Osteoporosis affects over 220 million people worldwide, and currently there is no ‘cure’ for the disease. Thus, there is a need to develop evidence-based, safe and acceptable prevention strategies at the population level that target multiple risk factors for fragility fractures to reduce the health and economic burden of the condition.Osteo-cise: Strong Bones for Life study will investigate the effectiveness and feasibility of a multi-component targeted exercise, osteoporosis education/awareness and behavioural change program for improving bone health and muscle function and reducing falls risk in community-dwelling older adults at an increased risk of fracture. Men and women aged ≥60 years will participate in an 18-month randomised controlled trial comprising a 12-month structured and supervised community-based program and a 6-month ‘research to practise’ translational phase. Participants will be randomly assigned to either the Osteo-cise intervention or a self-management control group. The intervention will comprise a multi-modal exercise program incorporating high velocity progressive resistance training, moderate impact weight-bearing exercise and high challenging balance exercises performed three times weekly at local community-based fitness centres. A behavioural change program will be used to enhance exercise adoption and adherence to the program. Community-based osteoporosis education seminars will be conducted to improve participant knowledge and understanding of the risk factors and preventative measures for osteoporosis, falls and fractures. The primary outcomes measures, to be collected at baseline, 6, 12, and 18 months, will include DXA-derived hip and spine bone mineral density measurements and functional muscle power (timed stair-climb test). Secondary outcomes measures include: MRI-assessed distal femur and proximal tibia trabecular bone micro-architecture, lower limb and back maximal muscle strength, balance and function , falls incidence and health-related quality of life. Cost-effectiveness will also be assessed.The Osteo-cise: Strong Bones for Life study will provide new information on the efficacy of a targeted multi-modal community-based exercise program incorporating high velocity resistance training, together with an osteoporosis education and behavioural change program for improving multiple risk factors for falls and fracture in older adults at risk of fragility fracture.The findings from the Australian New Zealand Clinical Trials Registry reference ACTRN12609000100291 Osteoporosis and related fractures are a serious public health problem worldwide because of the associated morbidity, mortality and health care costs. In 2011, 1.2 million Australians were diagnosed with osteoporosis and another 5.4 million had osteopenia and are therefore at risk of fragility fracture , almost Currently the medical paradigm of a ‘cure’ for osteoporosis is less than ideal because the pharmacological agents available are directed to those who have already had fragility fractures or have a high absolute fracture risk and the lowest bone density. However, in women it is estimated that more than 50% of fragility fractures occur in those with ‘osteopenia’ (BMD T-score −1.0 to −2.5 SD) and not ‘osteoporosis’ (T-score ≤ −2.5 SD) ,7 there Current national and international consensus osteoporosis management guidelines recommend a combination of weight-bearing and resistance training with challenging balance exercises to improve multiple risk factors for falls and fracture . At presPrograms incorporating high intensity PRT alone are also particularly effective for improving muscle strength, mass and size  and may The clinical relevance of maintaining lower extremity muscle power has been demonstrated in studies which have shown that relative to muscle strength, deficits in muscle power are a stronger predictor of disability and falls in older people ,18. PoweFor older people, preventing falls is imperative as around 90% of all osteoporotic fractures, particularly hip fractures, occur as a result of a fall ,22. FallOne of the key challenges facing health-care professionals when implementing any community-based exercise programs is how to enhance adoption and adherence to the program and achieve sustained behaviour change. In older adults, there is considerable evidence that the use of behavioural theory-based strategies can effectively enhance the adoption to and maintenance of exercise programs ,29. SpecOsteo-cise: Strong Bones for Life trial; an 18-month community-based randomised controlled trial designed to evaluate the effectiveness and feasibility of an evidence-based, multi-modal exercise, osteoporosis education and behavioural change program for improving bone health, muscle power and function in community-dwelling older adults at increased risk for falls and fracture. Secondary aims of the study are to assess the effects of the intervention on: 1) trabecular bone microarchitecture; 2) lower limb and back muscle strength; 3) falls incidence, and 4) health-related quality of life. We will also conduct a cost-utility analysis to facilitate the cost effectiveness compared with other interventions targeted across a range of chronic disorders. The long-term goal is that the Osteo-cise: Strong Bones for Life program will serve as a model for future osteoporosis and falls prevention programs that can be implemented within the community with the aim of reducing fracture incidence and related risk factors for fracture, and consequently reduce osteoporosis-related health care costs and morbidity.This paper describes the methods of the Osteo-cise: Strong Bones for Life is an 18-month multi-faceted randomised controlled trial involving community-dwelling men and women aged 60 years and over at increased risk of falls and fractures. The trial is divided into two phases: 1) a 12-month community-based structured and supervised intervention incorporating a multi-modal exercise program in conjunction with an osteoporosis education/awareness and a behavioural change program, and 2) a 6-month ‘research to practise’ translational period in which each community-based health and fitness centre will aim to continue to implement the Osteo-cise: Strong Bones for Life program independently of research staff. This translational phase is designed to evaluate the sustainability of the program in the ‘real world’. The trial is managed by the Department of Medicine, Northwest Academic Centre, The University of Melbourne, Western Hospital, Australia and has been approved by the Melbourne Health Human Research Ethics Committee (HREC 2008.136). The study is also registered with the Australian New Zealand Clinical Trials Registry [Reference ACTRN12609000100291].Men and women aged 60 years and over living independently in the community in the Western suburbs and surrounding regions of Melbourne, Australia, who fulfil the defined inclusion criteria outlined below will be invited to participate in the study.2; iii) no history of osteoporosis; iv) not undertaken resistance training and/or weight-bearing impact exercise more than once a week in the past three months; v) be willing to be randomised into either the ‘Osteo-cise’ intervention or usual care control group, and vi) be willing and able to travel to a local health and fitness centre three times per week for 18 months to complete the exercise program. Participants will be excluded from the study on the following criteria: i) current smoking; ii) current or prior (past 6 months) use of hormone replacement therapy ; iii) having sustained a low trauma fragility fracture in the past 6 months; iv) any medical condition  or use of medication known to influence bone metabolism or fracture risk ; v) initiating calcium or vitamin D supplementation in the preceding 6 months, or vi) expected travel of greater than 6 weeks in the next 18 months.Eligibility to participate in the study will be based on a three step screening process. First, all participants who enquire about participating in the study will be initially screened via the telephone. Participants must meet the following criteria: i) aged ≥60 years; ii) BMI <40 kg/mPotential participants will then have a DXA bone mineral density (BMD) scan and be eligible for randomisation if they are osteopenic (T-score between −1.0 and −2.5 SD) at the total hip, femoral neck or lumbar spine. Those with osteoporosis (T-score ≤ −2.5 SD) will be excluded and advised to consult their physician for follow-up care. Participants with normal BMD (greater than −1.0 SD) will complete a short falls and fracture risk questionnaire, adapted from Sanders et al.  . To avoid any potential contamination any couples enrolled in the study will be randomised into the same group. A flow diagram of the study protocol is outlined in Figure Following baseline testing participants will be randomised into either the Osteo-cise: Strong Bones for Life is a community-based program that includes four key components: 1) Osteo-cise: a multi-modal targeted osteoporosis and falls prevention exercise program; 2) Osteo-Adopt: a behavioural change program designed to optimise adherence to the Osteo-cise program; 3) Osteo-Ed: an osteoporosis awareness and education program for the study participants, and 4) Osteo-Instruct: a train-the-trainers workshop designed to update the exercise trainers with the latest osteoporosis prevention and management information and to instruct them on the aims and structure of the program. The structured exercise program is designed to run over 12 months and to be conducted within local community leisure or recreational health facilities under the supervision of Osteo-cise trained exercise instructors. Managers of local health and fitness centres within the western suburbs of Melbourne will be contacted by phone and invited to participate in the study. All interested managers and relevant staff will be given a detailed presentation outlining the program and requirements. Those that agree will then be asked to recommend suitably qualified exercise trainers to undertake the Osteo-Instruct ‘train-the-trainers’ workshop to implement the exercise program at their facility. Specific details on the program’s four key components are provided below.-cise group will be instructed to train at their nearest Osteo-cise health and fitness centre on three non-consecutive days per week for 18 months. The gymnasium membership for all participants during the initial 12 months will be subsidised. Exercise sessions will be conducted in small groups (a maximum of 10 per group) and monitored by qualified and certified exercise trainers who have completed the Osteo-Instruct training workshop. Before commencing the program, all participants will be required to attend an orientation session at their selected leisure facility to become familiar with the aims and design of the training program and the rules and regulations of each health and fitness centre.Participants randomised to the OsteoOsteo-cise program will be divided into a 4-week ‘Adoption Phase’ followed by four distinct 12-weekly mesocycles  using machine and free weights, moderate impact weight-bearing exercises, high challenge balance and mobility exercises, core muscle stabilization exercises and flexibility (stretching) exercises. All programs will be individually tailored and designed to follow the key training principles of specificity and progressive overload. To assist trainers with exercise selection for each participant and to ensure correct technique and exercise progression, trainers will be provided with an Osteo-cise exercise manual which will include detailed explanations and illustrations for all key exercises.The initial 12 months of the a) High velocity progressive resistance training (HV-PRT) or power trainingHV-PRT is a type of resistance training whereby the concentric (lifting) phase of the exercise is performed as rapidly as possible in order to maximise both movement speed and muscle force. A combination of pin-loaded machine weights, pulleys and free weights will be used to overload the specific muscle groups that attach to skeletal sites prone to osteoporotic fracture, particularly the hip and spine. Trainers will be advised to choose from the following core exercises: squats, leg press, lunges, bench step ups, hip extension, hip flexion, hip abduction, hip adduction, calf raises, back extension, lateral side bends, latissimus dorsi pull down (or seated row) and a combination of abdominal and core stability exercises. Where possible, participants will be asked to perform the exercises whilst standing in an attempt to optimise balance and muscle function. Additional exercises including bench press, military press, bicep curls, tricep extension and shoulder, lumbo-pelvic and spine stabilisation exercises will also be rotated throughout the program to ensure the development of muscle balance. For each exercise card a total of six resistance exercises will be performed in each training session, with new exercises introduced into the program at the beginning of each new mesocycle (i.e. every 12 weeks) where appropriate.Table b) Moderate impact weight-bearing exerciseOsteo-cise manual based on each participant’s ability and/or on the existence of any previous medical conditions (e.g. knee osteoarthritis). Exercises are divided into three categories: Level 1 - Stationary movements ; Level 2 - Forward/Backward movements ; and Level 3 - Lateral/Multidirectional movements . Each category has three levels  based on the degree of difficulty and the magnitude of the impact forces (ground reaction forces) associated with each exercise [The weight-bearing impact exercise component of the program will consist of a series of lower limb exercises aimed at specifically loading the hip. We have developed a battery of 27 bone friendly exercises which were found to be safe and effective for improving femoral neck and lumbar spine BMD in middle aged and elderly men ,37. Traiexercise . A totalexercise . Traininc) Balance and mobility trainingThe balance training component will incorporate a variety of static and dynamic balance exercises aimed at improving posture and anticipatory/reactive balance and mobility. Exercises will fall into three categories: 1) Fit-ball exercises , 2) Standing balance exercises (e.g. single leg standing), and 3) Dynamic functional exercises . Two challenging balance exercises will be performed in each session, with each exercise held for up to 30 seconds (e.g. 30 seconds of single leg standing) or performed for a given number of repetitions . Once an exercise is no longer challenging for the participant they will be instructed to progress to the next level of difficulty by changing the exercise using the following progressions: closing eyes, reducing base of support, confounding visual fixation (e.g. head turns), changing centre of mass (e.g. arm/leg lifts) or adding a secondary manual or cognitive task. The type of balance exercises and starting level of difficulty will be prescribed by the trainer according to each participant’s functional ability.d) Core and hip muscle stabilisation exercisesThe key muscle groups targeted in this component of the exercise program include the rotator cuff , scapular stabilisers , transverse abdominis and pelvic floor muscles. These muscles help to maintain good posture and trunk stability, which are important for balance and maximising muscle power . ParticiAn important component of this study is to develop a holistic community-based program that will provide older adults with the skills required to manage their own musculoskeletal health and promote behaviours that encourage adoption and maintenance of lifelong exercise participation. Increasing each participant’s motivation and readiness to exercise is crucial for long-term maintenance of musculoskeletal health. Consequently, widely established behavioural principles, particularly the Transtheoretical (Stages of Change) Model (TTM) and Social Cognitive Theory, will be utilised to initiate exercise adoption and guide long-term maintenance ,31. FundOsteo-cise program (‘buddy’ system) and telephone calls from the research staff or exercise trainers will also be used to optimise enjoyment of the program and hence adherence, as will quarterly newsletters aimed at providing information of interest . In addition, at 3-monthly intervals trainers will ask participants to complete a Behavioural Evaluation Form which requires the establishment of short- and long-term exercise goals and helps to recognise motivating factors and potential barriers to attaining these goals. Strategies to overcome these barriers may then be identified and discussed by participants together with their trainer. Trainers will also endeavour to prevent lapses by calling participants who have missed three consecutive training sessions and discuss strategies to improve adherence. Finally, positive reinforcement will be achieved through self-monitoring of progression marked by the completion of the exercise cards.Social support will be enhanced by organising participants into small exercise groups that facilitate socialisation and interaction. The development of relationships with other participants in the -Ed will be adapted from educational resources developed by Osteoporosis Australia that are based on current scientific evidence. Topics covered will include: 1) Osteoporosis – What are the risk factors?; 2) Exercise for optimal bone and muscle health; and 3) Nutrition for healthy bones. The Osteo-Ed seminars are intended to be informal sessions whereby questions and open discussion are encouraged. Each will run for approximately 60 minutes and will take place at selected Osteo-cise community leisure centres.Participants will be invited to attend three osteoporosis-related community educational seminars presented by the research staff. These sessions will aim to improve knowledge and understanding of risk factors and preventative measures for osteoporosis, falls and fractures so that participants are encouraged to actively manage their health. The content of OsteoOsteo-cise: Strong Bones for Life program will be required to attend a one-day training workshop that will cover information about the latest research on osteoporosis and falls; current treatment and management options; challenges facing older adults with or at risk of osteoporosis; basic nutrition for healthy bones; the benefits of exercise for preventing and managing osteoporosis and falls, including the most appropriate type, mode, intensity and frequency of training; safe exercise progressions; contraindicated exercises; and behavioural management strategies to enhance compliance to exercise. In addition, the Osteo-Instruct workshop will teach trainers how to identify early cues to poor adherence and strategies to prevent lapses and promote individuals’ self-confidence in their ability to undertake the exercise program. Importantly, the workshop will also familiarise the trainers with the design and specific aims of the Osteo-cise program. All trainers will be provided with a copy of the Osteo-cise training manual, which will contain all the essential information that is needed to implement the training program. This includes the rationale behind the program, training principles for optimal bone health, and a detailed description of each program component including progressions of exercise volume and intensity as well as illustrations of recommended exercises. Safety considerations, such as injury prevention and exercises to avoid for various disease states, will also be clearly highlighted in the trainer’s manual.All exercise trainers employed to work on the Trainers will be provided with a folder containing each study participant’s personal details, including relevant medical history and a copy of their physician's approval to exercise. Trainers will be required to document any contact made with participants throughout the intervention in this folder as well as any injuries or adverse events that occur as a result of the exercise sessions. The research team will maintain regular contact with the trainers and visit all health and fitness centres during each training cycle to ensure that the trainers are up-to-date with the program and that the quality of the program is being upheld and delivered as intended.Osteo-cise program.The self-management control group will serve as the comparison group in the intervention. Participants assigned to this group will receive general consumer information taken from Osteoporosis Australia fact sheets, including: “What is osteoporosis?”, “What are the risk factors for osteoporosis?” and “Calcium, vitamin D and exercise tips for preventing osteoporosis”. The aim is to enable these participants to actively take charge of their own musculoskeletal health and make educated decisions to seek further medical information and appropriate services to help prevent osteoporosis, falls and fractures. This group will undertake exactly the same testing protocol as the intervention group, but will not participate in the structured 3 capsule (Blackmores Vitamin D3) each day. All supplements will be provided free of charge.To ensure that daily calcium intakes meet the current recommended dietary intake of 1000 to 1300 mg/d for men and women aged over 50 years and that vitamin D levels are close to optimal (at least 60 to 75 nmol/L), participants in both groups will be requested to consume 2x350 mg elemental calcium tablets  and a single 1000 IU vitamin D‘research-to-practise’ phase, participants in the Osteo-cise program will be invited to continue the training program which will be administered by staff at each health and fitness centre with little or no input from the research staff. This translational phase is designed to evaluate the sustainability of the program in the ‘real world’. Participants in both groups will continue to take vitamin D and calcium supplementation over this period dispensed at no personal cost.During the final 6-month In order to calculate the number of participants required for this study, power calculations were performed based on BMD and functional muscle power results from previous exercise intervention trials ,39. It wA summary of the outcome measures to be collected is shown in Table The primary outcome measures will be changes in proximal femur and lumbar spine BMD and lower limb functional muscle power.2) will be measured at the lumbar spine (L1-L4) and proximal femur  using a Hologic Discovery W dual-energy X-ray absorptiometry (DXA) machine with the APEX Software v3.2 . Standardized procedures for participant positioning and scan analysis will be used for all scans [Areal bone mineral density  testing on a LC20 weights machine . A 3-RM test is the maximum weight that can be lifted for three complete repetitions of an exercise whilst maintaining good technique. The bilateral leg press exercise will be employed to determine maximal leg strength (knee extensors) and the seated row will be used to determine maximal back strength. The following formula used by Wathen et al.  will be Gymaware power monitoring system . Peak muscle power at each of the five loads will be assessed following the 3-RM testing and the calculation of 1-RM. All participants will complete two repetitions in succession at each 40%, 50%, 60%, 70% and 80% of their calculated 1-RM, with a 60 second rest between each test. Participants will be instructed to perform the concentric phase of the exercise as rapidly as possible but the eccentric (lowering) phase at a normal, controlled speed. For each test load, the highest peak power from the two repetitions and the corresponding velocity will be recorded.Peak muscle power of the lower limbs will be recorded on the bilateral leg press machine at five different loads  by using the A series of commonly used functional tests will be used to assess lower limb function, dynamic balance and gait.four square step test (FSST) provides a measure of dynamic standing balance and stepping speed in four different directions [The rections . To comprections . With a rections . The tesrections .timed-up-and-go test (TUG) is a measure of dynamic balance during three commonly performed functional activities: standing up and sitting down in a chair, walking and turning [The  turning . To incr turning .30-second sit-to-stand test provides a measure of lower-extremity muscle strength where participants will be instructed to stand fully upright and then return to the seated position as many times as possible in 30 seconds [The  seconds . This te seconds .functional reach test (FRT) will be used to assess bilateral stance dynamic balance [The  balance . In this balance  and has  balance ,50.All participants will be invited to have a Magnetic Resonance Imaging (MRI) scan of the left knee at baseline and 18 months to assess the effects of the intervention on trabecular bone micro-architecture at the distal femur and proximal tibia. MRI of the left knee will be acquired on a 3.0 T MR scanner  using an eight-channel phased array knee coil . Images will be acquired with an axial 3D, phase cycled, fully balanced, steady-state coherent imaging pulse sequence (3D FIESTA-C), utilising the following parameters: repetition time ~11.8 ms, echo time 1.0 ms, flip angle 60 degrees, resolution 0.195 × 0.195, 512 × 384 matrix, slice thickness 1 mm and a scanning time ~16 minutes. A total of 50 slices will be acquired with a field of view of 10 cm.Analysis of trabecular bone micro-architecture outcomes will be performed using an interface description language (IDL)-based image software program . Image processing consists of five steps including coil sensitivity correction, trabecular region segmentation, manual region adjustment, registration and bone/marrow thresholding, as described in detail by Newitt et al. . The bonunintentionally coming to the ground or some lower level and other than as a consequence of a sudden onset of paralysis, epileptic seizure, or overwhelming external force” [Osteo-cise training sessions will be documented by the trainers in an Incident Report Form located in the Osteo-cise gym folder.Falls and adverse events, including fractures, will be ascertained using specific monthly ‘falls calendars’. A fall will be defined as “l force” . ParticiHeight will be measured with a standardised wall mounted stadiometer to the nearest 0.1 cm. Body weight will be measured using digital scales to the nearest 0.1 kg. Total body lean mass, fat mass and percentage body fat will be determined from the total body DXA scan using a Hologic Discovery W dual-energy X-ray absorptiometry (DXA) machine with the APEX Software v3.2 . All follow-up measurements will be analyzed using the ‘comparison’ feature of the Hologic APEX 3.2 analysis program. The short term co-efficient of variation for repeated measurements of total body lean mass and fat mass in our laboratory is 0.6% and 1.2%, respectively.Participants will be directed to a local pathology collection centre following each testing visit to provide a fasted, morning (8 to 10 am) blood sample. Blood samples will be tested for serum calcium, albumin, phosphate, creatinine, alkaline phosphatase and C-reactive protein. Remaining serum will be aliquoted and stored at −80°C until completion of the study when samples will be analysed for the following hormonal measures: serum 25-hydroxyvitamin D, parathyroid hormone (PTH) and insulin-like growth factor-1 (IGF-1).All participants will complete a lifestyle questionnaire detailing education background, current and past employment, history of disease(s)/illnesses, previous fractures, family history of fractures/osteoporosis, current medications and dietary supplements, average weekly alcohol consumption, and weekly television viewing and sitting time. For female participants, menstrual history will be documented including age of onset of menopause, menstrual cycle regularity and history of oral contraceptive and HRT use.Osteo-cise exercise program will be evaluated via self-completed exercise cards that research staff will collect from each health and fitness centre approximately 3-monthly throughout the intervention. Compliance with taking the prescribed calcium and vitamin D supplements will be determined by a medication count when remaining bottles are returned at each testing appointment.Compliance with the The CHAMPS physical activity questionnaire will be used to assess current participation in a range of low, moderate, and vigorous physical activities at baseline, 6, 12 and 18 months of the study. This self-report questionnaire has been designed for use in older adults and has been found to be reliable, valid and sensitive to changes in physical activity behaviour . ParticiNutrient intakes will be assessed at each testing visit using 24-hour dietary recall whereby participants will record the type, amount and time of consumption of all food and fluid consumed over a 24-hour period. Participants will be encouraged to provide as much detail as possible including brand names of known foods and exact cooking methods. This questionnaire will be checked for completeness by research staff at each respective testing appointment so that any ambiguous or missing information can be clarified. Dietary information from the questionnaires will be entered and analysed using Australia-specific dietary analysis software .Osteo-cise: Strong Bones for Life program. The outcome will be expressed as a cost per quality-adjusted life-years (QALYs) gained. This method of cost analysis involves an assessment of incremental change in health-related quality of life and the monetary costs related to the development and implementation of the Osteo-cise program as well as monetary costs related to any adverse events such as injury. The change in quality of life between the groups will be calculated using the difference in QALYs from baseline to the 12-month time point and will be determined using the EuroQoL-5D questionnaire [The CUA will determine the quality of health outcomes averted by the ionnaire .The EuroQoL-5D considers five dimensions of health, including mobility, self-care, usual activities, pain/discomfort and anxiety/depression. The responses will be scored/weighted using recently published algorithms for Australia . The assTo evaluate the effect of the program on each participant’s knowledge and health beliefs related to osteoporosis, the Osteoporosis Knowledge Assessment Tool (OKAT)  and OsteHealth-related quality of life will be assessed at each visit using the SF-36 questionnaire, which is a general measure of health status including eight scales: Physical functioning, Role-Physical, Bodily pain, General Health, Vitality, Social Functioning, Role-Emotional and Mental Health . This teStatistical analyses will be computed using STATA statistical software . Baseline and demographic data will be presented using descriptive statistics. All intervention data will be analysed according to the principle of intention-to-treat (ITT) and adjusted for multiple comparisons where appropriate. Non- normally distributed data will be transformed prior to analysis. Comparisons between the groups for all continuous primary and secondary outcomes variables will be made using repeated measures analysis of variance (ANOVA) for both time and group-by-time interactions. ANOVA or analysis of covariance (ANCOVA) will be used for absolute and/or percent changes after 12 and 18 months after adjusting for relevant confounders. Falls will be analysed according to the rate of falls per person-year, the proportion sustaining one or more falls and injurious falls during follow-up. The number of falls will be analysed using Poisson regression models with robust standard errors to allow for non-independence of multiple events for the same participant and negative binomial regression models allowing for overdispersion.p < 0.05 or smaller where adjusted for multiple comparisons.Cost utility analysis: Cost data is often skewed and thus not normally distributed. Therefore the Kruskal-Wallis one-way analysis of variance will be used to test the difference in cost and quality of life between the ‘usual care’ and exercise groups. To investigate the difference in cost between the groups, the transformed cost variable will be used as the dependent variable in a multivariable ordinary least square (OLS) regression model. All data will be presented as means ± SD or 95% CI unless stated. The significance level will be Osteo-cise: Strong Bones for Life project is unique in that it is designed as an evidence-based ‘research to practise' trial to evaluate the feasibility and effectiveness of a multifaceted community-based exercise, osteoporosis education/awareness and behavioural change program for improving musculoskeletal health and function in older adults at increased risk of osteoporosis, falls and fractures. Specifically, this project has been designed to: i) provide greater access and increased opportunities for older adults living within the broader community to participate in a safe and evidence-based multifaceted exercise and osteoporosis education program; ii) evaluate the effectiveness of a high velocity PRT in combination with weight-bearing exercise and challenging balance training for improving BMD, body composition, muscle strength and functional performance in older adults at increased risk of falling and fracture; iii) the program incorporates well established behavioural theories and strategies to maximise participant adherence to the program, as well as participant education seminars and written material to maximise osteoporosis-related knowledge and encourage long-term positive changes in health behaviour, and iv) to enhance the capacity for community-based health care professionals and the health and fitness industry to implement an evidence-based targeted osteoporosis and falls prevention program through training and support, and assist them with the establishment of their own sustainable program following the completion of the 12-month intervention. It is intended that the results of the study will inform future clinical practice in order to reduce the global rates of osteoporosis-related fractures.Osteoporosis and associated fractures are a growing public health concern globally, but current practice is largely aimed at secondary prevention after fractures have occurred, rather than primary prevention at the community level . The OstThe authors declare that they have no competing interests.RMD originated the idea for the study and will supervise the project. RMD, PRE, KMS, CAN, KH and CAB were co-investigators of the successful funding proposal. CAB and JG will act as trial coordinators and will be responsible for the data acquisition. JG, CAB and RMD wrote the manuscript and PRE, KMS, CAN and KH reviewed draft versions. All authors have read and approved the final version.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/13/78/prepub


The 2004 Niigata-Chuetsu earthquake of Japan caused considerable damage. We assessed long-term changes in psychological distress among earthquake victims during the period 5 years after the earthquake.The participants were people aged 18 years or older living in Yamakoshi, a community in Niigata Prefecture near the epicenter. A self-administered questionnaire survey was conducted annually for 5 consecutive years after the earthquake. Response rates were 1316/1841 (71.5%) in 2005, 667/1381 (48.3%) in 2006, 753/1451 (51.9%) in 2007, 541/1243 (43.5%) in 2008, and 814/1158 (70.3%) in 2009. The questionnaire asked about demographic characteristics, including sex, age, employment status, social network, and psychological status. Psychological distress was assessed using the 12-item General Health Questionnaire and was defined as a total score of 4 or higher.P < 0.0001) gradually from 2005 (51.0%) to 2008 (30.1%) but tended to increase from 2008 to 2009 (P = 0.1590). Subgroup analyses showed that prevalence did not decrease over the 5-year study period among participants with poor social contact (P = 0.0659). From 2008 to 2009 prevalence increased in women  and participants aged 65 years or older .The overall prevalence of psychological distress decreased (The prevalence of psychological distress in Yamakoshi people decreased steadily during the 4 years immediately after the earthquake but appeared to increase thereafter. The earthquake victims are still reestablishing their lives. Thus, continued attention should be focused on maintaining and further assessing their mental health. After the Niigata-Chuetsu earthquake, various short-term psychiatric problems and symptoms of psychological distress were documented among the victims.3The 2004 Niigata-Chuetsu earthquake in Japan had a near-epicenter maximum seismic intensity of 7 on the Japan Meteorological Agency’s Intensity (JMAI) scale and killed more than 60 people. Approximately 103 000 people sought refuge, and 16 000 houses were destroyed.4,5 Similar long-standing adverse effects on psychological health may have been present after the Niigata-Chuetsu earthquake. Thousands of people in the disaster area required temporary housing for 3 years,6 and financial problems due to property damage and/or unemployment after the earthquake were long-lasting.2 Thus, the long-term effects of psychological distress after the Niigata-Chuetsu earthquake warrant investigation.Psychological problems appear to persist long after earthquakes. Previous epidemiologic studies found that the prevalence of psychological distress remains elevated many years after earthquakes.The village of Yamakoshi (currently part of Nagaoka City) was located near the epicenter of the earthquake, where physical damage was enormous. All village residents sought refuge in a nearby city after the event. To care for these people, annual health checks were conducted for 5 consecutive years after the earthquake. In this setting, the psychological status of Yamakoshi residents was also evaluated. The aim of this study was to assess long-term changes in psychological distress among the resident population during the 5 years after the Niigata-Chuetsu earthquake.7 This survey was conducted by the local government and the Niigata Institute for Traumatic Stress  as part of post-earthquake health checks for people registered as Yamakoshi residents between 2005 and 2009. All residents aged 18 years or older were targeted. Response rates to the survey were 1402/1841 (76.2%) in 2005, 729/1381 (52.8%) in 2006, 841/1451 (58.7%) in 2007, 594/1243 (47.9%) in 2008, and 883/1158 (77.3%) in 2009. After excluding people with missing data on age, sex, or psychological status, the final response rates were 1316/1841 (71.5%) in 2005, 667/1381 (48.3%) in 2006, 753/1451 (51.9%) in 2007, 541/1243 (43.5%) in 2008, and 814/1158 (70.3%) in 2009. Although the response rate differed by year, 224 participants participated in all 5 surveys. This subgroup was also analyzed for comparison with the results of whole-population analyses.The Niigata-Chuetsu earthquake occurred on October 23, 2004 and measured M 6.8 on the Richter scale. The epicenter was located at latitude 37°29′ N and longitude 138°87′ E.Self-administered questionnaires for the years 2005 through 2008 were delivered and collected by hand (for participants living in temporary refugee housing) or sent and collected by mail (for other participants). The 2009 questionnaires were collected by hand from all participants. The questionnaires elicited demographic information on sex, age, employment status, social network, and psychological status. Regarding social networks, participants were asked, “Do you easily talk with or call on neighbors in the community?”. Answers were categorized as “often,” “sometimes,” “not often,” or “rarely.” Participant psychological status was assessed using the 12-item General Health Questionnaire (GHQ-12). This study received approval from the Ethics Committee of the Niigata University School of Medicine.8,9 The GHQ is a self-administered tool originally developed as a screening tool for non-psychotic psychiatric illnesses10 and is used in clinical settings and in epidemiologic studies of mental health status in general populations. Participants are asked to assess their moods, feelings, and behaviors during the previous 4 weeks, and the tool is used to evaluate their responses on a 4-point response scale. All GHQ-12 items were rated using the GHQ method (0-0-1-1) before being summed to a total score . A person with a high GHQ score is considered to have a high level of psychological distress, including depression, anxiety, and other psychiatric symptoms. Honda et al reported that a score of 4 or higher had satisfactory sensitivity and specificity as a GHQ-12 cutoff score in the Japanese general population; we therefore used this value.9The outcome of this study was level of psychological distress, as measured by the previously validated Japanese version of the GHQ-12.11 The χ2 test was used to compare prevalence rates between 2 groups. Multiple logistic regression analysis was used to determine if sex , age , employment status , and social contact  were independently related to the outcome variable. Data were analyzed utilizing SAS statistical software . A P value of less than 0.05 was considered to indicate statistical significance.The study outcome was prevalence of psychological distress, as defined by a GHQ-12 score of 4 or higher. The secular trend in the prevalence of psychological distress during the 5-year study period was observed and tested using the Cochran-Armitage test for trend. Secular trends were investigated by sex and age group, eg, elderly people (≥65 years of age) versus younger people (≤64 years of age). Secular trends were also investigated according to job status (unemployed vs other) and level of social contact (often/sometimes vs not often/rarely) for the respective years, because lack of employment and loss of contact in the community were reported to be strongly associated with psychological distress in a cross-sectional study of the Niigata-Chuetsu earthquake.Table P < 0.0001). The secular trend in prevalence among the 224 participants .The secular change in the prevalence of psychological distress in all participants, as well as in the 224 participants who participated in all 5 surveys, is illustrated in Figure P = 0.0659). In relation to the respective comparison groups, the prevalence of psychological distress was higher among those reporting infrequent social contact , jobless status (unemployed vs other), and degree of social contact (often/sometimes vs not often/rarely) are shown in Figure P = 0.1590). However, changes in prevalence within some subgroups  and participants aged 65 years or older . Multiple logistic regression analysis was conducted to identify independent factors related to change in distress status in 2008–2009 as an outcome variable  in participants who participated in both the 2008 and 2009 examinations. This analysis revealed that none of the 4 possible predictors—ie, age (P = 0.1105), sex (P = 0.4550), employment status (P = 0.3360), and social contact (P = 0.7121)—were independently associated with change in prevalence in 2008–2009. Another multiple logistic regression analysis was conducted to identify independent factors related to psychological distress in 2009  among participants who participated in the 2009 examinations. Psychological distress was independently associated with social contact , employment status , and sex , but not age .Despite the overall decreasing trend in prevalence, psychological distress appeared to increase from 2008 to 2009 Figure , althougThis study presented findings related to recovery from psychological distress among adults living in a community hit by a large earthquake. We found that the prevalence of psychological distress decreased gradually and reached its lowest point at 4 years after the earthquake.12,13 Bland et al12 assessed symptoms of psychological distress in people 7 years after the 1980 earthquake and found that levels of psychological distress were higher among those who had reported damage from the earthquake than among those who had not. Priebe et al13 assessed mental disorders in a randomly selected sample of 200 people who had experienced a 1997 earthquake in Italy 8 years before and concluded that the prevalence of mental disorders did not differ from that in comparable populations. Although the results of these 2 studies are inconsistent and not directly comparable with ours, the findings suggest that a large earthquake could affect the mental health of victims for a very long time, up to 7 years. Thus, to facilitate comparison with previous studies, further follow-up investigation in Yamakoshi is warranted.Although the short-term effects of earthquakes on mental health are well-documented, there are limited data on the long-term impacts of such events. Most prior studies assessed psychological disorders several months or a few years after earthquakes, but few studies investigated long-term outcomes .11 found that earthquake victims who were estranged from others in their community were at higher risk (OR = 7) for psychological distress 3 years after the Niigata-Chuetsu earthquake. Bland et al14 reported that those who were evacuated farther away from family or friends had higher levels of psychological distress 3 to 4 years after an earthquake in Italy. Kiliç et al15 showed that disruption of social networks due to relocation increased psychological distress 4 years after 2 severe earthquakes in Turkey.The present subgroup analysis showed that the prevalence of psychological distress did not decrease over 5 years among those with poor social contact. This finding agrees with the results of a number of previous reports on earthquakes, which showed that disruption of social networks is a major factor in poor mental health. Oyama et al11,16 This may be due in part to financial burdens from house damage that adversely affect psychological health.17The prevalence of psychological distress was higher among unemployed people, which was also noted in other studies.18 but a sex difference in the prevalence of GHQ-defined psychological distress was not found in a large Japanese population.19 A possible explanation for this higher prevalence in women may be the traditional, dependent roles of women in rural Japanese communities, including Yamakoshi.11,20 In such communities, women have a major role at home: they manage most of the housework and care for all family members, including their husband, children, and husband’s parents.11 Because of role change, post-earthquake burdens may have been greater for women than for men. The long-term higher prevalence of psychological distress in women versus men is noteworthy in relation to suicide rate after earthquakes. Long-term suicide rates after the Niigata-Chuetsu earthquake increased among women and decreased among men.21 The suicide rate among women may have been elevated because the prevalence of psychological distress in women was higher and increased over time.The prevalence of psychological distress was higher among women than among men in 2005, 2006, and 2009. In general, common mental disorders are more prevalent among women,The prevalence of psychological distress generally decreased after the earthquake, although there was an unexpected increase from 2008 to 2009. While multiple logistic regression analysis did not identify independent factors that contributed to this increase, there might have been stress-related factors beginning in 2009. Many people had been struggling to reestablish their lives and had difficulty continuing their daily tasks, which may have been reflected in greater psychological distress in 2009.12,22 In fact, the Niigata prefectural government reported declines in per capita income in the disaster areas after the Niigata-Chuetsu earthquake.23 Per capita income in the disaster areas decreased in 2008–2009, after rising in 2005–2007 as a result of temporary financial aid from the government  aged 20 to 69 years. This suggests that the prevalence of psychological distress in the present population was higher than that in a normal Japanese population.We evaluated the prevalence of psychological distress in an earthquake-stricken area rather than in a normal population. Few studies have used the GHQ-12 to investigate the prevalence of psychological distress in normal Japanese populations. Using the same GHQ-12 cutoff score, of 3/4, Shimbo et alA major limitation of this study is that participation rates differed throughout the 5-year study period; those between 2006 and 2008 (around 50%) were lower than those in 2005 and 2009. This discrepancy may have influenced prevalence rates. Secondly, we did not assess psychological distress before the earthquake and thus cannot determine whether the prevalence of psychological distress returned to pre-earthquake levels. Finally, the residents of Yamakoshi are mostly elderly adults in a rural area and, hence, generalization of our results requires caution. Our findings might not be applicable to younger populations in urban areas. Despite these limitations, data on long-term changes in post-earthquake psychological status among people living in a community near an earthquake epicenter are rare and worth reporting.In summary, the overall prevalence of psychological distress steadily decreased during the 4-year period after the earthquake; however, prevalence tended to increase between the fourth and fifth years after the earthquake. In addition, the prevalence of psychological distress did not decrease among those who reported poor social contact. Rebuilding of the lives of earthquake victim is ongoing; thus, their mental health status should be closely monitored.Abstract in Japanese.


Based on the self-efficacy theory, an online and a face-to-face self-management programs ‘Challenge your Arthritis’ for young adults with a rheumatic disease have recently been developed. These two courses are led by young peer leaders. The objective of this study was to test the feasibility of the online and face-to-face self-management program.Feasibility was evaluated on items of perceived usefulness, perceived ease of use, user-acceptance, and adherence to both programs in young adults and peer leaders. Additional analyses of interactions on the e-Health applications, discussion board and chat board, were conducted.Twenty-two young adults with a diagnosed rheumatic disease participated in the study: 12 young adults followed the online program and 10 followed the face-to-face program. Both programs appeared to be feasible, especially in dealing with problems in daily life, and the participants indicated the time investment as ‘worthwhile’. In using the online program, no technical problems occurred. Participants found the program easy to use, user friendly, and liked the ‘look and feel’ of the program.Both the online and the face-to-face versions of a self-management program. ‘Challenge your arthritis’ were found to be feasible and well appreciated by young adults with a rheumatic disease. Because these programs are likely to be a practical aid to health practices, a randomized controlled study to investigate the effects on patient outcomes is planned. Numerous rheumatic diseases such as arthritis, fibromyalgia and systemic lupus erythematosus affect children . These dTo educate and counsel young adults, we first developed an outpatient transition clinic, a digital portal and an information website . Users oEthical approval was obtained by the ethics committee of University Medical Center Utrecht. The registration number is 10–325.We developed an online version, using a safe website and a face-to-face version so young patients could choose to participate in the way that best suited their current lifestyle. All these initiatives were taken in close cooperation with the Dutch Rheumatism Patient League (DRPL) and young adults from the outpatient transition clinic of University Medical Center. Both groups participated actively in the development of the program. For the development, the transition outpatient clinic received a grant from the Dutch Arthritis Association.The ‘Challenge your Arthritis’ program is a multi-component, interactive program of education, self-management strategies and social support. The aim of ‘Challenge your Arthritis’ is to enhance patients’ self-management in coping with their chronic disease. The program is given by peer leaders. To our knowledge, this is the first self-management program for this specific young group given by peer leaders in the Netherlands.We conducted this quantitative feasibility study to evaluate perceived usefulness, perceived ease of use and user acceptance of the online or face-to-face version of ‘Challenge your Arthritis’ in participating young adults and peer leaders. Additional qualitative analyses of the digital communication within the online version on chat and discussion board were carried out.http://www.reumauitgedaagd.nl in January 2011, were asked to participate. Information about the program was spread by placing leaflets in the waiting room of University Medical Centers in the Netherlands and on the website of the Dutch Rheumatism Patient League.Young adults aged 16–25 years, who had registered for the self-management program ‘Challenge your arthritis’ on the website Young adults chose voluntarily either for the online or the face-to-face program. Those young adults who initially did not want to participate in the study were given the opportunity to join the program later on. Inclusion criteria were:1) Each participant had to have a rheumatic diagnosis made by paediatrician or rheumatologist;2) Access to a home-based computer with Internet;3) Each had to be be able to read and write in Dutch; and4) No previously participation in a self-management program.Informed consent was obtained from the participant and if young adults were younger then 18 years old, also from their parents. The peer leaders who participated in this study were young adults in the age of 20–30 years who had a rheumatic disease themselves.The online and face-to-face version ‘Challenge your arthritis’ were based on self-efficacy theory . Self-mahttp://www.jong-en-reuma.nl (in Dutch). This website contains information about medical issues and themes like dealing with the consequences of having a rheumatic disease, feeling depressed, exercises, work, study, relationship and intimacy.Next the participants of the program were allowed to use information presented on the website The online program consists of password-protected, interactive web-based self-management instruction with three e-Health applications including a chat section, home exercises and a discussion board. Once a week, the group  had a planned group chat for a maximum of 90 minutes. Within the chat, the weekly theme was clarified, goals were set and the participants were allowed to practice, ask questions, play a game or watch a real live story video, based on the weekly theme. The home exercises were discussed and evaluated. After the chat, participants were allowed to work through the program at any time at home and do the exercises (one hour a week). In addition, a discussion board was used by trainers and participants to offer encouragement and share tips.For six weeks, participants worked chronologically through the program using six themes Table . On averThe face-to-face version of the program was organized during a weekend in a holiday resort. In three days, 12 hours in total, participants (8–12 young adults) and two peer leaders worked through the same program and themes  and the website of the Dutch Arthritis Association. Peer leaders were selected through assessments and interviews conducted by the DRPL. The selection process utilized questions on age, disease duration, motivation, perceptions on self-management and strategies. Finally, the peer leader was trained through a train-the-trainer educational program by the UMC Utrecht and a professional coaching organization (Work21.nl). This program consisted of following the training as participant, knowledge of the different themes, and teaching training skills. The peer leaders had a volunteer contract and received a stipend from the Dutch Arthritis Association for each program worked.Two moderators assisted the peer leaders during the online and face-to-face versions of the program, but were not ‘visible’ to the participants. These moderators were a professional coach of the train-the-trainer program, transition coordinator, or a communication advisor of UMC Utrecht.We collected demographic variables including age, sex, diagnosis, disease duration, current treatment, and educational level at baseline by means of an online questionnaire as well as data about the use of Internet and self-reported Internet skills by participants of the online program.Three months after starting the online version and two weeks after completing the face-to-face version, feasibility was evaluated using the Technology Acceptance Model (TAM) ,12. TAM Although the TAM is mostly used to evaluate information technology, we chose the TAM to examine the face-to-face version as well, in order to compare both versions of the program.The concepts were measured by using online questionnaires for each program (TAM online and TAM live). Both questionnaires contained seven items concerning usefulness and user acceptance. Due to the different forms (face-to-face and online), the concept perceived ease of use differs in this questionnaire. All questions were answered on a categorical scale with room for additional comments. In addition, there was one question on how much each subject appreciated the program on a scale of 0 to 10 . Concepts and questions of the TAM are described in Table The peer leaders were asked to fill in an online TAM-trainer questionnaire to give their opinion on perceived usefulness, perceived ease of use and user acceptance of the program in which they participated. In addition, three questions were asked on fulfilling the role of peer leader (preparation and execution) as well as willingness to lead the training again. The peer leaders were also asked to rate their opinion of the program.Adherence to the program was measured after completing the programs by describing how many people had completed the whole course. Also each participant’s presence during the chats on the discussion board and finishing the exercises of the online program were measured. Content of the interaction on discussion board and chat were available in text and were studied after finishing the online program.Participants of both programs were also asked to describe and to evaluate the goals they wanted to achieve within the program. The fulfilling of the goal was evaluated by the participants themselves and written down by the peer leaders. In the face-to-face version of the program, the goals were evaluated verbally during the last session. In the online training goals were evaluated in the last chat session. The young adults were asked to score their satisfaction on achieving their goals on a scale of ‘0’ to ‘10’ .All quantitative data were entered into an SPSS 15.0 database and processed using descriptive statistics. The five possible answers on the concepts ‘perceived usefulness’ were combined in three answers: ‘agree’, ‘agree/disagree’ and ‘disagree’ and analyzed, using frequency scores. An item was considered as sufficient if 2/3 of the participants agreed with the item. Participation in the e-Health application, chat, discussion board, home exercises, was counted throughout the content management system of the website. Additional comments of the participants were collected afterwards by the researcher (JA) and were thematically organized and reported.Explorative qualitative analyses of the interaction on the e-Health applications were performed by three researchers . They coded all transcripts independently. Relevant fragments were first categorized into concepts of “topics of discussion”, “type of questions” and content and subsequently categorized into subthemes, using inductive analysis until consensus was reached.For evaluation of the goals and appreciation of the program, mean and range were computed.The online self-management program began in January 2011 with two groups of six participants. Eleven of the participants followed the whole program and participated in the study. One dropped out, due to an exacerbation of illness. One participant was lost to follow-up. The face-to-face version started in March 2011. There were no dropouts during the weekend experience though one participant was lost to follow up.Sixteen participants were female; only 3 males participated in this study. The mean age was 21 years in the face-to-face group and 22 years in the online group. The demographics are described in Table All participants of the online program used the Internet on a daily basis. Email, chat and visiting social media were used most often. They all regularly searched for health information on different websites.Seven out of ten participants rated the program as useful considering ‘dealing with problems in daily life’. Now that they know the program and form, they would all recommend the program to others and even participate again. Nine out of ten participants indicated the time investment as worthwhile Table .The participants of the face-to-face program valued the program as equally useful when considering ‘carry out treatment, daily live and addition to healthcare’. All participants indicated the time investment as ‘worthwhile’. Six out of ten would participate again Table .All participants found the online program ‘easy to use’ and appreciated the ‘look and feel’ of the website. There were no great difficulties with logging in or technical bugs and they could easily find what they were looking for.The perceived ease of use of the content of the face-to-face program was judged positively by the participants. Relations & intimacy and ‘having control over your life and arthritis’ received the highest scores Table . PositivThere were no dropouts in the face-to-face weekend program. Twelve participants started the online program; eleven finished it after six weeks. One participant dropped out after three weeks due to an increase of disease activity. Nearly all online participants logged in twice a week on the website and participated in the 90 minutes weekly chat. Two participants missed one chat, due to hospitalization and school activities. Ninety-five percent of the home exercises were finished. In total, 191 messages were posted on the discussion board; 17 messages were sent by the trainer, 174 messages were sent by the participants with a mean number of 21 messages per participant.On the discussion board, the main topic of the posted messages was sharing experiences on the themes of the program (for example: what does arthritis mean to you or how do you handle problems) and discussion of questions about the home exercises. Real life examples were given to clarify their experiences. Tips and tricks about dealing with fatigue and dealing with friends were shared. Support was given in case of concerns about their future or communication problems with the health care provider or the mentor at school or work.Furthermore, individual goals to achieve in the program and future goals were discussed. Feedback and support were given if they had undertaken a step to achieve their goal . In the group chat, the homework was discussed and the new theme was explained. Despite the fact that they couldn’t see each other–no webcams were used, the young adults shared a lot of personal experiences . Encouragement, tips, tricks and support were also given in this case.The 10 participants of the online training formulated a total of fourteen personal goals; the 9 face-to-face participants formulated a total of fifteen goals Table . After sConcerning the perceived usefulness, three of the four peer leaders of the online training rated the domain ‘dealing with problems in daily live’ as the most useful. All four peer leaders found the program and the online applications ‘easy to use’ and ‘clear in their purpose’. There were no big technical problems or bugs. All peer leaders were willing to lead the program again. Two peer leaders were surprised by the level of intimacy and frankness the group reached despite the fact that they could not ‘actually see each other live’. Additional comments were made about the preparation needed (‘I didn’t plan enough time to prepare myself’) and the execution of the program (‘is there an online tool available for keeping track of the exercises of the participants?’). The collaboration with the peer leaders was highly appreciated. The program in general received a mean overall score of 7.5 (range 7–8).All peer leaders rated that the face-to-face program ‘as useful’ on all aspects. Overall scores on content and form for the face-to-face self-management program were good, except for ‘healthy nutrition’ (a topic of the Sport and Exercise theme). They would recommend the program to others and felt confident ‘to fulfill their role as peer leader’. They were also willing to give the training again. Three out of four peer leaders recommended that ‘there should be more physical activities at the start of the program’. Peer leaders also noticed that more attention should be paid on the theme of feeling blue or depression. The face-to- face program received a mean score of 7.7 (range 6–10).This study assessed the feasibility of an online and a face-to-face version of a recently developed self-management program ‘Challenge your arthritis’. This program was designed to help young adults with rheumatic diseases manage their chronic health condition. Considering the three domains of feasibility, the young adults and peer leaders appreciated the online and face-to-face program both as useful and found the time investment ‘worthwhile’.They all would recommend the program in which they participated to other young adults with a rheumatic disease and all stated that they were likely to participate again, now they know the program’s content and form.To predict the acceptance of a  program, we used the TAM model  in orderFrom the start of the process of development, we chose to have an active involvement with the young adults themselves which could have attributed to the positive outcomes of feasibility. Active involvement of end users is recognized as a critical factor for the actual use of the intervention, by Van Gemert-Pijnen et al. . They stThe positive outcomes of the patients and peer leaders on the feasibility of the program may have been influenced by the active involvement of the young adults themselves.Adherence to both versions of the program was high, the dropout rate was low. This is in contrast with the results of the ‘Eysenbach’ study  in whichStinson et al.  exploredBased on our own practice with young adults and the theory of Bandura , we knowOur study showed that young adults were positive about the content and felt comfortable to talk about personal information in the online program. These findings were also recognized in the feasibility study of White  among a We have shown that both versions of the self-management program ‘Challenge your arthritis’ are feasible and are appreciated by young adults with a rheumatic disease. The involvement of the end user in the development of the program has contributed to the usefulness, ease of use and user acceptance. The support of self-management of chronically ill young patients is an important task of all health care professionals ,4,5,8,22JIA: Juvenile idiopathic arthritis; DRPL: Dutch rheumatism patient league; TAM: Technology acceptance model; MCTD: Mixed connected tissue disease.The authors declare that they have no competing interests.JA designed and coordinated the study, contributed to data collection, data analyses and interpretation, compiled the manuscript first and final manuscript draft. HvO and AAK were involved in the study design, data analyses and interpretation and drafting the final manuscript. LS and MZ participated in the design of the study, data collected, data analysis, interpretation and compiled the first manuscript draft. AdV, as patient representative of the DRPL and co project leader of this (research) project, helped to coordinate this study. HB endorsed the study and was involved in drafting the manuscript. All authors read and commented on the manuscript. All authors read and approved the final manuscript.