported that in his class, children who are behind on schoolwork occasionally have to finish their work at the cost of recess time. In other cases, earlier PA routines implemented by teachers seem to have been forgotten along the way: #6: “Yes and then we made up these little dances”. #4: “Yeah we used to do that every other lesson”. #6: “Right, but now the teacher kind of…also because we’ve had the holidays…she kind of forgot about it” . It appeared that the priority given to PA depends strongly on the teacher. Many children mentioned that they have regular PA breaks or extra recess time with certain teachers, but not with others: “Perceived differences in preferences between children: Children perceived several differences between children that may influence participation in school-based PA. First, several children mentioned gender differences. For example, one boy observed that girls always tend to choose dancing activities (such as Just Dance TM), which, according to him, demotivates boys to be physically active: “Then we’re not enjoying it, and instead we’ll sit down and not move at all” . Another boy believed that girls generally prefer talking over being physically active during recess. Both boys and girls mentioned that boys tend to play more roughly, which may be off-putting for girls who want to join. age differences. For example, boys in one focus group perceived the school sports day as “boring” and “not challenging” because they had to do the same activities as the younger children. In addition, several children indicated that children in the lower grades get allotted more recess/playing time, and that the playground equipment is not sufficiently tailored to older children: “Nowadays, all the sports equipment is made for small children” . Second, children mentioned differences in skill levels also influence PA participation, as occurs to this girl when talking about making PE more challenging, “Yeah, [PE] could be more challenging, but it shouldn’t be made too difficult because some children might not be able to keep up” . Third, children perceived that active and non-active children, “Some people just prefer sitting on their chair” . Lastly, some children observed differences between Overcoming the differences between children in relation to PA participation: Children discussed that due to above-mentioned differences, it may be difficult to satisfy everyone when it comes to additional PA in school. Although some children did not necessarily experience this as a problem—“Yeah but there will always be something that somebody doesn’t like” —many others emphasized the importance of “keeping it fun for everybody” . In most focus groups, children discussed efforts that should be made to make sure that all children (want to) participate. Without necessarily agreeing on one best option, they proposed several potential strategies to take into account children’s different needs and preferences. allowing children to choose their own activities, or to choose from a range of options which increases the chance of everyone finding something that fits their interest. In this respect, some children suggested organizing separate activities and/or providing different equipment for girls and boys and for children with diverse skill levels .Second, a couple of children suggested positive reinforcement. Girls suggested that children or teachers could try to encourage hesitant children to join in games during recess or offer them a reward as an incentive to participate: “Maybe they can be allowed to do something else afterwards, like drawing” . In one focus group, boys indicated that it would be important that teachers provide a rationale for  PA: #4: “Well, teachers should stimulate [PA] more and also explain the purpose of it […] because some children ask themselves, why are we doing this?”. #1: “Yeah, why should you be active?” . Finally, a few girls pointed at the benefits of habituation: “No you should just let him participate and in the end he might learn to like it because he’s done it so often” . Therefore, they considered it important that children are willing try out new activities that are chosen by others. A third line of thinking in some focus groups with girls concerned employing Lastly, children mentioned several external barriers and facilitators that may influence the implementation of  PA in school.Weather: The weather was mentioned as an important determinant of  PA time. One boy indicated that they are often kept inside during recess when it rains: “Usually when it rains we don’t go outside but stay in and watch a video or film or something” . Another girl remarked that the school sports day had recently been cancelled twice due to bad weather. As a solution, two boys proposed to catch up lost recess time later, and to buy adequate outdoor boots for everyone. Conversely, children mentioned that when the weather is good, they sometimes get extra PA time outdoors, such as playing games in the nearby park. Current school policies: Children also gave examples of school policies that impede being active in school. For instance, they mentioned that some areas that offer opportunities to be physically active, such as the bushes, the lawn, and access to equipment in the shed, are restricted to them. In one focus group (FG7) children mentioned that they do not have recess on Wednesday since they already have PE that day. Lack of space and resources: Children recognized and discussed that carrying out some of their ideas for extra PA would require considerable planning and organization because of limited space and resources in the school. Therefore, they suggested to keep group sizes manageable, implement activity timetables , and build multi-functional exercise facilities, such as a soccer field that serves as an ice-skating rink in winter. Costs: The children were also very conscious of the monetary costs connected to their PA ideas, and therefore designated some ideas as not feasible in advance, e.g., weekly school outings that cost money or buying gaming consoles for everyone. As a solution to financial barriers, children suggested organizing a charity run or fundraising activity to raise money, for example, to buy new playground equipment or materials.To the best of our knowledge, this is the first study that comprehensively explored the views and needs of 10–13-year-old children to increase PA opportunities in the broader primary school setting. Children provided various ideas for additional PA and discussed important factors that need to be taken into account when developing feasible, enjoyable, and sustainable school-based PA programs. In line with the socio-ecological model , childreDespite the fact that children with different activity levels participated in each focus group, almost all children in our study were enthusiastic about additional PA in school, which is in line with earlier research showing that many children and young people generally enjoy participating in PA , and wanTo date, however, recommendations to increase school-based PA have often targeted increasing knowledge on the long-term health benefits of PA . It mighAlthough almost all children acknowledged the importance of PA and showed a positive attitude towards additional PA in school, there appeared to be a gap between “willing” and “having the opportunity” to participate in  PA in school. In line with the findings of a systematic review of Morton et al (2016) focusing on adolescents , childreChildren mentioned several factors that are, according to them, important to stay motivated to participate in PA. We will now highlight the major themes that emerged. Children stressed the importance of involving them and giving them voices when it comes to additional PA in school. Children particularly recognized motivational benefits of student participation in relation to durable PA interventions, as they indicated that involving them in choosing and inventing activities will motivate them to sustain in PA participation in the long run. This finding can be explained using the self-determination theory, which postulates that three basic psychological needs  need to be fulfilled in order to have children intrinsically motivated to engage and sustain in a health behaviour such as PA ,76. WithOn the other hand, children also indicated a need for guidance in their PA choices as they suggested that teachers can help them in choosing or designing PA activities. This aligns with the finding that, to successfully implement educational innovations and school health promotion programs, co-creation with all stakeholders is recommended, leading to increased ownership of the intervention in both students and teachers ,77,78. MOur results indicate that 10- to 13-year-old children are very capable of inventing solutions to perceived barriers . Hence, it seems of considerable value to involve children actively and make “additional PA in school” a shared project of teachers and children. One specific way in which to increase student participation in school-based PA could be establishing a child-PA-committee, as suggested by some boys in our study. Lastly, children considered variation not only important to make PA enjoyable see , but alsIn line with earlier research on PA promotion in general , children in our study reported several factors that are important to make school-based PA enjoyable, such as variation ,43,66,79Many of the children’s suggestions centered around expanding time of the existing PA curriculum, such as increasing the duration and frequency of PE, recess, and occasional activities . These findings confirm the results of earlier studies and reflect the need of children to be more physically active during school time ,73,82. HAdditionally, children had various ideas for additional PA in school that seem relatively easy to realize in daily school practice. For instance, children indicated that more effective PA time could be achieved during current PE lessons, for example by playing music to stimulate movement during waiting times, by providing short activities in between exercises/games, or by providing exercises with different intensity levels for children that need more of a challenge. Likewise, providing children with activities during recess could also stimulate them to be (more) physically active. These suggestions all appear within the control of a (PE) teacher to realize and can therefore be relatively easily implemented. In the case of the Netherlands, PE is often taught by classroom teachers instead of PE specialists, which could potentially hamper the delivery of quality PE . InvestiAnother suggested form of feasible additional PA was PA in the classroom, either in the form of short exercise breaks  or physically active academic lessons (only suggested by girls). Children preferred to have the exercise breaks in between lessons, which aligns with their need to regularly alternate working on school tasks with being active. Children’s suggestions for classroom-based PA are in line with forms of PA that teachers and principals consider most feasible in school, i.e., short exercise breaks of 5 to 10 minutes ,85 or acAlso, worthwhile reporting is the apparent contradiction between children’s need for “tailored PA” and “including everyone in PA.” On the one hand, children indicated the importance of taking into account their individual needs and preferences, while on the other hand they emphasized that efforts must be made to make sure that all children can participate in additional PA in school. Related to the first, earlier studies have repeatedly recommended developing individually tailored PA programs ,41,43,65Although children emphasized the importance of taking into account individual preferences, another new finding of this study is that they also indicated that it is fine to perform PA activities that they consider less fun, as long as everyone’s preferences are represented once in a while. As such, it seems important for future research to invest more in active engagement/participation of children when developing PA programs ,77,78. IOur study has several strengths. First, we used children’s views as the starting point and children were not restricted by researchers’ preconceived notions, resulting in an in-depth and comprehensive exploration of children’s perceptions of additional PA in the primary school setting. Second, we included a task-based activity, resulting in a broad representation of different viewpoints and opinions. Third, we included schools in both regional and urban areas of the Netherlands, and made efforts to include children with different PA levels in each focus group to avoid selection bias. Fourth, by including our interview guide and an extensive audit trail, we provide trustworthiness and transparency in the data collection and analysis process. Our study also has some limitations. First, due to the nature of qualitative research, our findings may have limited generalizability, for example, to other school systems and to children with other cultural backgrounds (most children were of Dutch origin). Moreover, we have to keep in mind that each school has its own context, which influences children’s ideas regarding PA opportunities in their particular school. Second, although we included children with different activity levels, it is possible that more children who were already enthusiastic about PA signed up to participate. A third potential limitation is that we started the data analysis after data collection was concluded, which prevented ad hoc adjustments to the interview protocol. However, we pilot-tested the interview guide beforehand. Fourth, one focus group included eight girls and was difficult to moderate. This could have inhibited some girls to express their opinions. Lastly, we aimed to collaborate with two interns of an external institution, but unfortunately, we noticed that they did not follow the interview protocol. Therefore, we decided not to use data from these two focus groups. Although the interns wrote their internship report on this data, we could not fully avoid research waste. Nevertheless, we reached saturation with the available focus groups.In general, primary schoolchildren who participated in this focus group study would welcome additional PA opportunities in school and expressed a desire to be more physically active during the school day. Schools and researchers should capitalize on this enthusiasm when developing PA programs, while the child-perceived beneficial practice-based effects of additional PA, such as restored attention in the classroom, warrant further investigation. Children in this study suggested various ways to increase PA in school, of which finding ways to improve effective PE time and providing short activity breaks in between lessons seem relatively easy to implement in daily school practice. Future research could provide further insight into whether including the child-identified suggestions are indeed effective in structurally raising their PA levels. Furthermore, children perceived choice and variation as important for keeping the PA options attractive in the long term and identified teachers as both a key barrier and facilitator of PA participation. We therefore recommend actively involving children in efforts to increase school-based PA and to make “additional PA in school” a shared project of teachers and students. Overall, our study provides a comprehensive overview of children’s voices regarding additional PA in school, which could be used to inform the development of future PA interventions aimed at increasing the activity levels of children in primary school. To ensure relevance to local contexts, it is important that these strategies include the involvement of children, teachers, and other key stakeholders.


Adherence to osteoporosis treatment is crucial for good treatment effects. However, adherence has been shown to be poor and a substantial part of the patients don’t even initiate treatment. This study aimed to gain insight into the considerations of both osteoporosis patients and general practitioners (GP) concerning intentional non-initiation of bisphosphonate treatment.Osteoporosis patients and GPs were recruited from the SALT Osteoporosis Study and a transmural fracture liaison service, both carried out in the Netherlands. Using questionnaires, we identified non-starters and starters of bisphosphonate treatment. Semi-structured interviews were conducted to gain a detailed overview of all considerations until saturation of the data was reached. Starters were asked to reflect on the considerations that were brought forward by the non-starters. Interviews were open coded and the codes were classified into main themes and subthemes using an inductive approach.16 non-starters, 10 starters, and 13 GPs were interviewed. We identified three main themes: insufficient medical advice, attitudes towards medication use including concerns about side effects, and disease awareness. From patients’ as well as GPs’ perspective, insufficient or ambiguous information from the GP influenced the decision of the non-starters to not start bisphosphonates. In contrast, starters were either properly informed, or they collected information themselves. Patients’ aversion towards medication, fear of side effects, and a low risk perception also contributed to not starting the medication, whereas starters were aware of their fracture risk and were confident of the outcome of the treatment. Concerns about osteoporosis treatment and its side effects were also expressed by several GPs. Some GPs appeared to have a limited understanding of the current osteoporosis guidelines and the indications for treatment.Many reasons we found for not starting bisphosphonate treatment were related to the patients or the GPs themselves being insufficiently informed. Attitudes of the GPs were shown to play a role in the decision of patients not to start treatment. Interventions need to be developed that are aimed at GPs, and at education of patients.The online version of this article (10.1186/s12875-018-0828-0) contains supplementary material, which is available to authorized users. Osteoporosis is a condition that affects 1.9 per 1000 men and 16.1 per 1000 women in the Netherlands . FracturOsteoporosis can be treated with bone-sparing drugs. Bisphosphonates inhibit bone resorption, thereby reducing the risk of future fractures , 6. The The process of adherence involves initiation, implementation, and continuation of medication use. Non-adherence can be the result of late or non-starting of the treatment, sub-optimal implementation of the prescribed dosing scheme, and/or early discontinuation of the treatment . The reaAbout 30% of osteoporosis patients do not start their prescribed medication . UnderstWe carried out a qualitative study in which we performed semi-structured interviews, based on thematic analysis with elements of grounded theory . We inteParticipants were recruited from a fracture prevention study and an ongoing fracture liaison service in the Netherlands. The common denominator of both is that the fracture risk assessment is centrally organised after which the GP receives the results of the evaluation and a treatment advice provided by an expert panel. From that point on, the GP is responsible for the initiation of treatment and for monitoring of the patient.T < − 2.5) or prevalent vertebral fracture. Therefore, more patients have an indication for bisphosphonate treatment in the SOS than in usual care. Treatment initiation was documented as part of the study by the GP. Non-starters received a written request to participate in our qualitative interview via the GP and were approached for an interview if they indicated to be willing to participate.First, patients were recruited from the SALT Osteoporosis Study (SOS) . The SOSSecondly, patients were recruited from a transmural fracture liaison service located in the Onze Lieve Vrouwe Gasthuis hospital in Amsterdam, the Netherlands. In this fracture liaison service, the GP has a central role in initiating osteoporosis screening and initiating and monitoring subsequent treatment. The service is offered to all patients aged 50 years or older who come to the emergency department of the Onze Lieve Vrouwe Gasthuis hospital with a fracture. In consultation with the GP, patients undergo an evaluation program, including dual x-ray absorptiometry and vertebral assessment. Evaluations and treatment advices are the responsibility of an expert team. Patients identified with a high fracture risk according to the Dutch guidelines for GPs have an indication for treatment with bisphosphonates. Accordingly, the GP initiates treatment. For this study, patients received a questionnaire several months after their visit to the fracture liaison service, in which we inquired whether treatment with bisphosphonates was initiated.Non-starters were contacted with the request for an interview. We also contacted patients for an interview who indicated to have started and continued the treatment (starters). Furthermore, we contacted the GPs of the non-starters, and asked them for an interview. Not all GPs of the interviewed patients of this study were willing to participate in an interview. We therefore contacted additional GPs from the groups of GPs participating in the SOS study who had patients who had not started bisphosphonate treatment.The interviews with the patients were conducted face-to-face, at the patients’ home. Prior to the interview, there was no relationship between the patient and the interviewer. Before the start of the actual interview, the purpose of the interview was explained, as well as the procedure . Semi-structured interviews were performed using a topic list , three GPs in training  and three medical students  carried out the interviews between March 2013 and September 2016. Training of the interviewers involved practice interviews plus evaluation with the principle investigator (PE). In order to ensure optimal quality of the interviews, all interviews were analysed on content as well as competence of the interviewing techniques and discussed with the interviewer before a new interview could be performed.The interviews were audio-recorded and transcribed verbatim. Transcripts were not returned to the participants for comments or corrections. The transcripts of the patient interviews were coded using the Atlas-ti qualitative data analysis software package, and the interviews with GPs were coded in Microsoft Excel 2007. Inductive analyses were performed. The interviews were analysed independently by two researchers . After individual coding of the interviews, the analyses were compared and discussed until consensus was reached. Disagreements were discussed with the principal investigator (PE), who also ensured the consistency of analysis method. The interviews were open-coded in the same order as the interviews were performed. The goal of open coding was to identify all aspects of the text that related to the research question. The labels of the open codes represented the text as closely as possible. In addition, these open codes were classified into main themes and subthemes. After each interview, the interview was analysed to find new themes. When there were no new themes after two subsequent interviews, we concluded that saturation was reached and ceased the interviews. The interviews of the starters were analysed to evaluated whether the reasons of non-starters were also expressed by starters, or whether they were refuted by starters.One patient was excluded because she was sure that her GP had advised her not to start treatment. We reached saturation of data after we interviewed 16 non-starters, 13 GPs, and 10 starters. Mean age of the patients was 76.3 years, 22 out of the 26 patients were female, and 10 out of 26 patients were recruited from the fracture liaison service. Of the non-starters, only 8 had had a previous fracture, whereas all starters had a previous fracture. Among the patients without a previous fracture, one patient was identified with a vertebral fracture despite normal BMD. The mean duration of the interviews was 28:52 min for non-starters, 14:13 min for GPs and 11:12 min for starters. After analysis, we identified three main themes in the considerations patients and GPs had for not starting bisphosphonate treatment. These three themes, with subthemes, are described below.I read about osteoporosis and its treatment before the consultation” and “a GP knows what he talks about. If he gives me advice, I follow it”.Non-starters’ knowledge on osteoporosis medication was limited: most of the non-starters did not know how bisphosphonates work. Many non-starters said that they had expected to have been given more information by the GP. Starters were either well informed and had been actively seeking information themselves, or they were rather passive and followed the instructions from their GP: “I would like to know to what extent I have it, whether it is really severe”. One non-starter mentioned that her impression was that the GP did not understand the explanation herself. Many non-starters felt their GP easily accepted their decision and thereby approved their decision. As one non-starter pointed out: “And what did your GP tell you? Well, he said, if you do not want to take the medication, that’s fine, it’s up to you”. Furthermore, non-starters indicated that their GP gave mixed signals concerning whether or not to start with bisphosphonate treatment. Some non-starters said that some GPs in the end agreed with them to not start using bisphosphonates. As one non-starter explained: “He (the GP) said, honestly, I don’t think it’s necessary for you to take the medication, I have forgotten why you should take the medication, because he said, you are a bit on the verge”. These issues were not recognized by the starters.Several non-starters reported that they had not fully understood the information: “Uhm, I have talked about my doubts concerning this intervention towards my patient, yes”. The GPs sometimes did not question the decision of their patient not to start with the medication. The GPs gave the argument that they wish to respect the self-determination of the patient, and therefore, they would not go against the decision of their patient. Some GPs mentioned they felt unable to redirect the decision.Some GPs acknowledged that risks and details were not fully discussed during the consultation and that in some cases, the patient made a decision based on too little information. Time constraints were mentioned as reason. Some GPs mentioned to have provided mixed signals concerning treatment: “This is what I expected, so I thought to myself, I’m not going to put too much energy in this”, or “It makes no sense, she will stop anyway. I mean, whatever I prescribe her she will just quit”.GPs indicated that the decision of the patient fitted with the GPs’ impression of the patients’ beliefs concerning healthcare. One GP pointed out: “The theme medication concerns attitude towards preventive medication in general, attitude towards osteoporosis treatment, and side effects.I just don’t like pills, I think it’s all poison”. Some non-starters only want to take medication that it is absolutely necessary: “I think when you really need it, when something is life threatening, I would be okay with it”. The starters, in general, did not express an aversion against medication, although some starters were also critical about any medication they take. Some non-starters felt confident about their own health and had a preference for lifestyle interventions: “I believe in my own healthy lifestyle”. Some of them also pointed out that they had a fear for side effects in general, or a distrust in the pharmaceutical industry: “I am always afraid of side effects”, and “There is a commercial aspect related to the pharmaceutical industry, I mean profit seeking”. Starters did not express a real aversion in the pharmaceutical industry. With respect to treatment duration one starter mentioned: “I have a healthy distrust in the pharmaceutical industry. So I think that I would have checked this (the treatment duration) in due time”.Many non-starters indicated that they have an aversion against medication in general, and that they would rather not take any medicine: “I doubt every form of preventive research or preventive treatment”.Some GPs mentioned that they have an aversion against preventive medicine in general: “And my mom, who had terrible osteoporosis, she had to take a lot of stuff. She still had to get a new hip and new knee, despite all the medication”. In contrast, starters generally trusted the treatment advice they received from their GP, and expressed no distrust in the effectiveness of osteoporosis medication: “Before the GP called me, I was already convinced that I would start using the medication”, and: “With this medication, you can really prevent something”. Furthermore, some starters expressed a positive attitude towards treatment: “It is what it is. But luckily, there is treatment available”.Many non-starters were unsure about the effectiveness of osteoporosis medication: “Well, the period between taking the medication and eating is really too long for me”, and “The only thing I did was starting to take calcium and those vitamins”. Some starters acknowledged that the intake of bisphosphonates is not very practical, but they got used to it, and did not see the intake instructions as a reason not to start with treatment: “It took a lot of effort to get into the rhythm to start using the medication”.Many non-starters felt the intake instructions would result in practical problems, and they therefore preferred to take other medication such as calcium and vitamin D: “I think all that osteoporosis, it’s very vague if I’m honest. What is meaningful, and what is not. The vitamin D, I also think that’s a difficult subject”. Some GPs indicated that they were ambiguous about bisphosphonate treatment and its indication. “If it’s evident a patient has osteoporosis, then you can choose to protect them, but I think the indication to treat patients is more and more expanded”.Some GPs also doubted the effectiveness of osteoporosis treatment. One GP described: “I thought, I don’t want those side effects, I already have fatigue, and I think I don’t have a very strong stomach”, whereas starters had no fear for side effects before starting the medication: “The information leaflet is miserable, but I just put it aside and just trust the medication”. Several non-starters indicated that side effects experienced by relatives or friends influenced their decision not to start bisphosphonate treatment. One non-starter explained: “I know that my cousins, my sisters, all could not endure that stuff”. Another non-starter recalled: “A friend of mine, she started a year ago. After the first box she said, I will stop with this mess, I’m not doing it any longer! She was done with it. She felt uncomfortable, so you have to take something that makes you feel bad, and you don’t sense that your bones are weak. Why would you take it?”Many non-starters expressed fear concerning the possible side effects of bisphosphonate treatment: “My idea was, those bisphosphonates are not going to work, she cannot handle that anyway. She always has complaints of her stomach and oesophagus”, and “To give her bisphosphonates intravenously is also not going to work, because then she will feel sick for a year and I will be blamed for it”. Furthermore, some GPs thought that some patients are more prone to experience side effects: “she asked me about the side effects of bisphosphonates. I told her. Then we both thought, this is going to be a mess, we should not do this”.Some GPs agreed with the concern of possible side effects, and expected side effects to occur with specific patients: “This theme refers to the awareness of illness, prioritizing diseases, and risk acceptance.I thought about the facture risk in 5 or 10 years: there would be a risk, but in my opinion that was not enough to start taking medication”. The starters were more aware of the risks of osteoporosis than non-starters: “It shocked me that I had osteoporosis, I realised that something was wrong”. Many non-starters indicated that they trusted their own health, and that they did not believe their diagnosis: “I think I have pretty solid bones”, and “I am not convinced that I am at a higher risk than anyone else”. Non-starters who had a fracture after a fall, did not link their fracture to osteoporosis: “I broke my arm, my elbow, but then I had fallen from my bike. I think that even a 6-year old child with strong bones would have broken their elbow”. Several starters, however, acknowledged that fractures they had experienced could be the consequence of osteoporosis and not just from an accident: “I suspected that something could be wrong. If you experience two fractures within 10 years, then something is probably wrong”. Some non-starters without fractures thought the absence of fractures was a proof of good bone health: “I don’t think I have it, well at least not very bad, because I have never had a fracture”.We observed a low risk perception in many non-starters. As one patient recalled: “The problem is not the treatment, but the diagnosis. She had a completely normal DXA result, and normal vitamin D levels. The only reason she got the diagnosis was that het risk for fractures was high was because she got a thoracic fracture due to a fall”. This GP apparently did not know that a vertebral fracture is a very important risk factor for new fractures and an indication for bisphosphonates that is independent of bone mineral density results.GPs were not always aware of the guidelines, and therefore an increased fracture risk was not always recognized. As one GP recalled: “And then I got the diagnosis of breast cancer, so then the conversation about osteoporosis stopped”. The issue of prioritizing other diseases did not come up among the starters. They were more aware of their risk than non-starters and thought it was important to prevent subsequent fractures.Some non-starters expressed that they prioritized other diseases they had, and that osteoporosis treatment therefore became less important: “I thought it was much more important that she took her thyroid tablets, and she is not taking them. And that she took her acenocoumarol”.Some GPs prioritized other diseases as well: “I don’t think osteoporosis is a disease, it’s just a part of getting older”. In contrast, starters did not accept osteoporosis as just a part of getting older: “Do you think osteoporosis is a part of getting older? Well, yes it is. But to me that is not a reason to just accept it if there are good treatment options available for it”. Also, some non-starters rather accepted the risks and consequences of osteoporosis. As one non-starter described: “I just take the risk to fall, then we will see what happens”. The starters were not willing to accept the risk of a fracture: “I thought, I am not going to take the risk that I will get another fracture”. One starter also expressed: “Being careful is always a good idea. But that does not mean you do not have to make sure your bones are as strong as possible. An accident can happen any time” . A few non-starters indicated that they just felt too old to start osteoporosis treatment: “I am 70 now, so how much longer do I have?”Some non-starters indicated that they feel osteoporosis is related to aging: “So yes, the quality of life at this moment is more important than the probable prevention of fractures”.Also some GPs accepted the consequences of osteoporosis. One GP mentioned: “In this study, we analysed considerations of patients as well as GPs about not starting with osteoporosis treatment, despite an indication for treatment. Using semi-structured interviews, we found that these considerations focused on three main themes: medical advice, attitudes towards medication use, and disease awareness. For non-starters, insufficient information and the attitude of the GP, aversion of medication, fear of side effects, and a low risk perception contributed to non-starting their prescribed medication. Starters indicated to be properly informed, or they collected information themselves. They were aware of their fracture risk and were confident in the outcome of the treatment. For GPs, concerns about the effectiveness of osteoporosis treatment or its side effects were important considerations for not prescribing osteoporosis medication. Attitudes of the GPs were shown to play a role in the decision of patients not to start treatment.To our knowledge, there are four studies available in which the reasons patients have for not starting bisphosphonate treatment were examined. Fear of side effects was reported as a primary reason for not starting with the medication in three of the studies , 15, 17.The currently identified considerations for non-initiation of osteoporosis treatment are very similar to previously identified considerations for non-adherence in general. Survey studies showed side effects as the most commonly reported reason to stop, but also concerns about the potential harms and motivational problems have been shown to be important . A previIn our study we explored the role of the GP in the decision about whether or not to start using osteoporosis medication. The quality of the medical consultation might be related to patient outcomes . ConfideA strength of our study is that we performed qualitative research into considerations for not starting bisphosphonate treatment. By performing semi-structured interviews, we could generate a detailed overview of considerations, which we could not have generated if we had used quantitative data only. Besides interviewing patients who did not start treatment, we also interviewed patients who had started, and GPs of non-starters. By doing so, we were able to explore the role of the GP in starting treatment, and to analyse whether patients who did start treatment had the same or other considerations for starting treatment. Furthermore, we were able to include patients from whom the GP had not prescribed medication during consultation, but who had an indication for treatment. These patients would have been missed if non-starters would have been identified by pharmacies.However, because of the qualitative nature of this study, our results need to be interpreted with caution and need to be confirmed in a large and non-selective sample. The study population was a self-selected population who joined either the Dutch SOS study, or were selected via a fracture liaison service. Therefore the results might not be applicable to other populations, or patients from secondary care. What additionally might have influenced our results is that there were more patients who had experienced a fracture in the sample of starters than in the sample of non-starters. This might have led to more focus on illness awareness among the starters. On the other hand, they might have been more motivated to start medication in order to prevent a next fracture. Other limitations are the relatively large number of interviewers, and the possibility that GPs mentioned other reasons behind their reluctance to prescribe to account for their behaviour.Previous interventions to improve medication adherence were mainly patient-focussed . Our stuIn conclusion, our comprehensive qualitative study examined the considerations of both osteoporosis patients and GPs concerning intentional non-initiation of bisphosphonate treatment. Most of the factors of non-initiation were comparable to the factors that play a role in non-adherence in general. New was the way patients describe that the GP had influenced their decision, either by giving the impression that they legitimized their decision, by showing doubt, or by having insufficient knowledge. It was shown that the content of medical advice of GPs to patients and their attitudes towards medication use were primary factors. Our findings suggest that primary care might be improved by increasing both GPs’ and patients’ knowledge as well as addressing expected barriers and discussing possible solutions, in order to increase the rate of patients who start using osteoporosis medication, and thus prevent future fractures. This suggestion needs to be further examined in interventional studies. The development of such interventions, in collaboration with patients, would be the next step.Additional file 1:Table S1. Final topic list for the interviews with patients and GPs. Topics discussed during interviews with patients and GPSs. (DOCX 13 kb)


Reversible phenotypic plasticity, the ability to change one’s phenotype repeatedly throughout life, can be selected for in environments that do not stay constant throughout an individual’s lifetime. It might also mitigate senescence, as the mismatch between the environment and a non-plastic individual’s traits is likely to increase as time passes. To understand why reversible plasticity may covary with lifespan, studies tend to assume unidirectional causality: plasticity evolves under suitable rates of environmental variation with respect to life history. Here we show that if lifespan also evolves in response to plasticity, then long life is not merely a context that sets the stage for lifelong plasticity. Instead, the causality is bidirectional because plasticity itself can select for longevity. Highly autocorrelated environmental fluctuations predict low investment in reversible plasticity and a phenotype that is poorly matched to the environment at older ages. Such environments select for high reproductive effort and short lifespans. Reversible phenotypic plasticity is expected to be favoured by long lifespan, as this increases the environmental variation individuals experience. Here, the authors develop a model showing how phenotypic plasticity can drive selection on lifespan, leading to coevolution of these traits. This definition differs from phenotypic switching2, a phenomenon where phenotypic change occurs without being related to the state of the environment as experienced by the organism. Organisms clearly vary in the extent of plasticity3, the age in which plasticity occurs4, and the general tendency for plasticity to be age dependent5. When the environment varies at a suitable rate with respect to the individual’s life history, we expect phenotypic plasticity7 as opposed to displaying a rigid expression of any genotype; this can extend to lifelong plasticity via reversible morphological change8 or behavioural changes9.Phenotypic plasticity is defined as the ability of one genotype to produce more than one phenotype depending on some environmental variable11. Empirically, there appears to be support for the idea that lifespan or slow life histories correlate with large brains or higher learning rates  in mammals12, birds14, and butterflies15. The direction of causality is subject to debate16. Is a long life a context that simply sets the stage for lifelong plasticity, or can reversible plasticity itself select for increased longevity? Theoretical studies tend to take the lifespan as the driver of patterns, and ask whether plasticity then evolves19. The possibility that plasticity itself might drive life history evolution is understudied, even though there are hints from (non-plastic) life history theory that old individuals show more mismatch with the environment20.Models generally suggest that organisms that are long lived relative to the rate of environmental fluctuations should be more plastic5 and the age-dependent expectation of phenotypic mismatch with the environment leading to senescence20 to predict how the life history of a species is expected to coevolve with plasticity. We allow phenotypes to be updated according to evolving schedules. The modification of the phenotype usually occurs in a direction that improves the match between the environment and the phenotype, but the updating process is error-prone and we also investigate how the magnitude of error changes evolutionary expectations. We assume that each phenotypic updating event is costly, compared with leaving one’s phenotype unchanged. The mismatch between the phenotype and the environment increases with the time since the last update (leading to a form of senescence). This increase should select for higher reproductive effort in early life at the cost of survival—i.e. a ‘fast’ life history—in organisms that do not update their phenotypes as time progresses. If, on the other hand, an organism repeatedly updates its phenotype, it is less likely to senesce due to being out of date. This selects for a ‘slow’ life history where the emphasis is on reaping the benefits of a potentially long life. Given the costs of updating, a recent update might be best followed by a period of no updating, leading to an evolutionary question of the schedule according to which an organism should perform new updates.Here we complement insights from age-dependent plasticityE, changes from one time step to the next, with the parameter p determining the autocorrelation in the environmental states. The environmental state is operationally defined by the value of the phenotype that is optimal for this environment. An individual with a phenotype that deviates from this has nonzero mismatch mi,t with negative impact on current reproduction as well as survival to the next time step. Survival simultaneously trades off with reproductive effort.Our individual-based simulation follows genotypes, phenotypes, survival, and reproduction individually for all members of the population. Individual lives last several time steps without a strict upper bound, thus generations overlap. The environment, u locus determines an individual’s update schedule and r its reproductive effort. Each individual, in each time step, either updates or does not update its phenotype, with the update probability modelled as an increasing function of the time Tu since the last update, with u determining how steeply the probability rises with Tu  perform an update with probability 1 regardless of u. Updating does not completely reset mismatch to zero but to a stochastic value that increases with an error term ɛ. This term can refer to, e.g., inappropriate phenotypic responses to the current environment , or to an organisms’s inability to measure the state of the environment perfectly.Each individual has a two-locus genotype, where the ci,t depends on the parent’s investment in reproduction, its mismatch, and whether it performed an update (thus paying updating costs)  and ri (for reproductive effort) with some small probability of mutation. Parental survival depends on mismatch and a cost of reproductive effort (which depends on ri) . Clutch size ts) Fig. . Offspriri) Fig. . Dead pap, and the updating error, ɛ. For each combination of p and ɛ  we start the simulation from a range of genetic values for u and r. The model is described in detail in the Methods section.We vary both the autocorrelation of the environment, p, indicated with colour in Fig. ɛ, indicated with symbol shape). Repeated runs with the same parameters typically lead to similar levels of reproductive effort while they can retain variation in the precise level of plasticity (the evolved updating schedule u). Even so, the solutions clearly group into distinct categories of either high, low, or (in the case of highly autocorrelated environments) intermediate updating frequency  that differ in the environments they evolved in (effectively an interspecific or interpopulation comparison). Species may differ in environmental autocorrelations , reproductive effort r, and the consequent lifespan under different environments. Stable environments (high p) generally lead to less plasticity , the above result of high plasticity associating with a slow life history Fig.  remains u), or between initial and evolved reproductive effort (r), for any species-specific parameter values; this indicates that the simulations proceeded beyond transient effects. However, a few exceptional cases indicate the possibility of alternative evolutionary equilibria. Low environmental autocorrelation and high updating error can yield two alternative life histories depending on the starting values used to initialize the population  and a slow life history, but in some cases, the population instead evolves a mirror image life history with little plasticity and high reproductive effort  updating schedule , and saw no qualitative changes in the results; quantitatively, we observed more frequent updating when the costs of doing so were lower (Supplementary Note ρ = 0.05), we find that populations either evolve similar strategies as with lower costs or alternatively so high reproductive efforts that all individuals die and there is no selection for plasticity  model) to confirm that it is indeed the environmental autocorrelation and not the total environmental variance that affects which strategies evolve  comes from a joint association with brain size, which could indicate high investment in behavioural flexibility.We also show some counterintuitive patterns. Slow environmental fluctuations, making any benefits of plasticity small, select against reversible plasticity, and this can lead to phenotypes that are poorly matched to the environment as a whole. In these highly autocorrelated environments, a relatively fast life history proves to be a better solution than any attempt to keep an individual’s own survival intact via plasticity. In an avian context, Sol et al.24, but we have not found examples of plasticity included in these studies. On the other hand, meta-analytic techniques have been used to quantify plasticity in a standardized manner across species26, but here, the studies have not been interested in lifespan variation. Clearly, there is scope for both methods to be employed in the same studies, as this would allow interspecific tests of our predictions; local adaptation can also be used as a framework permitting multi-population studies within a single species27. Alternatively, as a stronger method in terms of detecting causalities, experimental evolution approaches could investigate the coevolutionary patterns of lifespan and plasticity when environments vary in their autocorrelation structure. Experimental evolution approaches have already been used to select for plasticity28 on the one hand and senescence29 on the other; a simultaneous investigation of both responses could prove fruitful, and this approach could be made even more powerful by posing lifespan limitations on some lines but not others. A third approach could specifically focus on learning as a specific form of behavioural plasticity, and fourth, differences between the sexes in plasticity31 and lifespan29 could—again, if combined in a single study—also inform the validity of our model .The fast–slow life history continuum has been investigated across a range of species20. We show that this process of becoming outdated can occur within a species, while the opposite pattern (long life associating with low mismatch) can be predicted in between-population or between-species comparisons. In the latter kind of comparison, environments are likely to differ between species, and investment in reversible plasticity can lead to long lifespans that feature good matches between phenotypes and genotypes. We predict that the populations that are most mismatched to their environments live in environments that have intermediate autocorrelation, and in which accurate updating is not possible . Under such conditions, investing in reversible plasticity is selected against, and individuals consequently become more phenotypically mismatched after one season than individuals that live and evolve in more stable environments. The life history can still permit annual survival rates high enough to allow many individuals to survive beyond one season. The populations with the strongest increase in phenotypic mismatch with age are those that live in fast changing environments in which updating is very error-prone, effectively preventing plasticity as a solution to rapid environmental changes.Previous models have shown the potential for older individuals to become more mismatched to their environment if the environment is changing over timeIn conclusion, our study promotes the view that species can be placed along a fast–slow continuum of life history patterns in a manner that covaries with the degree of plasticity, with the causalities forming a feedback loop rather than being unidirectional. Although disentangling coevolving effects can be empirically difficult, we urge investigators to not assume a priori that the type of lifespan evolves first and plasticity follows; indeed, we found reproductive effort to respond very fast to environmental sampling regimes (plasticity), with the reverse rate of evolution being much slower.We use an individual-based simulation model where we model genotypes, phenotypes, survival, and reproduction individually for all members of the population. Population size is constantly 2000 individuals. An individual life lasts, potentially, several time steps, and the environment changes from one time step to the next. Since an individual is allowed to reproduce in every time step, generations are overlapping.E, varies on a continuous scale, and in each time step, t, the environment has one component that is drawn from the standard normal distribution and one component from the previous environment. The relative weight of these two components is governed by a parameter, p, which therefore determines the autocorrelation in the environment: Et = p Et-1 + (1−p) ζ, where ζ is independently drawn from N. The value of Et is interpreted as the phenotypic value that results in zero mismatch; all other phenotypes have positive mismatch mi,t = |xi,t− Et|, where xi,t is the individual’s phenotype. Larger mismatch values translate into poorer reproduction and survival, as explained below. For illustration purposes, we also present statistics on the increase in phenotypic mismatch with age. This is done by extracting the slope from a linear regression of mi,t~agei,t including all individuals present in a population for the last 10 time steps of the simulation, to average out effects of any particular environment or environmental change.The environment, u, and the reproductive effort, r. Each individual, at the beginning of each time step, either updates or does not update its phenotype, with the probability that updating occurs modelled as an increasing function of the time Tu since the last update. The genotype, u, determines the how steeply the probability rises with Tu (high u implies frequent updating): i refers to the individual in question. We assume some plasticity always occurs, in that newborn individuals  perform an update with probability 1 regardless of ui. Updating does not completely reset mismatch to zero, instead, updating leading to phenotype that includes an error term: the post-update phenotype is Et + N. If ɛ = 0, updates will always perfectly remove the mismatch, while large ɛ can in principle also increase the mismatch between the organism and the environment at an update event. Individuals that did not perform an update are assumed keep their phenotype from the previous time step; xi,t = xi,t–1.An individual’s genotype consists of two components (loci) that are passed on to the offspring (with some mutation as described below): plasticity, which we model as the updating schedule ci,t, produced by each individual depends on three factors. The first, denoted ri, is a component of the genotype that denotes reproductive effort, bounded by an upper limit of 10. The second component is the level of mismatch to the current environment , and the third component is a penalty (κ) for individuals that in this time step performed an update. Expected clutch size combines these effects asU takes the value 1 for individuals who updated, and 0 otherwise  and ri (for reproductive effort) are inherited by all its offspring, with each of them also independently experiencing mutation, to yield μ is drawn from the normal distribution, μ ~ N.Each individual’s genotype values α0 = 0.05 is a baseline mortality, to which we add the mismatch with the environment and a term reflecting the cost of reproduction (high ρ implying large cost), which increases with an individual’s reproductive effort ri. New recruits replace dead adults, until there are no further vacancies in the population. Parents that are allowed to provide a recruit are drawn randomly from the population but probability of providing a recruit is weighted by expected clutch size ci,t.Parents die with probability ri2 Fig. , where αtmax = 50,000 time steps, At this point, we record the age and genotypic distribution of all individuals. In most cases, genotype values stabilize long before this, but in a few cases evolution needs a long time to reach the final values. Fitness components  are emergent properties of the model.The simulations are allowed to continue for p, and the updating error, ɛ. In each of these environmental scenarios, we start the simulation from a range of genetic values for uinit = {0.0100, 0.0316, 0.1000, 0.3162, 1.0000, 3.1623, 10.000} and for three different values of rinit = {1, 4, 7}.We vary both the autocorrelation in the environment, 32, ‘viridis’33 and ‘gridExtra’34.Figures are produced with R, version 3.5.0 and the package ‘ggplot2’The model is coded in MATLAB and code can be found at Dryad Digital Repository, 10.5061/dryad.m7b43mm.Supplementary InformationPeer Review File