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Abstract Background Coaching on Lifestyle (CooL) is a two-year healthcare intervention for people with overweight or obesity, stimulating weight reduction by promoting sustained healthier behavior. The objective of this study is to investigate the effects of CooL on participants’ anthropometrics, personal factors and behavioral factors over the two-year timeframe of CooL. Methods A descriptive case series study, using a broad set of routinely collected data on anthropometrics, personal factors and behavioral factors of adults living across the Netherlands. The data were collected between November 2018 and December 2021 among participants of CooL (N = 746) at three moments during the intervention: at baseline (T0), at 8 months (T1) after completion of phase 1 and at 24 months (T2) after ending CooL. Changes over time were analyzed using paired t-tests comparing baseline to T1 and baseline to T2. In addition, potential differences on outcomes in subgroups based on education level, weight status and group size were examined using paired t-tests and ANOVA-tests. Results The results showed positive changes on all outcomes at 24 months compared to baseline. The largest effects were on perceived health, attentiveness towards meal size and meal composition (large effect size). Mean weight loss was 4.13 kg (SD 7.54), and mean waist circumference decreased with 4.37 centimeters (SD 8.59), indicating a medium to large effect size. Changes were consistent across subgroups varying in educational level, BMI at baseline and group size. Conclusion The study demonstrated sustained weight-related effects of CooL over 24 months supporting its two-year duration. The results indicate that CooL, though not for every individual, is in general appropriate and effective for different group sizes and for a wide variety of participants regardless of level of education, or BMI at baseline. Trial registration Dutch Trial Register NTRNL6061 (13-01-2017). Registered at Overview of Medical Research in the Netherlands (OMON), via https://www.onderzoekmetmensen.nl/ .

BackgroundEngagement with and the potential impact of web-based interventions is often studied by tracking user behavior with web analytics. These metrics do provide insights into how users behave, but not why they behave as such. ObjectiveThis paper demonstrates how a mixed methods approach consisting of (1) a theoretical analysis of intended use, (2) a subsequent analysis of actual use, and (3) an exploration of user perceptions can provide insights into engagement with and potential impact of web-based interventions. This paper focuses on the exploration of user perceptions, using the chlamydia page of the Dutch sexual health intervention, Sense.info, as a demonstration case. This prevention-focused platform serves as the main source of sexual and reproductive health information (and care if needed) for young people aged 12-25 years in the Netherlands. MethodsFirst, acyclic behavior change diagrams were used to theoretically analyze the intended use of the chlamydia page. Acyclic behavior change diagrams display how behavior change principles are applied in an intervention and which subbehaviors and target behaviors are (aimed to be) influenced. This analysis indicated that one of the main aims of the page is to motivate sexually transmitted infection (STI) testing. Second, the actual use of the chlamydia page was analyzed with the web analytics tool Matomo. Despite the page’s aim of promoting STI testing, a relatively small percentage (n=4948, 14%) of the 35,347 transfers from this page were to the STI testing page. Based on these two phases, preliminary assumptions about use and impact were formulated. Third, to further explore these assumptions, a study combining the think-aloud method and semistructured interviews was executed with 15 young individuals aged 16-25 (mean 20, SD 2.5) years. Template analysis was used to analyze interview transcripts. ResultsParticipants found the information on the Sense.info chlamydia page reliable and would visit it mostly for self-diagnosis purposes if they experienced potential STI symptoms. A perceived facilitator for STI testing was the possibility to learn about the symptoms and consequences of chlamydia through the page. Barriers included an easily overlooked link to the STI testing page and the use of language not meeting the needs of participants. Participants offered suggestions for lowering the threshold for STI testing. ConclusionsThe mixed methods approach used provided detailed insights into the engagement with and potential impact of the Sense.info chlamydia page, as well as strategies to further engage end users and increase the potential impact of the page. We conclude that this approach, which triangulates findings from theoretical analysis with web analytics and a think-aloud study combined with semistructured interviews, may also have potential for the evaluation of web-based interventions in general.

Summary: Despite the widespread use of personalization of eHealth technologies, there is a lack of comprehensive understanding regarding its application. This systematic review aims to bridge this gap by identifying and clustering different personalization approaches based on the type of variables used for user segmentation and the adaptations to the eHealth technology and examining the role of computational methods in the literature. From the 412 included reports, we identified 13 clusters of personalization approaches, such as behavior + channeling and environment + recommendations. Within these clusters, 10 computational methods were utilized to match segments with technology adaptations, such as classification-based methods and reinforcement learning. Several gaps were identified in the literature, such as the limited exploration of technology-related variables, the limited focus on user interaction reminders, and a frequent reliance on a single type of variable for personalization. Future research should explore leveraging technology-specific features to attain individualistic segmentation approaches.

Objective Digital health interventions for behaviour change are usually complex interventions, and intervention developers should ‘articulate programme theory’, that is, they should offer detailed descriptions of individual intervention components and their proposed mechanisms of action. However, such detailed descriptions often remain lacking. The objective of this work was to provide a conceptual case study with an applied example of ‘articulating programme theory’ for a newly developed digital health intervention. Methods Intervention Mapping methodology was applied to arrive at a detailed description of programme theory for a newly developed digital health intervention that aims to support cardiac rehabilitation patients in establishing heart-healthy physical activity habits. Based on a Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) logic model of the problem, a logic model of change was developed. The proposed mechanisms of action were visualised in an acyclic behaviour change diagram. Results Programme theory for this digital health intervention includes 4 sub-behaviours of the main target behaviour (i.e. habitual heart-healthy physical activity), 8 personal determinants and 12 change objectives (i.e. changes needed at the determinant level to achieve the sub-behaviours). These are linked to 12 distinct features of the digital health intervention and 12 underlying behaviour change methods. Conclusions This case study offers a worked example of articulating programme theory for a digital health intervention using Intervention Mapping. Intervention developers and researchers may draw on this example to replicate the method, or to reflect on most suitable approaches for their own behaviour change interventions.

IntroductionSocial activities are important for health and act as a driver of cognitive reserve during aging. In this perspective paper, we describe challenges and outline future (research) endeavors to establish better operationalization of social activities in multidomain interventions to prevent dementia.BodyWe first address the lack of conceptual clarity, which makes it difficult to measure engagement in social activities. Second, drawing from our experience with the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER), we discuss social activities in multidomain dementia prevention interventions. Using qualitative data from the Multimodal Preventive Trial for Alzheimer’s Disease (MIND-ADmini), we reflect on participant experiences with social activities. Third, we address the potential and challenges of digital solutions in promoting social activities in interventions for dementia prevention. Finally, we share insights from a workshop on digital technology, where we consulted with individuals with and without cognitive impairment who have been involved in three European projects (i.e., EU-FINGERS, Multi-MeMo, and LETHE).DiscussionBased on these insights, we advocate for research that strengthens and accelerates the integration of social activities into multidomain interventions for dementia prevention. We propose several ways to achieve this: (a) by conducting mixed methods research to formulate a broadly accepted definition and instructions to measure social activities; (b) by focusing on promoting engagement in social activities beyond the intervention setting; and (c) by exploring the needs and preferences of older adults towards digitally-supported interventions and co-design of new technologies that enrich in-person social activities.

Abstract Background The main objective of this nationwide study was to investigate changes in outcomes between baseline and eight months of participation regarding anthropometrics, control and support, physical activity, diet attentiveness, perceived fitness, sleep, and stress of participants in Coaching on Lifestyle (CooL), a Combined Lifestyle Intervention (CLI). Since the study took place when the COVID-19 pandemic emerged, we defined a subobjective, i.e., to address changes in intervention outcomes over time while participants were exposed to pandemic-related restrictions and uncertainties. Methods Data were collected from November 2018 until October 2021 at different locations across the Netherlands from 1824 participating adults, meeting the CLI inclusion criteria. We collected a broad set of data on anthropometrics (weight, body mass index (BMI), waist circumference), control and support (self-mastery, social support), physical activity (sedentary time on least/most active days, physical active minutes), diet attentiveness (attentiveness to meal composition, awareness to amounts of food and attentiveness to consuming), alcohol consumption, smoking, perceived fitness (perceived health, fitness when waking, fitness during daytime, impact daily stress), sleep and stress. Results All outcomes showed improvements after eight months compared to baseline except for social support and smoking. Large effect sizes were found on weight (0.57), waist circumference (0.50) and perceived health (0.50). Behaviour patterns showed small to large effect sizes, with the largest effect sizes on diet attentiveness (i.e., attentiveness to meal composition (0.43), awareness to amounts of food (0.58) and attentiveness to consuming (0.39)). The outcomes of participants pre COVID-19 versus during COVID-19 showed differences on self-mastery (p = 0.01), sedentary time (all underlying constructs p

Abstract Background Understanding determinants of preventive sexual behaviours is important for intervention efforts to support these behaviours and, thereby, reduce STIs and HIV burden. In general, there is limited insight into determinants of preventive behaviours among university students in Mozambique. Therefore, this study set out to assess both the prevalence and the determinants of condom use and voluntary counselling and testing (VCT) service use in first year university students. Methods We conducted a cross-sectional study in May–September 2021, at the Universidade Católica de Moçambique and the Universidade Licungo, in Beira central Mozambique. We collected data on sociodemographic characteristics, heterosexual relationship experiences and personal determinants posited to be associated with condom use and VCT service use. We included 819 participants, who were selected using a clustered and random sampling design. We used Pearson's chi-square test to compare proportion and estimate the crude odd ratio as the effect size measure at 95% confidence interval, and Confidence Interval-Based Estimation of Relevance to determine correlation coefficients of means and the behaviours of interest at 95% confidence interval. Results Condoms were used by 96.1% of male participants and 95.0% of female participants. Additionally, 55.1% of male participants and 57.5% of female participants had previously used VCT services. Condom use was associated with discussing sexuality with mother, and self-efficacy for condom use negotiation, and negatively associated with attitudes that condoms reduce pleasure. VCT service use was associated with discussing sexuality with mother, sexual debut, having a sexual partner, and being in what they consider an important heterosexual relationship. Knowledge, attitude, self-efficacy and subjective norms were weakly associated with VCT service use. Conclusion In first year university students in Mozambique, reported condom use was high but VCT services were only used by about half of the participants. Interventions aiming to increase VCT service use should focus on improving communication between parents and their adolescent or young adult children, providing personalized risk information, demonstrating that VCT service use is pleasant and non-judgmental, improving users’ confidence to schedule a visit, and preparing users for possible positive testing results.

Abstract Background Intervention planners use logic models to design evidence-based health behavior interventions. Logic models that capture the complexity of health behavior necessitate additional computational techniques to inform decisions with respect to the design of interventions. Objective Using empirical data from a real intervention, the present paper demonstrates how machine learning can be used together with fuzzy cognitive maps to assist in designing health behavior change interventions. Methods A modified Real Coded Genetic algorithm was applied on longitudinal data from a real intervention study. The dataset contained information about 15 determinants of fruit intake among 257 adults in the Netherlands. Fuzzy cognitive maps were used to analyze the effect of two hypothetical intervention scenarios designed by domain experts. Results Simulations showed that the specified hypothetical interventions would have small impact on fruit intake. The results are consistent with the empirical evidence used in this paper. Conclusions Machine learning together with fuzzy cognitive maps can assist in building health behavior interventions with complex logic models. The testing of hypothetical scenarios may help interventionists finetune the intervention components thus increasing their potential effectiveness.

Objectives This study set out to understand how (which elements), in what context and why (which mechanisms) interventions are successful in reducing (problematic) alcohol use among older adults, from the perspective of professionals providing these interventions.Design Guided by a realist evaluation approach, an existing initial programme theory (IPT) on working elements in alcohol interventions was evaluated by conducting semistructured interviews with professionals.Setting and participants These professionals (N=20) provide interventions across several contexts: with or without practitioner involvement; in-person or not and in an individual or group setting. Data were coded and links between contexts, elements, mechanisms and outcomes were sought for to confirm, refute or refine the IPT.Results From the perspective of professionals, there are several general working elements in interventions for older adults: (1) pointing out risks and consequences of drinking behaviour; (2) paying attention to abstinence; (3) promoting contact with peers; (4) providing personalised content and (5) providing support. We also found context-specific working elements: (1) providing personalised conversations and motivational interviewing with practitioners; (2) ensuring safety, trust and a sense of connection and a location nearby home or a location that people are familiar with in person and (3) sharing experiences and tips in group interventions. Furthermore, the mechanisms awareness and accessible and low threshold participation were important contributors to positive intervention outcomes.Conclusion In addition to the IPT, our findings emphasise the need for social contact and support, personalised content, and strong relationships (both between client and practitioner, and client and peers) in interventions for older adults.

Background Digital health literacy (DHL) is the ability to find, understand, and appraise online health-related information, as well as apply it to health behavior. It has become a core competence for navigating online information and health service environments. DHL involves solving ill-structured problems, where the problem and its solution are not clearcut and may have no single answer, such as in the process of sensemaking. We employ and expand on information foraging theory to address how experts and novices in information retrieval perform a search task. Our overarching aim is to pinpoint best practices and pitfalls in understanding and appraising health-related information online to develop a digital intervention to increase DHL and critical thinking. Methods In this feasibility study, we recruited a total of twenty participants for our expert and novice subsamples. We collected sociodemographic data with a self-developed survey, video data through an observation protocol of a 10-minute search task, as well as audio-video data via a retrospective think-aloud. The three, multimodal data streams were transcribed and aligned. Codes were developed inductively in several iterations, then applied deductively to the entire dataset. Tabularized, coded and segmented qualitative data were used to create various quantitative models, which demonstrate viability for the qualitative and statistical comparison of our two subsamples. Results Data were visualized with Epistemic Network Analysis to analyze code co-occurrences in the three aligned data streams, and with Qualitative/Unified Exploration of State Transitions to examine the order in which participants in our two subsamples encountered online content. Conclusions This paper describes our methods and planned analyses elaborated with mock figures. Quantifying qualitative data, aligning data streams, and representing all information in a tabularized dataset allows us to group data according to various participant attributes and employ data visualization techniques to pinpoint patterns therein.

IntroductionDespite the well-known benefits of exercise-based cardiac rehabilitation for the secondary prevention of cardiovascular disease, participation in cardiac rehabilitation programmes and adherence to secondary prevention recommendations remain limited. Digital technologies have the potential to address low participation and adherence but attempts at implementing digital health interventions in real-life clinical practice frequently encounter various barriers. Studies about patients' experiences and perspectives regarding the use of digital technology can assist developers, researchers and clinicians in addressing or pre-empting patient-related barriers. This study was therefore conducted to investigate the experiences and perspectives of cardiac rehabilitation patients in Austria with regard to using digital technology for physical activity and exercise.MethodsTwenty-five current and former cardiac rehabilitation patients (18 men and 7 women, age range 39 to 83) with various cardiac conditions were recruited from a clinical site in Salzburg, Austria. Semi-structured qualitative interviews were audio-recorded and transcribed verbatim. The analysis followed a descriptive phenomenological approach, applying the framework analysis method.ResultsThe sample was diverse, including interviewees who readily used digital devices to support their physical activity, exercise and health monitoring, and interviewees who did not. Simplicity, convenience and accessibility were highlighted as important facilitators for the use of digital technology, while annoyance with digital devices, concerns about becoming dependent on them, or simply a preference to not use digital technology were commonly stated reasons for non-use. Interviewees' views on data protection, data sharing and artificial intelligence revealed wide variations in individuals' prior knowledge and experience about these topics, and a need for greater accessibility and transparency of data protection regulation and data sharing arrangements.DiscussionThese findings support the importance that is attributed to user-centred design methodologies in the conceptualisation and design of digital health interventions, and the imperative to develop solutions that are simple, accessible and that can be personalised according to the preferences and capabilities of the individual patient. Regarding data protection, data sharing and artificial intelligence, the findings indicate opportunity for information and education, as well as the need to offer patients transparency and accountability in order to build trust in digital technology and digital health interventions.

Abstract Purpose To produce a culturally adapted translation of the Rapid Assessment of Physical Activity (RAPA) questionnaire for German speaking Austrians and to conduct a linguistic validation of the new language version. Methods The original English RAPA questionnaire was translated into German for Austria and underwent an independent forward and back translation, followed by cognitive debriefing interviews with older adults aged 55 to 78 years with and without health conditions (n = 13), for linguistic validation. Results Several distinct choices were made in the translation of the RAPA questionnaire to German, including the use of colloquial terms for ‘physical activity’ and ‘intensity’; and the decision to keep to the original examples and images of different physical activities for illustrating the intensity levels (light, moderate, vigorous) of physical activity. In cognitive debriefing, interviewees commented that some example activities for the respective intensity levels could – depending on the individual – also represent a higher or lower intensity level; and that the wording of RAPA items 4 and 5, which describe the category ‘under-active regular’ aerobic activity, was difficult to understand. Both issues were addressed and resolved through minor iterative modifications made during the cognitive debriefing process. Conclusions A new version of the RAPA questionnaire in German for Austria has been produced by forward and back translation and linguistic validation. The questionnaire may now undergo psychometric evaluation.

(1) Background: A healthy lifestyle has a protective role against the onset and management of asthma and chronic obstructive pulmonary disease (COPD). Therefore, combined lifestyle interventions (CLIs) are a potentially valuable prevention approach. This review aims to provide an overview of existing CLIs for the prevention and management of asthma or COPD. (2) Methods: A systematic literature search was conducted using PubMed, EMBASE, and PsycInfo. Studies were included if CLIs targeted at least two lifestyle factors. (3) Results: Among the 56 included studies, 9 addressed asthma and 47 addressed COPD management, with no studies focusing on prevention. For both conditions, the most prevalent combination of lifestyle targets was diet and physical activity (PA), often combined with smoking cessation in COPD. The studied CLIs led to improvements in quality of life, respiratory symptoms, body mass index/weight, and exercise capacity. Behavioural changes were only measured in a limited number of studies and mainly showed improvements in dietary intake and PA level. (4) Conclusions: CLIs are effective within asthma and COPD management. Next to optimising the content and implementation of CLIs, these positive results warrant paying more attention to CLIs for persons with an increased risk profile for these chronic respiratory diseases.

Cardiac rehabilitation (CR) patients often do not sustain physical activity (PA) behaviour in the long run, once they progress into a self-management stage of secondary prevention. This study aimed to explore former CR patients' PA preferences, determinants (i.e., influencing factors) and motivation for sustained PA engagement. We conducted a cross-sectional multi-centre survey using an original questionnaire based on prior qualitative interviews with cardiac patients. Five CR centres in Austria posted 500 questionnaires to former CR patients who had completed CR approximately three years prior, and 117 patients (23%) responded. Descriptive analysis was used to analyse closed-ended questions, and self-determination theory (SDT) was applied as a qualitative framework to analyse open-ended questions concerning motivation for PA engagement. Patients were generally physically active, but the majority (75.3%) did not fulfil the World Health Organisation's recommendations for aerobic PA and muscle strengthening. Most patients preferred being physically active outdoors (70%), engaging in aerobic-related (95%), individual and non-competitive exercises, with cycling (52%), walking (32%) and hiking (25%) among the most popular activities. Main determinants of PA were health, pain and motivation for 80%, 68%, 67% of patients, respectively. A subset of patients (77%) expanded on their motivations behind PA. According to SDT, most reasons (90%) were regulated by autonomous motivation (either extrinsically autonomously-regulated or intrinsic motivation) and stemmed mostly from health-related goals (e.g., fitness, general health, weight control), future quality-of-life aspirations (e.g., self-sufficiency in old age, presence for loved ones, preserving mobility) and enjoyment of PA. Patients' responses underscore the importance of promoting not only general PA, but also muscle strengthening training in CR interventions to maximise optimal health benefits. Our data further suggest that interventions which are aligned to patients' health goals and foster autonomous motivation may be particularly beneficial in increasing adherence to PA in the long-term.

Objective Digital health technologies offer great potential to improve access and adherence to cardiovascular disease secondary prevention measures such as regular physical activity (PA). However, the use and perceptions of digital technology (DT) among cardiac rehabilitation (CR) patients are not well understood. The aim of this study was therefore to explore the use of DT in former CR patients’ daily lives, for PA and for health information; and to gain insight into patient perceptions of DT for PA, including barriers, facilitators and requested features. Methods A cross-sectional postal survey was conducted between May 2022 and January 2023. Five Austrian CR centres contacted 500 former patients who had completed a phase 2 CR programme from January 2019 onwards. One-hundred seventeen patients (mean [SD] age, 69 ± 10 years, 22% female) responded. Descriptive and thematic analyses were conducted for closed and open-ended questions, respectively. Results Results indicated high DT usage for communication and informational aspects, and to a large extent also for PA and health information seeking. Main facilitators of DT use for PA were attributed to health and behavioural monitoring. Main barriers were lack of perceived need, lack of interest and poor usability. Most frequently requested features included pulse and blood pressure measurement, step count and compatibility to other devices. Conclusions Patients generally used and perceived DT as beneficial in daily life and for secondary prevention purposes such as PA. The survey identified facilitators, barriers and feature requests, which may inform the design and implementation of digital health interventions for CR patients.

ABSTRACTObjective Regression analyses are commonly used for selecting determinants to target in behavior change interventions, but the aim of this article is to explain why regression analyses are not suitable for this purpose (i.e. the regression trap).Methods This aim is achieved by providing (1) a theoretical rationale based on overlap among determinants; (2) a mathematical rationale based on the formulas that are used to calculate regression coefficients; and (3) examples based on real-world data.Results First, the meaning of regression coefficients is commonly explained as expressing the association between a determinant and a target behavior ‘holding all other predictors constant.’ We explain that this often boils down to ‘neglecting a part of the psyche.’ Second, we demonstrate that the interpretation of regression coefficients is distorted by correlations between determinants. Third, the examples provided demonstrate the impact this has in practice. This results in interventions targeting determinants that are less relevant and, thereby, have less impact on behavior change.Conclusion There are theoretical, mathematical, and practical reasons why regression analyses, and by extension multivariate analyses relying on correlations, are not suitable to select determinants to target in behavior change interventions. Instead, intervention developers should consider univariate distributions and bivariate association estimates simultaneously and there are freely accessible tools available to do so.

ABSTRACTWhen developing behavior change interventions in a systematic way, it is important to select determinants relevant to the target behavior. Data is needed to gain insight into the determinant structures (the relative strengths of associations between determinants and behavior) and their univariate distributions. This insight is crucial to select the most relevant determinants, but at the same time institutions tasked with behavior change (e.g. prevention organizations, municipal health services) often operate under prohibitive resource constraints, which also extend to how easily they can collect data from a sample. This paper introduces CIBERlite – an approach that furnishes the intervention developer with an idea of the relevance of a limited number of determinants using short measurements informed by theory. The first study (N = 401) in a series of three explores the convergent validity of short and full measurements of determinants derived from the Reasoned Action Approach. The short measurements are used in the main study (N = 415) that serves as a proof-of-concept for the CIBERlite plot, an efficient visualization combining data of determinant structures and their univariate distributions for eight behaviors. The unexpected patterns detected in the main study led to an expert estimation study (N = 45), which shows that individual experts have difficulty in predicting how people score on determinants. This stresses the importance of conducting determinant studies and CIBERlite is a valuable alternative to do so if resources are limited.

BackgroundThe COVID-19 pandemic revealed that with high infection rates, health services conducting contact tracing (CT) could become overburdened, leading to limited or incomplete CT. Digital CT support (DCTS) tools are designed to mimic traditional CT, by transferring a part of or all the tasks of CT into the hands of citizens. Besides saving time for health services, these tools may help to increase the number of contacts retrieved during the contact identification process, quantity and quality of contact details, and speed of the contact notification process. The added value of DCTS tools for CT is currently unknown. ObjectiveTo help determine whether DCTS tools could improve the effectiveness of CT, this study aims to develop a framework for the comprehensive assessment of these tools. MethodsA framework containing evaluation topics, research questions, accompanying study designs, and methods was developed based on consultations with CT experts from municipal public health services and national public health authorities, complemented with scientific literature. ResultsThese efforts resulted in a framework aiming to assist with the assessment of the following aspects of CT: speed; comprehensiveness; effectiveness with regard to contact notification; positive case detection; potential workload reduction of public health professionals; demographics related to adoption and reach; and user experiences of public health professionals, index cases, and contacts. ConclusionsThis framework provides guidance for researchers and policy makers in designing their own evaluation studies, the findings of which can help determine how and the extent to which DCTS tools should be implemented as a CT strategy for future infectious disease outbreaks.

BackgroundWeb-based sexual health interventions may be more acceptable to people compared with face-to-face support, given the stigma and embarrassment often associated with sexual problems. The Dutch public sexual health clinics (SHCs) conducted an implementation pilot with 4 web-based self-training programs on sexual dysfunctions (WSTPs) for young people. In addition to a basic sexuality program, the WSTPs focused on the following complaints: pain during intercourse, premature ejaculation, and no sex drive. ObjectiveThis study aims to gain insight into the potential reach of the freely offered WSTPs; use, acceptance, evaluation, and perceived impact of the WSTPs by young people; and evaluation and acceptance of the WSTPs by nurses of the SHCs. MethodsA quantitative baseline measurement (BM) and a follow-up measurement (FM) were conducted among the users. In addition, qualitative data were gathered through video interviews with a sample of respondents of the FM and nurses of the SHCs to gain more in-depth insights into their assessment of the WSTPs. Participants were recruited via social media, posters, and referrals by nurses of the SHCs. Quantitative data were analyzed using descriptive statistics. Independent 2-tailed t tests and one-way independent ANOVAs were used to compare the scores between subgroups based on background characteristics. Dependent 2-tailed t tests were used to assess the possible changes between BM and FM. The interviews were analyzed using a thematic analysis. ResultsA total of 1028 young people (aged 16-24 y) completed the BM, 666 started with 1 of the WSTPs, and 104 participants completed the FM. In addition, 8 users and 8 nurses were interviewed. Of the participants who completed the BM, 87.74% (902/1028) experienced moderate (411/1028, 39.98%) to high (491/1028, 47.76%) severity of complaints, of which 20.43% (210/1028) had had them for >1 year and 27.82% (286/1028) even for ≥2 years, and 38.91% (400/1028) were dissatisfied with their sex lives. Only 8.75% (90/1028) had sought professional help in the past 2 years. At FM, users rated satisfaction with their sex life more positively than they did at BM, and they experienced less discomfort from their complaints. The overall rating was positive, with a mean report grade of 7.3 (SD 1.45; on a 10-point scale). Anonymity, clear information and explanation, and practical exercises are indicated as strengths of the WSTPs, leading to more understanding and normalization. Nurses appreciate the high quality of information and accessibility of the WSTPs. They consider them as a valuable addition to the consultation hours. ConclusionsWSTPs can reach a large number of young people with sexual problems who are less likely to seek professional help. This can result in an improved understanding of their issues, a decrease in complaints, and reduced barriers to communicating with a partner or professional.

BackgroundSouth Africa, a middle-income country, has an adolescent fertility rate far higher than that of high-income countries. Adolescent girls and young women have an increased risk of pregnancy-related complications and lower antenatal appointment attendance rates than older adult pregnant women. Mobile health (mHealth) interventions to improve health behaviors among pregnant adolescent girls and young women in low- and middle-income countries are scarce. ObjectiveThis paper describes the development and components of an mHealth intervention to improve antenatal appointment attendance and health behavioral determinants among pregnant adolescent girls and young women in South Africa and details the protocol for a pilot randomized controlled trial that evaluated the intervention’s efficacy and user acceptability. MethodsThe intervention, Teen MomConnect, sent tailored motivational behavior change and behavioral reinforcement SMS text messages to participants about antenatal appointment keeping and pregnancy behaviors. The delivery methodology of the intervention was adapted from MomConnect, an mHealth education program for pregnant women in South Africa that has nationwide coverage. In addition, participants received a face-to-face motivational interviewing session delivered by a trained research assistant. Pregnant adolescent girls and young women aged 13 to 20 years were recruited from health facilities and community networks. Participants were randomized into the control group that received the standard MomConnect health SMS text messages or the experimental group that received the Teen MomConnect intervention. Participants completed a baseline questionnaire upon enrollment in the study and a follow-up questionnaire after the end of their pregnancy. The questionnaires assessed demographic characteristics, pregnancy behaviors, and the psychosocial determinants of antenatal appointment attendance (knowledge, attitudes, social support, risk perceptions, self-efficacy, intention, and action planning). Feasibility was assessed using descriptive analyses of acceptability, study implementation processes, and perceived satisfaction with the intervention. The number of appointments attended was obtained from the participants’ clinic records. Appointment attendance was compared between the control and experimental groups, as were awareness of HIV status and the psychosocial determinants of antenatal appointment attendance. ResultsParticipant recruitment was conducted from May 2018 to December 2018, and the questionnaire-based data collection was completed by December 2019. Overall, 412 participants were enrolled. ConclusionsThis paper describes the Teen MomConnect intervention to improve antenatal appointment attendance and pregnancy health behaviors among adolescent girls and young women. The results on the intervention’s preliminary efficacy and user acceptability will inform policy makers and health program officers on how tailored, age-appropriate, and motivational health behavior messages can be delivered via mobile phone to pregnant adolescent girls and young women. Trial RegistrationPan African Clinical Trial Registry (PACTR) PACTR201912734889796; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9565 International Registered Report Identifier (IRRID)DERR1-10.2196/43654

ABSTRACTBackground Behavior change interventions have a vital role in enhancing human health and well-being. Nevertheless, concerns have been raised about suboptimal reporting of behavior change interventions, making analyses, replications, and intervention re-use hard or impossible to conduct.Objective This paper introduces acyclic behavior change diagrams (ABCDs) to achieve more transparent development, evaluation, and reporting of behavior change interventions. ABCDs are a visual representation of the assumptions regarding causal-structural chains that underlie putative active ingredients of behavior change interventions. These causal-structural chains link the behavior change principles that are applied in an intervention to the (determinants of) behavior targeted in that intervention.Conclusions ABCDs are helpful in making implicit assumptions explicit and help communicate assumptions with team members and other stakeholders. Moreover, we believe they make evaluation easier, and their machine-readability allows for ABCDs to be imported directly into (systematic review) databases with negligible costs while disclosing complete and accurate data. Finally, the ABCD approach fits well with other initiatives to gain a deeper understanding and synthesis of the literature on active intervention elements.

Abstract Background Social networks, i.e., all social relationships that people have, contribute to well-being and health. Governmental measures against COVID-19 were explicitly aimed to decrease physical social contact. We evaluated ego-centric social network structure and function, and changes therein, among various sociodemographic subgroups before and during the COVID-19 pandemic. Methods Independently living Dutch adults aged 40 years and older participating in the SaNAE longitudinal cohort study filled in online questionnaires in 2019 and 2020. Changes in network size (network structure) and social supporters (network function) were assessed. Associations with risk for changes (versus stable) were assessed for sociodemographic subgroups (sex, age, educational level, and urbanization level) using multivariable regression analyses, adjusted for confounders. Results Of 3,344 respondents 55% were men with a mean age of 65 years (age range 41–95 in 2020). In all assessed sociodemographic subgroups, decreases were observed in mean network size (total population: 11.4 to 9.8), the number of emotional supporters (7.2 to 6.1), and practical supporters (2.2 to 1.8), and an increase in the number of informational supporters (4.1 to 4.7). In all subgroups, the networks changed to being more family oriented. Some individuals increased their network size or number of supporters; they were more often women, higher-educated, or living in rural areas. Conclusion The COVID-19 pandemic impacted social networks of people aged 40 years and older, as they increased informational support and reduced the number of their social relationships, mainly in terms of emotional and practical supporters. Notably, some individuals did not show such unfavorable trends and managed to reorganize their networks to attribute social support roles more centrally.

Abstract Background In the Netherlands, all women aged 30–60 years are invited to participate in the national cervical cancer screening programme, which is aimed at early detection and treatment of precancerous lesions. One fourth of the Dutch population has a migration background, with Turkish and Moroccan immigrants being the largest immigrant populations. Turkish‐ and Moroccan‐Dutch women show lower screening participation rates and a higher incidence of cervical cancer, compared to native Dutch women. Since current information materials are not tailored to these women's needs, we developed a short culturally sensitive educational video to facilitate informed decision‐making for cervical cancer screening among Turkish‐ and Moroccan‐Dutch women. This article describes the development process of this video and the lessons learned. Methods Using the Entertainment–Education communication strategy, we collaborated with an interdisciplinary team of Turkish‐ and Moroccan‐Dutch women, researchers, public health experts, and creative media professionals. We developed the video following the different stages of the Media Mapping model: Orientation, Crystallization, Design/Production, Implementation, and Dissemination. Each stage is described in the paper. Results The video was developed in Moroccan‐Arabic, ‐Berber and Turkish, and emphasized three main themes: (1) more certainty about having cervical (pre)cancer and the possibility to prevent treatment, surgery, or premature death, and because of this, being there for the children, (2) according to the Islam, a woman should take good care of her health, and (3) anxiety, shame, and privacy. Conclusions A short culturally sensitive educational video, delivered as part of a larger intervention together with the current information brochure, was developed based on theory and grounded in the needs of Turkish‐ and Moroccan‐Dutch women. The value and effectiveness of this intervention to facilitate informed cervical cancer screening decisions are evaluated in a randomised controlled trial. Patient or Public Contribution We collaborated with Turkish‐ and Moroccan‐Dutch women during the development process of a short culturally sensitive educational video. Turkish‐ and Moroccan‐Dutch women were also invited to watch the raw footage to verify whether the content and presentation matched their needs and requirements.

Abstract Background Antenatal care is imperative for adolescents and young women, due to their increased risk of pregnancy-related complications. Evidence on the psychosocial determinants of antenatal attendance among this vulnerable group is lacking. This study assessed the relevance of the psychosocial sub-determinants of intention and self-efficacy to attend antenatal appointments among pregnant adolescents and young women in Cape Town, South Africa; with a view to informing behaviour change interventions. Methods Pregnant women and girls aged 13-20 years were recruited to complete a cross-sectional questionnaire assessing their pregnancy experiences, pregnancy-related knowledge and psychosocial determinants related to antenatal care seeking. Confidence Interval Based Estimation of Relevance (CIBER) analysis was used to examine the association of the psychosocial sub-determinants with the intention and self-efficacy to attend antenatal appointments, and to establish their relevance for behaviour change interventions. The psychosocial sub-determinants comprised knowledge, risk perceptions, and peer, partner, family and individual participant attitudes. Results The mean gestation age of participants (n=575) was 18.7 weeks, and the mean age was 18 years. Risk perceptions of experiencing preeclampsia and heavy bleeding during pregnancy or childbirth if clinic appointments are not attended had moderate mean scores and were positively correlated with intention and self-efficacy, which makes them relevant intervention targets. Several family, peer, partner and individual participant attitudes that affirmed timely appointment attendance had strong positive associations with intention and self-efficacy but their mean score were already high. Conclusions Given the high means of the family, peer, partner and individual participant attitudes, the relevance of these attitudinal items as intervention targets was relatively low. Further studies are recommended to assess the relevance of these sub-determinants in similar populations.

BackgroundPatient online access to medical records is assumed to facilitate patient empowerment and advance patient-centered health care. However, to date, the actual effects of online access to medical records perceived by patients and other outcomes are insufficiently empirically tested. ObjectiveThis study aimed to investigate the effects of online access to medical records on patient empowerment, informed decision-making, and the patient-provider relationship perceived by patients. MethodsA nationwide, 2-wave, longitudinal survey study was conducted among Dutch adults (N=2402). Linear regression analyses were performed. In model 1, the perceived effects of online access to medical records (measured at T1 [first measurement; July 2021]) on 16 outcomes (measured at T2 [second measurement; January 2022]), which were associated with the use of online access to general practice medical records in previous research, were investigated. Model 2 included sociodemographic factors and patient characteristics as confounders. ResultsUsers indicated more strongly than nonusers that online access to medical records would increase their participation in health care, improve the relationship with their general practitioner, and support informed decision-making. These results were robust when adjusted for the influence of confounders. Effect sizes were very small, with unstandardized regression coefficients (B) ranging between −0.39 and 0.28. Higher digital and health literacy were associated with higher ratings of almost all effects. ConclusionsOnline access to medical records has the potential to empower patients and foster informed decision-making among patients. The effects in this study were small but might grow over time. Other factors, such as the attitude of general practitioners toward online access to medical records, might moderate these effects. The results indicate that the potential benefits of online access to medical records might be unevenly distributed. We suggest future exploration of the conditions under which online access to medical records can improve health care system functioning and efficiency without increasing health inequality.

BackgroundReducing the rates of sexually transmitted infections (STIs) among young people is a public health priority. The best way to avoid STIs from penetrative sex is to use a condom, but young people report inconsistent use. A missed opportunity to intervene to increase condom use is when young people access self-sampling kits for STIs through the internet. The potential of this opportunity is enhanced by the increasing numbers of young people being tested through this route every year in England. Hence, in a cocreation by young people, stakeholders, and researchers, Wrapped was developed––a fully automated, multicomponent, and interactive digital behavior change intervention developed for users of STI self-sampling websites, who are aged 16-24 years. ObjectiveThis paper is a protocol for a feasibility randomized controlled trial (fRCT). The fRCT seeks to establish whether it is feasible to run a randomized controlled trial to test the effectiveness and cost-effectiveness of Wrapped. Wrapped aims to reduce the incidence of STIs through increasing correct and consistent use of condoms among users of STI self-sampling websites, who are aged 16-24 years. MethodsA 2-arm parallel-group randomized fRCT of Wrapped plus usual care, compared to usual care only (basic information on STIs and condom use), with a nested qualitative study. A minimum of 230 participants (aged 16-24 years) are recruited from an existing chlamydia self-sampling website. Participants are randomized into 1 of 2 parallel groups (1:1 allocation). Primary outcomes are the percentage of users recruited to the fRCT and the percentage of randomized participants who return a chlamydia self-sampling kit at month 12. Additionally, besides chlamydia positivity based on biological samples, surveys at baseline, month 3, month 6, and month 12, are used to assess condom use attitude, behavioral capability, self-efficacy, and intention, along with details of any partnered sexual activity and condom use, and health economic data. Nested qualitative interviews with trial participants are used to gain insight into the factors affecting recruitment and attrition. ResultsRecruitment to the fRCT began in March 2021 and was completed in October 2021. Data collection was completed in December 2022. ConclusionsThis feasibility study will provide data to inform the design of a future-definitive trial. This work is timely given a rapid rise in the use of internet testing for STIs and the sustained high levels of STIs among young people. Trial RegistrationISRCTN Registry ISRCTN17478654; http://www.isrctn.com/ISRCTN17478654 International Registered Report Identifier (IRRID)DERR1-10.2196/43645

Abstract Background Most diagnosed oral cancer cases in Saudi Arabia are in the Jazan region. A common type of smokeless tobacco "Shammah" is prevalent in this region. This study aimed to gain an in-depth understanding of the possible psychosocial determinants of Shammah consumption among adult Shammah users in Jazan region. Methods A qualitative study was conducted by means of one-on-one interviews among thirty adult Shammah users. Participants were recruited by means of a purposive sampling technique. Data were collected using a semi-structured interview guide utilizing face-to-face and phone-call interviews. Thematic analysis with hybrid approach was used to analyze the dataset. Results Twenty-four sub-codes within four overarching themes were generated. Participants revealed uncertainty related to Shammah composition, how to quit knowledge and Shammah prevention/cessation programs. Shammah use identified as a normal phenomenon in society. Its use was frequently reported in participants’ close network but most users faced family and peers’ disapproval. Some users expressed joy, happiness and focused when using Shammah. Others were disgusted or neutral. Many users believed Shammah causes cancer and tears oral tissues. Others believed it relieves toothache or has no effect. Majority of users were confident to quit and recalled some quitting aids. Toothache, craving, drinking tea and chewing Khat (leaves of Catha edulis plant that causes moderate euphoria) perceived to be triggers to use Shammah. Availability of Shammah, withdrawal symptoms, stress, lack of support, seeing others using Shammah, losing part of routine and toothache were barriers to quit. Conclusions Shammah use was associated with uncertainty about Shammah composition and quitting knowledge, social acceptability, influence from family/friends, a range of positive and negative attitudinal beliefs toward its use and high quitting efficacy beliefs. Future interventions targeting Shammah should address the acknowledged triggers and barriers in the present study including the dual use of Shammah and Khat.

This study assessed inequality in maternal healthcare service utilization in the Democratic Republic of the Congo, using the Demographic and Health Surveys of 2007 and 2013–2014. We assessed the magnitude of inequality using logistical regressions, analyzed the distribution of inequality using the Gini coefficient and the Lorenz curve, and used the Wagstaff method to assess inequality trends. Women were less likely to have their first antenatal care visit within the first trimester and to attend more antenatal care visits when living in eastern Congo. Women in rural areas were less likely to deliver by cesarean section and to receive postnatal care. Women with middle, richer, and richest wealth indexes were more likely to complete more antenatal care visits, to deliver by cesarean section, and to receive postnatal care. Over time, inequality in utilization decreased for antenatal and postnatal care but increased for delivery by cesarean sections, suggesting that innovative strategies are needed to improve utilization among poorer, rural, and underserved women.

Populations in post-conflict settings often have increased healthcare needs, residing in settings where basic services needed to maintain good health may be non-existent or hard to access. Therefore, there is a need for better identification and reallocation of resources as part of the post-conflict health rehabilitation effort. Assets can be described as the collective resources that individuals and communities have at their disposal, which protect against adverse health outcomes and promote health status. This study applies an asset-based approach to explore the most optimal design of health services and to identify the resource constraints for basic health service delivery to the most vulnerable communities in eastern Congo. We implemented the asset mapping in two phases. Firstly, we combined a qualitative survey with community walks to identify the assets already present in the communities. Secondly, we conducted group discussions to map out assets that are the core of asset-based community development (ABCD) practice. We finally documented all assets in a Community Asset Spreadsheet. Overall, 210 assets were identified as available and potentially valuable resources for the communities in eastern Congo. Among them, 57 were related to local associations, 23 to land and physical environments, 43 to local institutions, 46 to individuals, 35 to economy and exchange, and only 6 to culture, history, and stories. Drawing upon the findings of the qualitative survey, community walks, and group discussions, we concluded that an important number of resources are in place for basic health service delivery. By activating existing and potential resources, the most vulnerable populations in eastern Congo might have the required resources for basic health service delivery. Our findings support the use of an asset-mapping research method as appropriate for identifying existing and potential resources for basic health services in a post-conflict setting.

Plain language summary Antenatal care is the routine health care of pregnant women in order to diagnose pregnancy complications and to provide information about lifestyle, pregnancy and delivery. Maternal deaths among teenage mothers in South Africa is high and is largely due to conditions that can be prevented or managed by high quality antenatal care. Timely and routine antenatal care is therefore crucial for pregnant teenagers. The way in which pregnant teenagers are treated by health care workers at antenatal clinics influences their clinic attendance. This study reports on the experiences of pregnant teenagers with health care workers, when accessing antenatal care in Cape Town, South Africa. Nineteen pregnant girls aged 13–19 years were interviewed. Some positive experiences such as respectful and supportive treatment were reported. However, more negative experiences were reported, including victimization; discrimination against being pregnant at a young age; feeling disregarded and excluded; a lack of information about pregnancy, health and childbirth; being discouraged from attending the clinics; and mental health distress. In conclusion, many teenagers felt mistreated and discriminated against by the health care workers, which discouraged their clinic attendance. Maternal health care workers in South Africa need to receive support and regular training to provide youth friendly antenatal care to teenage girls.

BackgroundIn the Netherlands, since 1996, a national cervical cancer (CC) screening program has been implemented for women aged 30 to 60 years. Regional screening organizations send an invitation letter and information brochure in Dutch to the home addresses of targeted women every 5 years. Although this screening is free of charge, Turkish- and Moroccan-Dutch women, especially, show low screening participation and limited informed decision-making (IDM). As Turkish- and Moroccan-Dutch women indicated their need for information on the practical, emotional, cultural, and religious aspects of CC screening, we developed a culturally sensitive educational video (CSEV) as an addition to the current information brochure. ObjectiveIn this study, we aimed to evaluate the added effect of the CSEV on IDM regarding CC screening participation among Turkish and Moroccan women aged 30 to 60 years in the Netherlands through a randomized intervention study. MethodsInitial respondents were recruited via several social media platforms and invited to complete a web-based questionnaire. Following respondent-driven sampling, respondents were asked to recruit a number of peers from their social networks to complete the same questionnaire. Respondents were randomly assigned to the control (current information brochure) or intervention condition (brochure and CSEV). We measured respondents’ knowledge and attitude regarding CC screening and their intention to participate in the next CC screening round before and after the control or intervention condition. We evaluated the added effect of the CSEV (above the brochure) on their knowledge, attitude, intention, and IDM using intention-to-treat analyses. ResultsThe final sample (n=1564) included 686 (43.86%) Turkish and 878 (56.14%) Moroccan-Dutch women. Of this sample, 50.7% (793/1564) were randomized to the control group (350/793, 44.1% Turkish and 443/793, 55.9% Moroccan) and 49.3% (771/1564) to the intervention group (336/771, 43.6% Turkish and 435/771, 56.4% Moroccan). Among the Turkish-Dutch women, 33.1% (116/350) of the control respondents and 40.5% (136/336) of the intervention respondents consulted the brochure (not statistically significant). Among Moroccan-Dutch women, these percentages were 28.2% (125/443) and 37.9% (165/435), respectively (P=.003). Of all intervention respondents, 96.1% (323/336; Turkish) and 84.4% (367/435; Moroccan) consulted the CSEV. The CSEV resulted in more positive screening attitudes among Moroccan-Dutch women than the brochure (323/435, 74.3% vs 303/443, 68.4%; P=.07). Women, who had never participated in CC screening before, showed significantly more often a positive attitude toward CC screening compared with the control group (P=.01). ConclusionsOur short and easily implementable CSEV resulted in more positive screening attitudes, especially in Moroccan-Dutch women. As the CSEV was also watched far more often than the current brochure was read, this intervention can contribute to better reach and more informed CC screening decisions among Turkish- and Moroccan-Dutch women. Trial RegistrationInternational Clinical Trial Registry Platform NL8453; https://tinyurl.com/2dvbjxvc

BackgroundDiagnosis of people with HIV is vital in achieving the 95-95-95 global targets. The proportion of people with HIV who know they have HIV in Sudan is low. Promoting engagement of healthcare providers (HCPs) in offering HIV Testing and Counseling (HTC) services would improve the percentage of diagnosed people with HIV in the country. This study aims to assess the psychosocial beliefs associated with HCPs' intention and behavior to offer HTC services and their relevance for intervention.MethodsThis institutional cross-sectional study was conducted in Kassala State, from July 2019 to February 2020, among 438 healthcare providers from public health facilities. A self-administered questionnaire was used to assess behavior and intention to offer HTC services and related behavioral, normative, and control beliefs. Data were analyzed using R software. Confidence Interval Based Estimation of Relevance (CIBER) was used to estimate the relevance of the beliefs to interventions.ResultsThe CIBER analysis showed that the belief “It causes many worries for patients if I offer or counsel them about HIV test” was negatively associated with HCPs' intention and behavior to offer HTC services and a highly relevant belief for intervention. The belief “My manager thinks I should offer or counsel patients about HIV test” was positively associated with the behavior and intention to offer HTC services and was a relatively highly relevant belief. The control belief “Patients are at low risk of HIV and do not need offering or counseling about HIV test” was negatively associated with HCPs' intention and behavior and was relevant for intervention. The control belief “If I offered or counseled patients about HIV test, I would spend more time with them” was negatively associated with the intention and behavior of HCPs toward HTC services, with high relevance to target with intervention. The belief “My colleagues think I should offer or counsel patients about HIV test” was weakly associated with behavior and intention, and it is a low relevant belief for intervention.ConclusionDifferent psychosocial beliefs among healthcare providers can influence their intention and behavior to offer HTC services to patients. More relevant beliefs are required to be targeted with interventions to promote the intention and behavior of providing HTC services among health care providers.

BackgroundLack of physical activity is a critical contributing risk factor to cardiovascular disease. Hence, regular physical activity is a mainstay in the primary and secondary prevention of cardiovascular disease. Despite the extensive promotion of physical activity in both primary and secondary prevention programs, including cardiac rehabilitation, physical activity levels in the cardiac population remain low. Therefore, it is crucial to understand critical determinants that influence physical activity behavior. ObjectiveThis study aims to deliver a systematic review of studies with collated observational data exploring the association between determinants and physical activity behavior in the target population. These new insights inform the design of future interventions targeted at lasting heart-healthy physical activity behavior in the cardiac population. MethodsPrimary studies with observational quantitative data on determinants and their association with physical activity behavior in the cardiac population will be included. Information on relevant primary studies will be retrieved from various databases, including Embase, CINAHL, MEDLINE, PsycInfo, and Web of Science Core Collection. Six reviewers will independently double-screen articles. Studies will be selected according to the prespecified inclusion and exclusion criteria. Data will be extracted and entered into suitable worksheets. The US-based National Heart, Lung, and Blood Institute’s Study Quality Assessment Tool for Observational Studies will be used to assess the quality of all eligible primary studies. The results will be presented in a descriptive and narrative synthesis. If the type and quality of data are suitable, meta-analyses will be conducted. Study reporting will follow the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. ResultsData collection started in September 2020, and the literature search was updated in July 2021. Data synthesis is ongoing, and the literature search will be updated in October 2022. ConclusionsThis review will be valuable to relevant stakeholders, including clinicians and health care professionals, intervention developers, and decision makers in health care. It lays a comprehensive foundation for understanding the determinants of physical activity to inform the design of secondary prevention interventions relevant to the cardiac population. Trial RegistrationPROSPERO CRD42020206637; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=206637 International Registered Report Identifier (IRRID)RR1-10.2196/39188

FCMpy is an open-source Python module for building and analyzing Fuzzy Cognitive Maps (FCMs). The module provides tools for end-to-end projects involving FCMs. It is able to derive fuzzy causal weights from qualitative data or simulating the system behavior. Additionally, it includes machine learning algorithms (e.g., Nonlinear Hebbian Learning, Active Hebbian Learning, Genetic Algorithms, and Deterministic Learning) to adjust the FCM causal weight matrix and to solve classification problems. Finally, users can easily implement scenario analysis by simulating hypothetical interventions (i.e., analyzing what-if scenarios). FCMpy is the first open-source module that contains all the functionalities necessary for FCM oriented projects. This work aims to enable researchers from different areas, such as psychology, cognitive science, or engineering, to easily and efficiently develop and test their FCM models without the need for extensive programming knowledge.

The COVID-19 pandemic has temporarily disrupted access to clinic-based sexual health care for men who have sex with men (MSM) in the Netherlands. The importance of home-based sexual health care has been underpinned as an extension of clinic-based care. This paper aims to assess intention to use, and acceptability of home-based sexual health care among MSM who previously attended clinic-based sexual health care. In November 2020, 424 MSM who had attended an STI clinic pre-pandemic were invited to participate in an online survey; 154 MSM completed the survey (response 36%). Intention to use self-sampling STI/HIV tests was assessed (median; scale 0–100) and compared across sociodemographic and sexual behavior characteristics by Kruskal-Wallis H tests. Descriptive analyses provided insights in acceptability of home-based sexual health care. Of participants (median age 47), 60.4% (93/154) tested for STI/HIV in the past 6 months, most of them attended a clinic. The median score on intention to use self-sampling tests was 86.5 (SD = 33.4) and did not differ by sociodemographic or sexual behavioral characteristics (all p-values > 0.1). Participants were positive toward online sexual health counseling (median attitude = 75.0, SD = 29.6) and their main preferred topics were PrEP use and STI/HIV testing. MSM who attended clinic-based care expressed intention to use self-sampling tests and a positive attitude toward online sexual health counseling. Home-based sexual health care elements are not currently integrated within Dutch clinic-based sexual health care and should be considered an addition for continued provision of care and extended reach of MSM.

BackgroundSmoking continues to be a driver of mortality. Various forms of evidence-based cessation assistance exist; however, their use is limited. The choice between them may also induce decisional conflict. Offering decision aids (DAs) may be beneficial; however, insights into their effective elements are lacking. ObjectiveThis study tested the added value of an effective element (ie, an “explicit value clarification method” paired with computer-tailored advice indicating the most fitting cessation assistance) of a web-based smoking cessation DA. MethodsA web-based randomized controlled trial was conducted among smokers motivated to stop smoking within 6 months. The intervention group received a DA with the aforementioned elements, and the control group received the same DA without these elements. The primary outcome measure was 7-day point prevalence abstinence 6 months after baseline (time point 3 [t=3]). Secondary outcome measures were 7-day point prevalence of abstinence 1 month after baseline (time point 2 [t=2]), evidence-based cessation assistance use (t=2 and t=3), and decisional conflict (immediately after DA; time point 1). Logistic and linear regression analyses were performed to assess the outcomes. Analyses were conducted following 2 (decisional conflict) and 3 (smoking cessation) outcome scenarios: complete cases, worst-case scenario (assuming that dropouts still smoked), and multiple imputations. A priori sample size calculation indicated that 796 participants were needed. The participants were mainly recruited on the web (eg, social media). All the data were self-reported. ResultsOverall, 2375 participants were randomized (intervention n=1164, 49.01%), of whom 599 (25.22%; intervention n=275, 45.91%) completed the DAs, and 276 (11.62%; intervention n=143, 51.81%), 97 (4.08%; intervention n=54, 55.67%), and 103 (4.34%; intervention n=56, 54.37%) completed time point 1, t=2, and t=3, respectively. More participants stopped smoking in the intervention group (23/63, 37%) than in the control group (14/52, 27%) after 6 months; however, this was only statistically significant in the worst-case scenario (crude P=.02; adjusted P=.04). Effects on the secondary outcomes were only observed for smoking abstinence after 1 month (15/55, 27%, compared with 7/46, 15%, in the crude and adjusted models, respectively; P=.02) and for cessation assistance uptake after 1 month (26/56, 46% compared with 18/47, 38% only in the crude model; P=.04) and 6 months (38/61, 62% compared with 26/50, 52%; crude P=.01; adjusted P=.02) but only in the worst-case scenario. Nonuse attrition was 34.19% higher in the intervention group than in the control group (P

BackgroundDigital technology uses in cardiology have become a popular research focus in recent years. However, there has been no published bibliometric report that analyzed the corresponding academic literature in order to derive key publishing trends and characteristics of this scientific area. ObjectiveWe used a bibliometric approach to identify and analyze the academic literature on digital technology uses in cardiology, and to unveil popular research topics, key authors, institutions, countries, and journals. We further captured the cardiovascular conditions and diagnostic tools most commonly investigated within this field. MethodsThe Web of Science electronic database was queried to identify relevant papers on digital technology uses in cardiology. Publication and citation data were acquired directly from the database. Complete bibliographic data were exported to VOSviewer, a dedicated bibliometric software package, and related to the semantic content of titles, abstracts, and keywords. A term map was constructed for findings visualization. ResultsThe analysis was based on data from 12,529 papers. Of the top 5 most productive institutions, 4 were based in the United States. The United States was the most productive country (4224/12,529, 33.7%), followed by United Kingdom (1136/12,529, 9.1%), Germany (1067/12,529, 8.5%), China (682/12,529, 5.4%), and Italy (622/12,529, 5.0%). Cardiovascular diseases that had been frequently investigated included hypertension (152/12,529, 1.2%), atrial fibrillation (122/12,529, 1.0%), atherosclerosis (116/12,529, 0.9%), heart failure (106/12,529, 0.8%), and arterial stiffness (80/12,529, 0.6%). Recurring modalities were electrocardiography (170/12,529, 1.4%), angiography (127/12,529, 1.0%), echocardiography (127/12,529, 1.0%), digital subtraction angiography (111/12,529, 0.9%), and photoplethysmography (80/12,529, 0.6%). For a literature subset on smartphone apps and wearable devices, the Journal of Medical Internet Research (20/632, 3.2%) and other JMIR portfolio journals (51/632, 8.0%) were the major publishing venues. ConclusionsDigital technology uses in cardiology target physicians, patients, and the general public. Their functions range from assisting diagnosis, recording cardiovascular parameters, and patient education, to teaching laypersons about cardiopulmonary resuscitation. This field already has had a great impact in health care, and we anticipate continued growth.

In Sudan, the HIV testing rates during pregnancy remain low. Limitations in scaling and uptake of PMTCT services are linked to several factors within the healthcare system, including the motivation of healthcare providers. This article describes how a health facility-based health promotion intervention plan was developed, implemented, and evaluated to increase the uptake of PMTCT services using the Intervention Mapping approach. Individual-level and environmental determinants were previously identified and included in the intervention plan. Some factors that impacted the intention of women to test for HIV during pregnancy include level of knowledge on MTCT, who offers the HIV test, the fear and tension experienced when thinking about HIV/AIDS, the non-confidentiality of the HIV test results, and self-efficacy. This provides insights into how to develop, implement, and evaluate a facility-based health promotion intervention. The pre-assessment was critical in shaping the intervention and making it relevant and evidence based. The Intervention Mapping approach that was applied facilitated the systematic design of the intervention and supported guiding the implementation.

Abstract Background There is limited information about the psychosocial sub-determinants regarding the use of HIV Testing and Counselling (HTC) services among suspected Tuberculosis (TB) patients in Sudan. This study aimed to assess the association between psychosocial beliefs and the intention to use HTC services and to establish the relevance of these beliefs for developing behaviour change interventions among suspected TB patients. Methods Suspected TB patients (N = 383) from four separate TB facilities completed a cross-sectional questionnaire which was based on the Reasoned Action Approach theory. Eligibility criteria included attending Tuberculosis Management Units in Kassala State as suspected TB patients and aged 18–64 years. A Confidence Interval Based Estimation of Relevance (CIBER) analysis approach was employed to investigate the association of the beliefs with the intention to use HTC services and to establish their relevance to be targeted in behaviour change interventions. Results The CIBER results showed the beliefs included in the study accounted for 59 to 70% of the variance in intention to use HTC services. The belief “My friends think I have to use HTC services” was positively associated with the intent to use HTC, and it is highly relevant for intervention development. The belief “I would fear to be stigmatized if I get a HIV positive result” was negatively related to the intention to use HTC services and was considered a highly relevant belief. The belief “If I use HTC services, health care providers will keep my HIV test result confidential” was strongly associated with the intention to use HTC services. However, the relevance of this belief as a target for future interventions development was relatively low. Past experience with HTC services was weakly associated with the intention to use HTC services. Conclusion The intention to use HTC was a function of psychosocial beliefs. The beliefs investigated varied in their relevance for interventions designed to encourage the use of HTC services. Interventions to promote intention to use HIV testing and counselling services should address the most relevant beliefs (sub-determinants). Further study is needed to establish the relevance of sub-determinants of the intention to use HTC services for interventions development.

Abstract Background As organ donation registration rates remain low, especially among lower-educated people, it is important to support this group in making their registration decision. To prepare lower-educated students in the Netherlands for making a well-informed decision, an interactive educational program was developed. We aim to understand both the (quality of) implementation as well as to contextualize the effects of this program in a lower-educated school setting. Methods The process evaluation was part of a Cluster Randomized Controlled Trial, in which 11 schools for Intermediate Vocational Education throughout the Netherlands participated. Teachers who taught a course on Citizenship delivered three intervention elements (i.e. video fragments and discussion, quizzes with tailored feedback and an exercise filling out a registration form) to their students. Implementation was assessed by interviews with teachers, questionnaires from students, logbooks from teachers and user data from Google Analytics. Results The program was well received and implemented, but on-the-spot adaptations were made by teachers to fit their students better. Within the lower-educated target group, differences between students are high in terms of active participation, reading abilities, knowledge and attention span. The program fit well within their regular teaching activities, but the topic of organ donation is not always prioritized by teachers. Conclusions We see opportunities to disseminate the program on a larger scale and reach a group that has been neglected in organ donation education before. Within the program, there are possibilities to increase the effectiveness of the program, such as alternative delivery methods for the elements with a lot of text, the addition of booster sessions and guidelines for teachers to adapt the program to students of different levels within Intermediate Vocational Education. Moreover, in order to have an impact on a national level, strategies need to be employed to reach high numbers of students and, therefore, support on a higher level is needed (both within schools and at policy level). Trial registration Dutch Trial Register, NTR6771 . Prospectively registered on 24 October 2017.

Abstract Background Explicit and implicit attitudes have been studied extensively, but there is less attention to reducing dissonance between them. This is relevant because this dissonance (IED) results in distress and has inconsistent effects on behavior, e.g. less physical activity but more smoking. Mindfulness decreases dissonance between self-related explicit and implicit constructs. This study investigates if, and which, specific mindfulness subskills are associated with decreased dissonance between explicit and implicit attitudes, and whether mindfulness subskills moderate the relationship between IED and intention/behavior. Method At baseline and one and three months thereafter, participants’ (N = 1476) explicit attitudes, implicit attitudes, red meat consumption (RMC), intention to reduce RMC as well as levels of trait mindfulness were assessed. Results Mindfulness subskills were not associated with decreased IED. IED was associated with lower RMC and a higher intention to reduce RMC. The mindfulness subskill acceptance buffered the effect of IED on intention, seemingly offering a skill to deal with dissonant attitudes, which was unidentified until now. Conclusion The mindfulness subskill accepting without judgment functions as a way to deal with dissonance. Future research should use this novel finding and investigate whether mindfulness can be used as a buffer in contexts where dissonance results in maladaptive behaviors.

Background: Despite nutritional benefits, a high consumption of red meat is not without risks as it is linked to the development of certain types of cancer as well as to other non-communicable diseases, such as type II diabetes or cardiovascular diseases. Moreover, the production of meat has negative effects on the environment. Therefore, a transition to a less meat-based diet could be beneficial. It is unclear how explicit cognitions towards red meat consumption and implicit attitudes jointly influence intention and consumption. We tested the additive pattern (both types of cognitions explain unique variance) and interactive pattern (both types interact in the prediction). Method: At baseline (T0; N = 1790) and one (T1; n = 980) and three months thereafter (T2; n = 556), explicit cognitions, red meat consumption, and implicit attitudes were assessed among a Dutch sample. Results: Only explicit cognitions were associated with red meat consumption. Implicit attitudes moderated the effect of self-efficacy on T0-RMC; negative implicit attitudes strengthened this effect. T0-intention was associated with explicit cognitions and implicit attitudes. Additionally, negative implicit attitudes strengthened the effect of social norms on T0 and T2-intention. Regarding red meat consumption, support for the interactive pattern was found. For intention there was support for the interactive and additive pattern. Conclusion: Interventions aiming to reduce red meat consumption in the general public might profit from changing implicit attitudes in addition to explicit cognitions.

BackgroundSleep has a major impact on health, which makes it a relevant topic for research and health practitioners. Research on sleep determinants, i.e. factors that positively or negatively influence sleep, is fragmented.ObjectiveThe purpose of this umbrella review is to provide an overview of the current evidence on determinants of natural adult sleep.MethodsA comprehensive literature search was performed on determinants of sleep. Reviews and meta-analyses on natural adult sleep were included. Six electronic databases (PubMed, WoS, Embase, CINAHL, PsycInfo and Cochrane) were used for the search, last accessed September 2021. The quality of the selected articles was assessed using the AMSTAR2 tool. Results were categorized in four main categories: biological, behavioral, environmental and personal/socio-economical determinants.ResultsIn total 93 reviews and meta-analyses resulted in a total of 30 identified determinants. The impact of each determinant differs per individual and per situation. Each determinant was found to affect different sleep parameters and the relationship with sleep is influenced by both generic and specific moderators.DiscussionA comprehensive overview on relevant sleep determinants provides a practical and scientifically based starting point to identify relevant intervention approaches to secure or improve individual sleep quality. The difference in aggregation level of the determinants and in measurement methods are the major limitations of this umbrella review. Extending existing generic sleep hygiene rules with an overview of all types of potential determinants will enhance the awareness of the complexity and can be used to improve the effect of sleep interventions in health promotion.Trial registrationThe umbrella review was registered with PROSPERO (registration ID CRD42020149648) https://www.google.com/search?client=firefox-b-d&q=CRD42020149648.

Conflict can be a primary driver of health inequalities, but its impact on the distribution of social determinants of health is not very well documented. Also, there is limited evidence on the most suitable approaches aiming at addressing health inequalities in post-conflict settings. Thus, we undertook a systematic review of the literature concerning the current knowledge and knowledge gaps about structural determinants of health inequalities and assessed the effects of approaches aimed at addressing health inequalities in post-conflict settings. We performed a systematic search in bibliographic databases such as Web of Science, PubMed, and PsycINFO for relevant publications, as well as institutional websites that are relevant to this topic. The search was initiated in March 2018 and ultimately updated in December 2020. No time or geographical restrictions were applied. The quality of each study included in this review was independently assessed using criteria developed by CASP to assess all study types. Sixty-two articles were deemed eligible for analysis. The key findings were captured by the most vulnerable population groups, including the civilian population, women, children, internally displaced persons (IDPs), and people with symptoms of mental illness. A considerable range of approaches has been used to address health inequalities in post-conflict settings. These approaches include those used to address structural determinants of health inequalities which are accountable for the association between poverty, education, and health inequalities, the association between human rights and health inequalities, and the association between health inequalities and healthcare utilization patterns. However, these approaches may not be the most applicable in this environment. Given the multifactorial characteristics of health inequalities, it is important to work with the beneficiaries in developing a multi-sector approach and a strategy targeting long-term impacts by decision-makers at various levels. When addressing health inequalities in post-conflict settings, it may be best to combine approaches at different stages of the recovery process.

Abstract Background Organ donation registration rates remain low, especially among people with lower educational levels. An interactive educational intervention was developed to prepare lower-educated students in the Netherlands for making a well-informed decision about organ donation. This article reports on the effects of this intervention on the intention to register (i.e., the primary outcome in the study at hand) and beliefs regarding organ donation. Materials and methods The effectiveness was investigated in a post-test-only cluster randomized controlled trial, in which the intervention was offered to the experimental group and after measurement also to the control group. Randomization to the experimental and control groups took place at a class level. Teachers of schools for Intermediate Vocational Education who taught a course on Citizenship delivered three intervention elements (i.e., video fragments and discussion, quizzes with tailored feedback and exercise filling out a registration form) to their students during two 50-min lessons. Results A total of 1170 students participated in the trial and filled out a questionnaire (45 experimental and 43 control classes). Compared to the control group, students in the experimental group had higher odds of having positive registration intentions (OR = 1.81; 95%CI [1.10–2.96]), their perceived knowledge was higher (B = 0.62; 95%CI [0.23–1.01]) and they had higher intentions to talk to family members (B = 0.68; 95%CI [0.28–1.08]) and friends (B = 0.36; 95%CI [0.07–0.66]) about organ donation. There were no effects on the choice students intended to register (OR = 1.08; 95%CI [0.67–1.73]). Conclusions Providing education in a classroom setting is an effective tool in increasing registration intentions. Despite uncertainties about the effects on actual registration behavior, a larger-scale dissemination of this intervention is recommended. Providing clear information and opening the discussion about organ donation is an important and promising first step towards higher registration rates. Trial registration The Dutch Trial Register, ID: NTR6771. Registered on 24 October 2017. https://www.trialregister.nl/trial/6557

Background: Unhealthy sexual behaviors, such as unprotected sexual intercourse and lack of using screening services increase cyclical transmission of sexually transmitted infections including Human Immunodeficiency Virus (HIV), especially among young adults. Hence health promotion programs can contribute to reduce the consequences, by changing (determinants of) these behaviors. Such interventions need to embrace a comprehensive approach and apply theory-and evidence-based methods. This article describes the protocol for a process and effect evaluation study of a sexually transmitted infection prevention program among university students in Beira city, central Mozambique.Methods: The on-going program at Universidade Católica de Moçambique is described following the six steps of Intervention Mapping (IM), with a focus on the evaluation plan (i.e., the final step in IM). The details regarding previous steps in the protocol are briefly described as well, as they lay the foundation for the final step. The overall study will apply a hybrid type 1 approach by assessing the effectiveness of the intervention while gettering implementation. The process evaluation will apply qualitative and quantitative methods to gain insight in the context, reach, dose delivered, dose received and recruitment. Interviews with closed and open-ended questions will be conducted with program implementers and users. A quasi-experimental non-equivalent control group design is used to evaluate the effectiveness. A cohort of university students will be followed for 6 months. Self-administrated questionnaires will be used to collect data every 3 months.Discussion: A combination of process and effect evaluation is proposed. This is a useful and fruitful procedure, since concurrent process evaluation can allow researchers to better interpret findings from the effect evaluation and understand how the intervention might replicate in similar contexts. We decided to follow the IM approach since, it is a theory-and evidence-based, systematic and detailed guide regarding what to do at every steps. A quasi-experimental non-equivalent control group design was chosen to fit the context of the study and generate outcomes with high external validity.Study Registration: 004/CIBS/2020.

Background: When reopening universities in times of COVID-19, students still have to adhere to COVID-19 behavioral guidelines. We explored what behavioral determinants (and underlying beliefs) related to the adherence to guidelines are both relevant and changeable, as input for future interventions. Methods: A cross-sectional online survey was conducted (Oct–Nov 2020), identifying behavioral determinants (and underlying beliefs) of university students' adherence to COVID-19-guidelines, including keeping 1.5 m distance, getting tested, and isolating (N = 255). Results: Attitude, perceived norm, self-efficacy, and several beliefs (e.g., risk perception beliefs ‘I am not afraid because I am young’ [r = −0.33; p

ObjectivesTo describe the step-by-step person-centered, theory-based development of the KELA.AE app for Arabic speaking hemodialysis patients.MethodsA step-by-step person-driven theory-based approach was conducted to develop a self-monitoring and educational dietary app for hemodialysis patients. The development follows the Integration, Design, Assessment, and Sharing (IDEAS) framework. Qualitative, semi-structured interviews with 6 hemodialysis patients and 6 healthcare practitioners (dietitians and nephrologists) were performed to assess the need for an app, the willingness to use an app, and features desired in an app.ResultsThe KELA.AE app, which includes a self-monitoring feature, CKD-friendly recipes, and a theory-based, evidence-based educational feature was developed. Qualitative analysis of interviews revealed two predominant themes from patient interviews ‘Experience with the diet’, ‘App evaluation’, and one theme from interviews with healthcare practitioners ‘App evaluation’. Patients expressed frustration with current accessibility of dietary information along with the need for educational materials in the app. The review of the KELA.AE prototype was positive overall, and patients reported a willingness to use the app. Healthcare practitioners considered the app accurate, simple, and culturally sensitive but expressed concerns about app misuse and the replacement of healthcare practitioners.ConclusionsThe KELA.AE app was found to be satisfactory and supportive of the participants' needs. Changes were made to the app as suggested during the interviews.

Abstract Background Explicit attitudes as well as implicit attitudes have been shown to be associated with physical activity (PA). These two types of attitudes can, however, be discrepant towards the same object or behavior. This study investigated whether there is a discrepancy between explicit and implicit attitudes (IED) regarding physical activity (PA), and whether IED moderates the relationship between explicit attitude and PA, and explicit attitude and PA intention. Methods At baseline (T0) and one (T1) and three months (T2) thereafter, students’ (N = 340) PA levels, intention, explicit attitudes, further PA determinants, e.g. self-efficacy, were assessed. Implicit attitudes towards PA were assessed by means of a tailored Single-Category Implicit Association task. Results IED was present but weak. Multiple hierarchical regressions revealed that IED did not moderate the relationship between explicit attitudes and PA or intention. Yet, IED was negatively associated with T0-PA and T1-PA. Conclusion The study revealed the important insight that IED is detrimental for PA. Interventions targeting attitudes to increase PA, should ensure that implicit and explicit attitudes regarding PA are concordant.