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The network approach has recently been introduced to clinical psychology and provides a powerful framework for analyzing variables in a system. Since then, its applications have rapidly spread to various fields of social sciences. Unlike in the case of clinical psychology, the peculiarities of the phenomena under study in social sciences have not received sufficient attention. In this paper, along with practical illustrations, we discuss what a system of psychological variables represents and what the interrelationships between the variables mean in the context of health behavior research. In addition, we touch upon the structural analysis of the system which hasn’t been the focus of the recent applications of network analysis in health psychology. In this paper, we illustrate two approaches of incorporating observable behavioral variables in a system and strategies for investigating structural components of the system. We illustrate these two approaches with an analysis of cross-sectional data on adolescents’ beliefs and behavior with respect to registering their choice regarding organ donation in the Netherlands. With this paper, we provide researchers with guidance on network analysis of psychological variables. Furthermore, we wish to facilitate a larger discussion on conceptualizing networks of psychological variables, which will guide the analysis and the interpretation of node level interactions as well as network level structures.

Jazan region of Saudi Arabia has a high prevalence of oral cancer: 35% of cases. However, little is known about the view of dentists and dental students on possible factors that contribute to this high rate with scarce efforts regarding prevention. The study investigated possible factors related to oral cancer as perceived by dentists and dental students, using a qualitative approach. Six focus groups conducted in Jazan Dental School (JDS) and participants included dental students, interns, faculty members, and key decision-makers. All participants acknowledged oral cancer a serious public health issue in Jazan affecting all ages. The majority thought that tobacco is a major risk factor in this region, which can easily be obtained by individuals of any age or gender. Further, formal dental education in the country is not focusing on the local related risk factors. Participants agreed that practicing oral cancer examination and its risk factors education is related to clinicians’ attitude and skills. Several participants declared that no organized effort established toward oral cancer and its risk factors in the region. Cultural acceptance of oral cancer risk factors was mentioned as one of the challenges for patients. The findings indicate that dental education and training at JDS are not focusing on necessary related oral health issues and their risk factors in the community. Also, it casts a new light on the fact that dentists are not educating their patients because they lack the knowledge and the skill of health education and patients’ communication methods. Electronic supplementary material The online version of this article (10.1007/s13187-019-01609-z) contains supplementary material, which is available to authorized users.

Aims: The Confidence Interval-Based Estimation of Relevance (CIBER) approach was used to assess the most relevant psychosocial determinants of both the intention to use cannabis and the intention to reduce or quit cannabis use among high school students.Methods: In 2017, 206 Dutch high school students completed questionnaires. Questionnaires measured cannabis use in the past six months, intention to use cannabis in the upcoming six months, intention to reduce or quit cannabis use in the upcoming six months, psychosocial determinants, and sociodemographic characteristics. The CIBER approach was used to estimate the relevance of determinants by calculating and visualizing confidence intervals for the means and correlation coefficients for intention to use cannabis as well as intention to reduce or quit cannabis use.Results: Cannabis use was reported by 28% (57/206), and 26% (54/206) had the intention to use cannabis. Risk perception, attitude, and the descriptive norm were evaluated as the most relevant determinants of the intention to use cannabis. Among cannabis users, 49% (28/57) had the intention to reduce or quit. Attitude and habit were evaluated as the most relevant determinants of the intention to reduce or quit cannabis use among cannabis users.Conclusion: Cannabis use was prevalent among Dutch high school students. Findings suggest that interventions aimed at preventing cannabis use among the general school population might best focus on the risk perception, attitude, and the descriptive norm, whereas interventions aimed at reducing cannabis use among cannabis users might best focus on attitude and habits.

This study is a process evaluation of an adolescent-focused intervention of the USAID Communication for Healthy Communities program, in Uganda. We used mixed methods including observation, consultations and review of program documents to collect data on program coverage, reach and factors influencing implementation. Findings show that program activities were successfully implemented through collaborative partnerships with service partners and the community. Interpersonal communication complemented by mass-media messaging was effective in reaching and empowering adolescents with health information to make informed choices for behavior change. The program used theoretical frameworks to guide targeted interventions through audience segmentation and community empowerment. Targeted mass-media messaging and placement was found to be pertinent for program reach. Working through existing community structures is important for an effective reach of health promotion programs. Lessons identified for scaling-up adolescent health programs include the need to harmonize training and deployment of community champions by development partners, recruit audience-specific influential champions and link income-generating activities to health education interventions. There is thus need to collaboratively develop and institutionalize effective monitoring and evaluation strategies during program inception and design phases for appropriate accountability, ownership and a continuation of gains.

Background Maternal mortality among adolescent mothers in South Africa is higher than many middle-income countries. This is largely attributable to conditions that can be prevented or managed by high quality antenatal care. The way in which pregnant adolescents are treated at antenatal clinics influences their timely utilization of antenatal services. This qualitative study reports on the experiences of pregnant adolescents with health care workers when accessing antenatal care. Methods Pregnant girls aged 13–19 (n = 19) who attended public health care facilities that provide Basic Antenatal Care (BANC) services in Cape Town, South Africa were recruited. Four face to face in-depth interviews and four mini focus group discussions were undertaken, facilitated by a topic guide. Thematic analyses were used to analyse the data. Results Experiences that reinforce antenatal attendance, such as respectful and supportive treatment, were outweighed by negative experiences, such as victimization; discrimination against being pregnant at a young age; experiencing disregard and exclusion; inadequate provision of information about pregnancy, health and childbirth; clinic attendance discouragement; and mental health turmoil. Conclusions There is evidence of a discordant relationship between the health care workers and the pregnant adolescents. Adolescents feel mistreated and discriminated against by the health care workers, which in turn discourages their attendance at antenatal clinics. Maternal health care workers need to receive support and regular training on the provision of youth friendly antenatal care and be regularly evaluated, to promote the provision of fair and high quality antenatal services for adolescent girls. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01211-x., 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. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01211-x.

Objectives: The objective of this study was to investigate dental patients’ behavior, thoughts, opinions and needs for oral cancer information, and dentists’ behavior regarding prevention and examination of oral cancer. Materials and Methods: This study utilized an exploratory sequential mixed methods design. Semi-structured interviews with open-ended questions were conducted for forty dental patients of both sexes. Based on the qualitative analysis, a structured questionnaire was developed and distributed among the participants. Data were analyzed for 315 participants to quantify their thoughts, needs, behavior and behavior expected from dentists regarding oral cancer. Frequency, percentages and cumulative percentages were calculated. Results: This study reveals that patients’ oral cancer knowledge levels were adequate, but most reported that their dentist had never examined them for oral cancer. Additionally, the participants had never performed self-examinations for oral cancer, nor were they aware of the possibility of doing so. Participants showed a preference for being examined and educated by their dentist about oral cancer and believed it would help early detection. Conclusions: The study participants are aware of oral cancer and its risk factors. The practice of oral cancer examinations and patient education of its risk factors by dental practitioners is limited. Patients feel a need for more attention to be paid to oral cancer examinations, preventive measures and targeted information on oral cancer risk factors.

Background: Adolescent hookah pipe use is on the rise despite it being a public health concern. Several studies focus on the external determinants of adolescent hookah pipe use but research focusing on the internal factors motivating adolescents to smoke the hookah pipe is sparse. Objective: Drawing on self-determination theory, a contemporary theory of human motivation, this study aimed to explore the basic psychological needs (BPN) and motivation of adolescent hookah pipe users and nonusers in an attempt to explore whether satisfaction or frustration of needs contributes to hookah pipe use. Method: Thirty adolescents, aged 13 to 19 years, participated in the qualitative study using one-on-one semistructured interviews. Each interview was audio recorded, transcribed, and thematically analysed. Results: This study revealed that satisfaction or frustration of BPN, particularly competence and relatedness influences adolescents’ decision to smoke or not smoke the hookah pipe. Hookah pipe users experience more needs frustration compared to hookah pipe nonusers. Furthermore, hookah pipe users are more extrinsically motivated to smoke, whereas hookah pipe nonusers are intrinsically motivated not to smoke. Conclusion: The internal factors associated with adolescent hookah pipe use is a relatively new perspective.

Purpose: Physical activity (PA) is crucial for health, but there is insufficient evidence about PA patterns and their operationalization. The authors developed two algorithms (SPORTconstant and SPORTlinear) to quantify PA patterns and check whether pattern information yields additional explained variance (compared with a compositional data approach [CoDA]). Methods: To measure PA, 397 (218 females) adolescents with a mean age of 12.4 (SD = 0.6) years wore an ActiGraph on their lower back for 1 week. The SPORT algorithms are based on a running value, each day starting with 0 and minutely adapting depending on the behavior being performed. The authors used linear regression models with a behavior-dependent constant (SPORTconstant) and a function of time-in-bout (SPORTlinear) as predictors and body mass index z scores (BMIz) and fat mass percentages (%FM) as exemplary outcomes. For generalizability, the models were validated using five-fold cross-validation where data were split up in five groups, and each of them was a test data set in one of five iterations. Results: The CoDA and the SPORTconstant models explained low variance in BMIz (2% and 1%) and low to moderate variance in %FM (both 5%). The variance being explained by the SPORTlinear models was 6% (BMIz) and 9% (%FM), which was significantly more than the CoDA models (p Conclusion: Among this group of adolescents, SPORTlinear explained more variance of BMIz and %FM than CoDA. These results suggest a way to enable research about PA patterns. Future research should apply the SPORTlinear algorithm in other target groups and with other health outcomes.

Background The renal diet is complex and requires alterations of the diet and careful monitoring of various nutrients. Elevated serum phosphorus is common among patients undergoing hemodialysis, and it is associated with many complications. Smartphone technology could be used to support both dietitians and patients by providing a source of accessible and reliable information. Objective The aim of this pilot is to assess the potential efficacy of an intervention using the educational and self-monitoring mobile app KELA.AE on the phosphorous management in hemodialysis patients. Results will be used to improve both the app and a planned, rigorous large-scale trial intended to assess app efficacy. Methods This is a prospective pilot study performed at the hemodialysis unit of Al Qassimi Hospital (Emirate of Sharjah, United Arab Emirates). All patients were assessed for eligibility and, based on inclusion criteria, considered for enrollment. Participants met with a dietitian once a week and used the mobile app regularly for 2 weeks. Outcomes (knowledge, self-reported nonadherence, dietary intake, anthropometry, and biochemical data) were measured. This pilot is reported as per guidelines for nonrandomized pilot and feasibility studies and in line with the CONSORT (Consolidated Standards of Reporting Trials) 2010 checklist for reporting pilot or feasibility trials. Results Of 26 subjects, 23 successfully completed the pilot. Patient dietary knowledge about phosphorous management improved from 51.4% (SD 13.9) to 68.1% (SD 13.3) after intervention with a large effect size (d=1.22, 95% CI 0.59 to 1.85). Dietary protein intake increased from a mean of 0.9 g/kg (SD 0.3) per day to a mean of 1.3 g/kg (SD 0.5) per day with a large effect size (d=1.07, 95% CI 0.45 to 1.69). Phosphorus to protein ratio dropped from a mean of 18.4 mg/g protein to 13.5 mg/g protein with a large effect size (d=0.83, 95% CI 0.22 to 1.43). There was no evidence of change in phosphorous intake, self-reported nonadherence, and serum phosphorus. Conclusions The findings of this prospective pilot reveal the potential efficacy of a smartphone app as a supportive nutrition education tool for phosphorus management in patients undergoing hemodialysis. This pilot study showed that the KELA.AE app has the potential to improve knowledge and dietary choices. A rigorous randomized controlled trial should be performed to evaluate the efficacy, assessing app use of a long-term intervention.

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.

Many societal problems are related to human behavior. To change behavior, it is crucial to be aware of Lewin’s formula indicating that behavior is a function of a person and their environment. Technology provides opportunities with regard to (measurement of) all three elements of this formula. This raises the question how existing technologies can be used to improve behavior change science.This article provides two answers to this question: application and innovation of theory. Technology can be used to apply behavior change methods in practice. For example, providing computer-tailored feedback based on a social-cognitive profile. Technology can also be used to innovate theory, which is less common, but results in more progress. For example, technology provides opportunities to triangulate ecological momentary assessment (EMA) with smartphone native sensor data to track behavior and environmental factors. If the opportunities provided by technology are combined with a rationale on how and which data to collect, then these data can be used to answer theoretically driven questions. Answering such questions results in better theories to both explain and change behavior. This is highly relevant for more effective and more efficient solutions to all societal problems related to human behavior.

Objective: The Celebrate Safe approach is a collaboration between public health organisations and music event/venue organisers to encourage health promotion interventions in nightlife settings and at music events. The purpose of this study was to evaluate the Celebrate Safe approach with regard to its impact on use of ear plugs among visitors of music events.Design: A pre-registered cluster-randomised controlled trial conducted at music events throughout the Netherlands (k = 15). In the experimental condition, event organisers were asked to share an online pre-event message about ear plugs, clearly indicate where visitors could buy ear plugs, and sell ear plugs at busy locations on the premises. Visitors were encouraged to wear ear plugs by means of an ‘ear check’ at the beginning of the event.Study sample : Observations to assess whether event visitors wear ear plugs (N = 3836).Results: A multilevel model, taking into account nesting of visitors within events, revealed that use of ear plugs at music events in the experimental condition was higher in comparison to events in the control condition (23% vs. 14%, OR = 1.9, 95%CI 1.2–3.0, p = 0.004).Conclusions: The Celebrate Safe approach has a positive impact on use of ear plugs among visitors of music events.

Background: In Sub-Saharan Africa access to and utilization of sexual and reproductive healthcare is unsatisfactory. Consequently, rates of teenage pregnancy and unsafe abortions among adolescents in Sub-Saharan Africa, including in South Africa remain a public health challenge. The aim of this study was to explore nurses' views on and perceptions of adolescent girls' barriers and needs to accessing and utilizing sexual and reproductive healthcare services.Methods: Twenty-four purposively selected healthcare workers from nine public healthcare facilities in Cape Town, South Africa participated in this qualitative descriptive study. Data were collected through nine group discussions, and audio-recorded with hand-written notes taken during the discussions. Data were analyzed using thematic analysis, following the Tesch's eight steps for coding and analysing qualitative data.Results: Sexual and reproductive healthcare nurses are generally supportive of adolescents who ask for and use contraceptives. Non-compliance to family planning regimens and repeated requests for termination of pregnancies were perceived by nurses as irresponsible behaviours which are particularly frustrating to them and not in concordance with their personal values. The subsequent nurse-adolescent interactions sometimes appeared to hinder access to and utilization of sexual and reproductive healthcare services by adolescents.Conclusions: Nurses perceive certain behaviours of adolescent girls as irresponsible and warrant their negative attitudes and reactions toward them. The negative attitudes and reactions of nurses potentially further compromises access to and utilization of sexual and reproductive healthcare services by adolescent girls in South Africa and requires urgent attention. Adolescent-friendly clinic hours together with youth-friendly nurses is likely to encourage adolescent girls to access sexual and reproductive healthcare services and improve the use thereof. (C) 2019 Published by Elsevier Ltd.

Adolescent hookah pipe use is increasing at a rapid rate, thus posing a major public health concern globally. The hookah pipe is a gateway substance to other substances that may be more harmful. Yet, at present, little is known about why adolescents are so drawn to this mechanism. It is this gap that this study attempted to fill. This study, therefore, aimed to review the determinants of adolescent hookah pipe use. An electronic search of 12 databases identified studies investigating determinants of adolescent hookah pipe use. Twenty-five studies sampling a total of 88,988 adolescents who use the hookah pipe were included. This study found that adolescent hookah pipe use is determined by an interplay of family factors, peer/friends factors, individual factors, school factors, the actual hookah pipe mechanism, advertisements, and awareness of hookah pipe lounges or bars. Prevention and early intervention strategies aimed at reducing adolescent hookah pipe use is needed.

Background Dietary interventions are effective prevention and treatment strategies for chronic diseases; however, they require extensive commitment, time, and resources. Dietary mobile applications (apps) have gained popularity and are thus being incorporated into dietary management. Objective The aim of this review is to assess the effects of the use of dietary mobile apps on nutritional outcomes in adults with chronic diseases. Methods A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using MEDLINE, PubMed, Embase, and CINAHL databases. The protocol was registered on PROSPERO. Intervention studies evaluating the nutritional outcomes of dietary apps, published in English between January 1, 2007 and November 15, 2017 were included. The methodological quality of included articles was assessed via the Academy of Nutrition and Dietetics' Quality Criteria Checklist: Primary Research. Heterogeneity was confirmed using the I2 index and a random-effects meta-analysis was performed for randomized controlled trials. Estimates of the pooled mean difference were calculated for app usage compared to no app usage. Main outcomes measure Nutritional outcomes, categorized as food-/nutrition-related, anthropometric measurements, pertinent clinical/biochemical data, and nutrition-focused physical findings, were extracted from the included intervention studies. Results Upon completion of the searches, 18,649 articles were identified, and data were extracted from 22 articles. Pooled estimates showed a significantly greater decrease in weight (–2.45 kg, 95% CI –3.33 to –1.58 kg; P Conclusions The findings of this systematic review and meta-analysis indicate that dietary mobile apps are effective self-monitoring tools, and that their use results in positive effects on measured nutritional outcomes in chronic diseases, especially weight loss.

Background: Use of HIV testing and counselling (HTC) services remains low among TB patients in Sudan. Identifying the social-cognitive (sub) determinants associated with HTC uptake is essential before developing interventions to promote uptake. This study aims to assess the sub-determinants of intention to use and actual behaviour of using HTC services among TB patients in Sudan and to ascertain the most relevant beliefs to inform future interventions.Methods: A cross-sectional study was carried out in five health facilities selected randomly in Kassala State. First, a small elicitation study (N = 25) was conducted to inform the Reasoned Action Approach (RAA) based questionnaire. A total of 411 TB patients completed the survey questionnaire. Confidence Interval Based Estimation of Relevance analysis (CIBER) was employed to establish the sub-determinants' relevance.Result: The studied beliefs explained 38–52% of the variance in the intention and 20–35% in the behaviour variance. The beliefs that “Using HTC services increases my fear of being tested positive for HIV” and “Using HTC services increases my fear of losing my partner if I have a positive test result” were negatively associated with intentions and use of HTC services; and both were highly relevant for intervention. The belief “If I use HTC services, I would know my HIV status” was positively associated with intentions and use of HTC services. However, it was less relevant for intervention. Perceived susceptibility to HIV infection was not associated with intention and only weakly associated with use of HTC services. Its relevance was low for intervention.Conclusions: The study showed that the social-cognitive beliefs (sub-determinants) vary in their relationship with the intention and use of HTC services among TB patients; with variable relevance for intervention. Interventions to enhance the use of HTC services should address the most relevant beliefs to maximise the effectiveness of interventions. Further studies are needed to identify other relevant sub-determinants of HTC use behaviour.

Background On January 30, 2020, the World Health Organization’s Emergency Committee declared the rapid, worldwide spread of COVID-19 a global health emergency. Since then, tireless efforts have been made to mitigate the spread of the disease and its impact, and these efforts have mostly relied on nonpharmaceutical interventions. By December 2020, the safety and efficacy of the first COVID-19 vaccines were demonstrated. The large social media platform Twitter has been used by medical researchers for the analysis of important public health topics, such as the public’s perception on antibiotic use and misuse and human papillomavirus vaccination. The analysis of Twitter-generated data can be further facilitated by using Twitter’s built-in, anonymous polling tool to gain insight into public health issues and obtain rapid feedback on an international scale. During the fast-paced course of the COVID-19 pandemic, the Twitter polling system has provided a viable method for gaining rapid, large-scale, international public health insights on highly relevant and timely SARS-CoV-2–related topics. Objective The purpose of this study was to understand the public’s perception on the safety and acceptance of COVID-19 vaccines in real time by using Twitter polls. Methods We developed 2 Twitter polls to explore the public’s views on available COVID-19 vaccines. The surveys were pinned to the Digital Health and Patient Safety Platform Twitter timeline for 1 week in mid-February 2021, and Twitter users and influencers were asked to participate in and retweet the polls to reach the largest possible audience. Results The adequacy of COVID-19 vaccine safety (ie, the safety of currently available vaccines; poll 1) was agreed upon by 1579 out of 3439 (45.9%) Twitter users. In contrast, almost as many Twitter users (1434/3439, 41.7%) were unsure about the safety of COVID-19 vaccines. Only 5.2% (179/3439) of Twitter users rated the available COVID-19 vaccines as generally unsafe. Poll 2, which addressed the question of whether users would undergo vaccination, was answered affirmatively by 82.8% (2862/3457) of Twitter users, and only 8% (277/3457) categorically rejected vaccination at the time of polling. Conclusions In contrast to the perceived high level of uncertainty about the safety of the available COVID-19 vaccines, we observed an elevated willingness to undergo vaccination among our study sample. Since people's perceptions and views are strongly influenced by social media, the snapshots provided by these media platforms represent a static image of a moving target. Thus, the results of this study need to be followed up by long-term surveys to maintain their validity. This is especially relevant due to the circumstances of the fast-paced pandemic and the need to not miss sudden rises in the incidence of vaccine hesitancy, which may have detrimental effects on the pandemic’s course.

Background Virtual reality (VR) and augmented reality (AR) have recently become popular research themes. However, there are no published bibliometric reports that have analyzed the corresponding scientific literature in relation to the application of these technologies in medicine. Objective We used a bibliometric approach to identify and analyze the scientific literature on VR and AR research in medicine, revealing the popular research topics, key authors, scientific institutions, countries, and journals. We further aimed to capture and describe the themes and medical conditions most commonly investigated by VR and AR research. Methods The Web of Science electronic database was searched to identify relevant papers on VR research in medicine. Basic publication and citation data were acquired using the “Analyze” and “Create Citation Report” functions of the database. Complete bibliographic data were exported to VOSviewer and Bibliometrix, dedicated bibliometric software packages, for further analyses. Visualization maps were generated to illustrate the recurring keywords and words mentioned in the titles and abstracts. Results The analysis was based on data from 8399 papers. Major research themes were diagnostic and surgical procedures, as well as rehabilitation. Commonly studied medical conditions were pain, stroke, anxiety, depression, fear, cancer, and neurodegenerative disorders. Overall, contributions to the literature were globally distributed with heaviest contributions from the United States and United Kingdom. Studies from more clinically related research areas such as surgery, psychology, neurosciences, and rehabilitation had higher average numbers of citations than studies from computer sciences and engineering. Conclusions The conducted bibliometric analysis unequivocally reveals the versatile emerging applications of VR and AR in medicine. With the further maturation of the technology and improved accessibility in countries where VR and AR research is strong, we expect it to have a marked impact on clinical practice and in the life of patients.

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.

Objective: Although basing conclusions on confidence intervals for effect size estimates is preferred over relying on null hypothesis significance testing alone, confidence intervals in psychology are typically very wide. One reason may be a lack of easily applicable methods for planning studies to achieve sufficiently tight confidence intervals. This paper presents tables and freely accessible tools to facilitate planning studies for the desired accuracy in parameter estimation for a common effect size (Cohen’s d). In addition, the importance of such accuracy is demonstrated using data from the Reproducibility Project: Psychology (RPP).Results: It is shown that the sampling distribution of Cohen’s d is very wide unless sample sizes are considerably larger than what is common in psychology studies. This means that effect size estimates can vary substantially from sample to sample, even with perfect replications. The RPP replications’ confidence intervals for Cohen’s d have widths of around 1 standard deviation (95% confidence interval from 1.05 to 1.39). Therefore, point estimates obtained in replications are likely to vary substantially from the estimates from earlier studies.Conclusion: The implication is that researchers in psychology -and funders- will have to get used to conducting considerably larger studies if they are to build a strong evidence base.

Background Adequate sun safety during childhood is crucial for decreasing skin cancer risk in later life. Although parents are an essential target group in applying sun protection measures for their children, insight into the determinants associated with their sun protection behaviors is limited. Aims This study aims to identify the most relevant determinants in predicting multiple parental sun protection intentions and behaviors in different sun exposure situations. Method A longitudinal survey study with two measurements was conducted among Dutch parents ( N = 670) of children (4–12 years old). Twenty-seven sociocognitive determinants were examined in terms of relevance regarding four parental sun protection behaviors in different sun exposure situations. The Confidence Interval-Based Estimation of Relevance approach was used to visualize room for improvement (sample means) on all determinants and their association strengths (correlations) with sun protection intentions and behaviors. Results Behavior-specific rather than generic determinants were most relevant in explaining all sun protection behaviors. Of these determinants, attitude, self-efficacy and action planning, and especially parental feelings of difficulty in performing sun protection behaviors, were most relevant. Altogether, the explained variance of all sociocognitive determinants was highest for shade-seeking behavior ( R2 = .41 and .43) and lowest for supportive behavior ( R2 = .19 and .29) in both planned and incidental sun exposure situations, respectively. Discussion This study provides detailed insight into relevant sociocognitive determinants of parental sun protection behaviors in various sun exposure situations and directions for composing parental skin cancer prevention interventions. Conclusions Future composition of sun safety interventions should emphasize on enhancing parental feelings of self-efficacy, especially for shade-seeking and clothing behaviors.

Objective To explore how people experience organ donation decision-making under the conditions of an opt-in, opt-out or no-objection registration system. Design A between-subjects experimental 3 x 2 design (registration system x preselection). Participants (N = 1312) were presented with a description of one of the three registration systems and went through a mock donor registration process. In half of the conditions, the default option of the system was visualized by a ticked box. After, participants answered questions about their perceived autonomy and perceived effective decision-making. Main outcome measurements Perceived autonomy, perceived decision effectiveness and registration choice. Results The preselected box did not impact any of the outcomes. Participants had higher perceived autonomy under the conditions of an opt-in system. There were no differences in effective decision-making across conditions. Registration choices did differ across conditions and educational levels. In the opt-in system, participants more often made an active decision. Lower-educated participants were more likely to choose to do nothing, while higher-educated people more often made an active decision, especially in the no-objection system. Conclusion Where the opt-out system potentially leads to the highest number of donors, the opt-in system seems better in terms of preserving people's autonomy and motivating people to make an active decision.

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 Mobile technology has an impact on the health care sector, also within dietetics. Mobile health (mHealth) apps may be used for dietary assessment and self-monitoring, allowing for real-time reporting of food intakes. Changing eating behaviors is quite challenging, and patients undergoing hemodialysis, particularly, struggle to meet the target intakes set by dietary guidelines. Usage of mobile apps that are developed in a person-centered approach and in line with recommendations may support both patients and health care practitioners. Objective This study is a pilot that aims at estimating the potential efficacy of a dietary intervention using a theory-based, person-centered smartphone app. Results will be used to improve both the app and a planned large-scale trial intended to assess app efficacy thoroughly. Methods A prospective pilot study was performed at the hemodialysis unit of Al Qassimi Hospital (The Emirate of Sharjah). All patients that fulfilled the study inclusion criteria were considered eligible to be enrolled in the pilot study. Upon successful installation of the app, users met with a dietitian once a week. Outcomes were measured at baseline (T0) and 2 weeks post app usage (T1). This pilot is reported as per guidelines for nonrandomized pilot and feasibility studies and in line with the CONSORT 2010 checklist for reporting pilot or feasibility trials. Results A total of 23 patients completed the pilot intervention. Mean energy intakes increased from 24.4 kcal/kg/day (SD 8.0) to 29.1 kcal/kg/day (SD 7.8) with a medium effect size (d=0.6, 95% CI 0.0-1.2). Mean protein intakes increased from 0.9 g/kg/day (SD 0.3) to 1.3 g/kg/day (SD 0.5) with a large effect size (d=1.0, 95% CI 0.4-1.6); mean intake of high biological value (%HBV) proteins also increased from 58.6% (SD 10.1) to 70.1% (SD 10.7) with a large effect size (d=1.1, 95% CI 0.5-1.7). Dietary intakes of minerals did not change, apart from sodium which decreased from a mean intake of 2218.8 mg/day (SD 631.6) to 1895.3 mg/day (SD 581.0) with a medium effect size (d=0.5, 95% CI 0.1-1.1). Mean serum phosphorus, potassium, and albumin levels did not change relevantly. Mean serum iron increased from 7.9 mg/dL (SD 2.8) to 11.5 mg/dL (SD 7.9) postintervention with a medium effect size (d=0.6, 95% CI 0.0-1.2). Conclusions This pilot study showed that the KELA.AE app has the potential to improve dietary intakes. Processes related to procedure, resources, tools, and app improvement for a future trial were assessed. A more extended intervention using a randomized controlled trial is required to estimate parameters concerning app efficacy accurately.

Computer-tailored interventions, which deliver health messages adjusted based on characteristics of the message recipient, can effectively improve a range of health behaviours. Typically, the content of the message is tailored to user demographics, health behaviours and social cognitive factors (e.g., intentions, attitudes, self-efficacy, perceived social support) to increase message relevance, and thus the extent to which the message is read, considered and translated into attitude and behaviour change. Some researchers have suggested that the efficacy of computer-tailored interventions may be further enhanced by adapting messages to suit recipients' need for cognition (NFC) - a personality trait describing how individuals tend to process information. However, the likely impact of doing so, especially when tailored in conjunction with other variables, requires further consideration. It is possible that intervention effects may be reduced in some circumstances due to interactions with other variables (e.g., perceived relevance) that also influence information processing. From a practical point of view, it is also necessary to consider how to optimally operationalise and measure NFC if it is to be a useful tailoring variable. This paper aims to facilitate further research in this area by critically examining these issues based on relevant theories and existing evidence.

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

The General Data Protection Regulation (GDPR) is the new European Union-wide (EU) law on data protection, which is a great step towards more comprehensive and more far-reaching protection of individuals' personal data. In this editorial, we describe why and how we - as researchers within the field of health psychology - should care about the GDPR. In the first part, we explain when the GDPR is applicable, who is accountable for data protection, and what is covered by the notions of personal data and processing. In the second part, we explain aspects of the GDPR that are relevant for researchers within the field of health psychology (e.g., obtaining informed consent, data minimisation, and open science). We focus on questions that researchers may ask themselves in their daily practice. Compliance with the GDPR requires adopting research practices (e.g., data minimisation and anonymization procedures) that are not yet commonly used, but serve the fundamental right to protection of personal data of study participants.

There is an increasing concern on early initiation of sexual activity among adolescents, increasing sexually transmitted infections, and teenage pregnancy in Uganda. Adolescents perceptions of these sexual behaviors might be the result of discussing sexual and reproductive health issues with key influencing audiences. This study qualitatively explored the effect of sexuality discussions with key influencing audiences by means of in-depth interviews and focus group discussions with adolescents (N=83). Findings indicate that adolescence stage comes with changes of intense sexual desires, often presumed difficult to control thus leading adolescents to engage in sexual activities. Adolescents indicated that they were aware of the sexual behaviors such as condom use, contraception use, and multiple concurrent partnerships, but intertwined with persistent myths and misconceptions. Although discussing sexuality issues with someone was found to be instrumental, adolescent highlighted challenges that hinder discussion with key influencers. Challenges include, parents lack of time to talk to their children; some religious affiliations perceived to discourage use of contraception; limited skills of community health workers to address adolescent information needs; meetings held in groups not followed up with age-focused or one-on-one discussions; negative health workers’ attitudes and use of technical language; and peer pressure. These findings suggest the need to provide adequate and updated information to clear any misconceptions and strengthening of key influencers’ communication skills to gain confidence in addressing adolescent sexual and reproductive health needs.

Many adolescent girls start sexual activity early which exposes them to health risks of HIV and unplanned pregnancies. However, adolescent girls are less likely than boys to initiate discussion or demand use of condoms. Multiple sexual partnerships among girls are reported to be on the rise with eminent transactional sex and pre-marital relationships. The unmet need for contraception among adolescent girls is also high. A cross-sectional survey covering 16 districts in Uganda assessed the socio-cognitive factors associated with condom use, multiple sexual partnerships and contraception use among sexually active adolescent girls (N=255). There were strong associations between feeling confident to discuss contraceptive methods with a partner (OR = 9.41, 95 % CI = 3.54, 25.06), being comfortable to use contraception (OR = 30.61, 95% CI = 4.10, 228.64), discussing contraception use with someone (OR = 10.53, 95% CI = 5.61, 19.78), and contraception use. Whereas knowledge was found to have no significant relationship with service uptake, information services remain important in clearing any misconceptions and addressing any health concerns. It is imperative to explore communication factors including skills development and providing adequate health information to guide dialogue among adolescents and their key influencers.

This study aimed to explore perceived determinants of condom use behaviors among male clients of female commercial sex workers (FCSWs) in Belu and Malaka districts, Indonesia. One-on-one in-depth interviews guided by the Health Belief Model (HBM) were used to collect the data from participants ( n = 42). The Framework analysis for qualitative data was employed to analyze the data. Results demonstrated several factors associated with lack of and inconsistent condom use among the participants. They included self-perceived risk of contracting HIV infection, knowledge of the severity of HIV illness and its impacts, and condom use: its benefits and its influencing factors. Additionally, factors including reduced sexual pleasure and the lack of knowledge of how and where to access condoms were important perceived barriers to condom use among participants. Having seen images of HIV-/AIDS-positive people, knowing friends and relatives suffering from HIV, and knowing FCSWs as a high-risk group for HIV infection were the cues to using condoms among several participants. Likewise, self-efficacy was also associated with condom use behaviors among the participants. The findings indicate the needs for HIV/AIDS interventions that include dissemination of HIV/AIDS knowledge, condom promotion, and improvement in the availability of condoms for both FCSWs and their clients.

The problem of overburdening is increasing among informal caregivers. Some attention has been paid to relationship factors, positive effects of caregiving, and coping strategies in relation to caregivers' perceived burdens, as these factors might make valuable contributions. The aim of this study was to thoroughly explore the views, experiences, and interpretations of informal caregivers with regard to these factors, who lived in the southernmost part of the Netherlands. In this qualitative case study design, 26 informal caregivers were interviewed using a semistructured questionnaire. The respondents indicated that having a good relationship with the care recipient, experiencing positive effects of providing care, and using coping strategies reduced their burden. In the future, longitudinal research is warranted to determine the actual contribution of these factors.

Background Participating in regular physical activity is a recommended cancer recovery strategy for breast cancer survivors. However, tailored support services are not widely available and most survivors are insufficiently active to obtain health benefits. Delivering tailored programs via the Internet offers one promising approach. However, recent evaluations of such programs suggest that major improvements are needed to ensure programs meet the needs of users and are delivered in an engaging way. Understanding participants' experiences with current programs can help to inform the next generation of systems.Purpose The purposes of this study are to explore breast cancer survivor's perspectives of and experiences using a novel computer-tailored intervention and to describe recommendations for future iterations.Methods Qualitative data from a sub-sample of iMove More for Life study participants were analysed thematically to identify key themes. Participants long-term goals for participating in the program were explored by analysing open-ended data extracted from action plans completed during the intervention (n = 370). Participants negative and positive perceptions of the website and recommendations for improvement were explored using data extracted from open-ended survey items collected at the immediate intervention follow-up (n = 156).Results The majority of participants reported multi-faceted goals, consisting of two or more outcomes they hoped to achieve within a year. While clear themes were identified (e.g. 'being satisfied with body weight'), there was considerable variability in the scope of the goal (e.g. desired weight loss ranged from 2 to 30 kg). Participants' perceptions of the website were mixed, but clear indications were provided of how intervention content and structure could be improved.Conclusions This study provides insight into how to better accommodate breast cancer survivors in the future and ultimately design more engaging computer-tailored interventions.

The objective of this review was to provide an overview of behavioural interventions promoting condom use amongst female sex workers (FSW) in sub-Saharan Africa. A search of four electronic bibliographic databases from 1990 to September 2016 was carried out. The search was limited to articles published in English. Studies which evaluated behavioural interventions to increase condom use among FSWs were selected and reviewed. Data were extracted on effectiveness, condom use, intervention content, and process outcomes. A total of 20 eligible articles describing 18 interventions in sub-Saharan Africa on HIV prevention with condom use as an outcome measure were identified. Most of the behavioural interventions incorporated a combination of approaches: health education by peers, health workers and project staff, and activities by brothel owners and brothel managers. Most studies showed effectiveness of these interventions on condom use with paying clients. Five studies measuring condom use with regular non-paying partners recorded less consistent condom use with these partners. This review illustrates the existence of sufficient evidence showing the effectiveness of behavioural interventions targeting correct and consistent condom use by FSWs.Keywords: commercial sex worker, HIV, safe sex, sexual behaviour, prevention

The instrument of scientific publishing, originally a necessary tool to enable development of a global science, has evolved relatively little in response to technological advances. Current scientific publishing practices incentivize a number of harmful approaches to research. Health Psychology Bulletin was founded to address these issues. Health Psychology Bulletin (HPB) is a new open access journal that actively promotes full disclosure through publication of replication and analysis packages and that explicitly welcomes null findings, reports of failed manipulation, replications, as well as regular contributions. HPB strives to publish all conducted studies in a manner that maximizes the potential lessons that can be learned, fostering a shift from a competitive to a collaborative model of science. HPB also implements a double blind peer reviewing procedure that is unblinded and citable once an article is accepted, and HPB will strive to enable post-publication peer reviews. Finally, HPB offers authors the possibility to submit (and publish) their introductions, methods, study protocols and replication packages before data collection, thereby benefiting from the peer review process in optimization of their methodologies. By implementing these innovations, HPB aims to contribute to remedying a number of problems that have recently been identified in the way health psychology science is conducted. In addition, the European Health Psychology Society aims to offer a new accessible, affordable, and flexible outlet to her members (and non-member health psychology researchers).

Support by brothel leaders and the promotion of a conducive environment for HIV prevention programs within brothel establishments are important to promote a safe working environment for Brothel-Based Female Sex Workers (BB FSWs). This study assesses the effects of a cluster randomized pilot trial examining the use of brothel leaders to improve consistent condom use by FSWs residing in brothels and also assessed the feasibility of implementing a similar intervention on a broader scale. Ten brothels in Abuja, Nigeria were randomized and exposed to the experimental (n=5) and control (n=5) arms of the intervention. The feasibility of the intervention and consistent condom use outcomes by FSWs with different partner types as well as condom negotiation self-efficacy were measured. Condom use outcomes and condom negotiation self-efficacy outcomes were analysed using multi-level mixed regression models. A total of 243 FSWs were recruited into the study (control n=66 and experimental n=177) and 107 of them (44%) were available at 16 weeks follow-up. The intervention demonstrated feasibility and positive outcomes for consistent condom use with boyfriends, casual partners and clients of FSWs were obtained. The interaction effect between condition and time indicated increased consistent condom use with boyfriends in the experimental condition (p=0.02). Adherence to the intervention by the FSWs was moderate with the mean sessions attended at 4.4(SD=2.0). The attrition rate during the intervention was high due to mobility of the FSWs. The intervention showed feasibility and effect outcomes indicate promise in enhancing condom use with steady partners of BB FSWs. The design of HIV prevention interventions may benefit from the inclusion of gatekeepers in the promotion of condom use within the brothel, but an adequately powered phase III trial is needed to inform large-scale implementation of this approach.

A qualitative inquiry using individual interviews explored determinants of unprotected sexual behaviours favouring HIV transmission among Men who Have sex with Men (MSM) in Yogyakarta, Indonesia. The study was conducted in July 2015 with 24 MSM participants recruited using convenience sampling technique. Data were analysed using a qualitative data analysis framework, with the Social Cognitive Theory (SCT) employed as the study conceptual framework. Findings were grouped into a reciprocal triadic relationship involving behavioural, personal (cognitive) and environmental determinants. Behavioural determinants comprised having multiple casual sex partners, engagement in group sex and transactional sex practices. Environmental factors associated with unprotected sexual behaviours included influence of unsafe sex from regular partners and lack of access to HIV-related services. Personal (cognitive) determinants favouring unprotected sexual behaviours identified were lack of knowledge of condom and HIV/AIDS, individuals’ expectation of pleasurable sexual intercourse, and low self-efficacy to discuss condom use and HIV status with casual sex partners. As effort to address HIV in MSM in Indonesia is still at its infancy, the findings of the current study are insightful and will inform the development of evidence-based programs in addressing HIV/AIDS problem in MSM populations in Yogyakarta and other similar settings.

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.

Access to HIV/AIDS-related health services among transgender women living with HIV is still a major public health issue in many developing countries, and Indonesia is not an exception. However, reportedly compared to other settings in the country, transgender women in Yogyakarta have a good access to the HIV-related health services. This study aimed to explore perceptions among transgender women living with HIV, locally known as waria, of factors supportive of their access to the services in Yogyakarta, Indonesia. A qualitative inquiry using in-depth interview method was conducted from December 2017 to February 2018 to collect the data from a selection of waria living with HIV (n = 29) recruited using both purposive and snowball sampling techniques. Data analysis employed a thematic approach which was guided by the framework analysis for qualitative data. The findings indicated several health service system-related determinants supportive of waria's access to HIV/AIDS-related health services. These included the availability of the services, the simplicity and convenience of accessibility to the services and the comfort felt by the participants while accessing the services. Health professionals' positive attitudes during healthcare provision, social relationships between waria and health professionals, proximity to healthcare facilities, free access to the services, and information sessions on HIV infection and prevention were also reported to enable participants' access to the services. These findings call to efforts and strengthening of HIV health service system to support and provide equal access to HIV/AIDS-related services including to all Indonesians living with HIV, but more so for transgender women and other high-risk groups such as sex workers and their clients and men who have sex with men.

Rationale: Efforts towards tobacco control are numerous, but relapse rates for smoking cessations remain high. Behavioral changes necessary for continuous cessation appear complex, variable and subject to social, biological, psychological and environmental determinants. Currently, most cessation studies concentrate on short-to midterm behavioral changes. Besides, they use fixed typologies, thereby failing to capture the temporal changes in smoking/cessation behaviors, and its determinants.Objective: To obtain long-term, data-driven longitudinal patterns or profiles of smoking, cessation, and related determinants in a cohort of adult smokers, and to investigate their dynamic links. Methods: The dataset originated from the International Tobacco Control (ITC) Netherlands Project, waves 2008 to 2016. Temporal dynamics of smoking/cessation, psychosocial constructs, and time-varying determinants of smoking were extracted with Group-Based Trajectory Modeling technique. Their associations were investigated via multiple regression models.Results: Substantial heterogeneity of smoking and cessation behaviors was unveiled. Most respondents were classified as persistent smokers, albeit with distinct levels of consumption. For a minority, cessation could be sustained between 1 and 8 years, while others showed relapsing or fluctuating smoking behavior. Links between smoking/cessation trajectories with those of psychosocial and sociodemographic variables were diverse. Notably, changes in two variables were aligned to behavioral changes towards cessation: decreasing number of smoking peers and attaining a higher self-perceived control.Conclusion: The unveiled heterogeneity of smoking behavior over time and the varied cross-dependencies between smoking data-driven typologies and those of underlying risk factors underscore the need of individually tailored approaches for motivational quitting.

Background Children 0-4 years attending childcare are more prone to acquire infections than home-cared children. Childcare illness absenteeism due to fever is mostly driven by fear towards fever in childcare staff and parents. This may cause high childcare absenteeism, healthcare service use, and work absenteeism in parents. This study evaluates a multicomponent intervention targeting determinants of decision-making among childcare staff on illness absenteeism due to fever and common infections. Methods The multicomponent intervention was developed based on the Intervention Mapping approach and consisted of (i) an educational session, (ii) a decision tool, (iii) an information booklet and (iv) an online video. The intervention was evaluated in a cluster randomized controlled trial in Southern Netherlands. Nine centres received the intervention and nine provided childcare-as-usual. Primary outcome measure was the percentage of illness absenteeism on cluster level, defined as number of childcare days absent due to illness on total of registered childcare contract days in a 12-week period. Secondary outcome measures included intended behaviour, attitude, risk perception, knowledge and self-efficacy of childcare staff. Outcomes were analyzed using linear mixed models accounting for clustering. Knowledge was descriptively analysed. Results Overall illness absenteeism was comparable in intervention (2.95%) and control group (2.52%). Secondary outcomes showed significant improvements in intervention group regarding intended behaviour, two of three attitude dimensions. Knowledge increased compared with control but no differences regarding self-efficacy. Conclusion The intervention was not effective in reducing illness absenteeism. However, the intervention improved determinants of decision-making such as intended behaviour, attitude, and knowledge on fever. Trial registration NTR6402 (registered on 21 April 2017).

BACKGROUND: Young people aged 16-24 years are disproportionately affected by sexually transmitted infections (STIs). STIs can have serious health consequences for affected individuals and the estimated annual cost of treatment to the National Health Service is £620 million. Accordingly, the UK government has made reducing the rates of STIs among this group a priority. A missed opportunity to intervene to increase condom use is when young people obtain self-sampling kits for STIs via the internet.OBJECTIVE: Our aim was to develop a theory-based tailored intervention to increase condom use for 16-24-years-olds accessing chlamydia self-sampling websites.METHODS: The intervention, Wrapped, was developed using Intervention Mapping and was co-designed with young people. The following steps were performed: (1) identification of important determinants of condom use and evidence of their changeability using computer and digital interventions; (2) setting the intervention goal, performance objectives, and change objectives; (3) identification of Behavior Change Principles (BCPs) and practical strategies to target these determinants; and (4) development of intervention materials able to deliver the BCPs and practical strategies.RESULTS: Users of existing chlamydia self-sampling websites are signposted to Wrapped after placing an order for a sampling kit. Salient barriers to condom use are identified by each user and relevant intervention components are allocated to target these. The components include the following: (1) a sample box of condoms, (2) an online condom distribution service, (3) a product for carrying condoms, (4) a condom demonstration video, (5) a series of videos on communication about condom use, and (6) erotic films of real couples discussing and demonstrating condom use.CONCLUSIONS: This intervention will be directed at young people who may be particularly receptive to messages and support for behavior change due to their testing status.

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.

Background. Registration rates are low for organ donation among lower educated adolescents in The Netherlands. This could be improved by preparing them for making a decision regarding donation when they become 18 years old. To do so, more insight is needed into their beliefs about organ donation and registration.Methods. A cross-sectional quantitative study was conducted among students in intermediate vocational education schools. Data were gathered my means of self-administrated questionnaires. The outcome measurements included current registration status, being an organ donor, intention to register, and intention to become a donor. Correlation coefficients were used to assess the strength of associations between beliefs and each of the 4 outcome measurements.Results. A total of 405 participants (mean age, 18.86 years) were included, of whom 26.6% had already registered a decision. Most beliefs showed a significant correlation with one or more of the outcomes. In general, the correlations were of small to medium size and participants scored around the middle of the scales on the beliefs.Conclusion. Means and correlations need to be combined to gain insight into the importance of certain beliefs for future interventions. However, it is plausible that, in addition to these explicit beliefs, implicit factors play a role in registration behavior. This could be explored in future research. Results could support intervention development for increasing registration rates.

Introduction: Adolescents in Uganda, as in other sub-Saharan countries, engage in sex with multiple concurrent partners, thus placing them at risk for HIV and unplanned pregnancies, but it is not clear why. This study explored why adolescents in Uganda engage in multiple concurrent sexual partnerships (MCSP).Methods: This study used a Core Processes methodology. We used the processes of brainstorming, and identification of evidence and theoretical support, in various phases/steps of intervention planning, to provide possible explanations for adolescent MCSP.Results: Adolescents were found to have limited knowledge of the risks associated with MCSP and perceived a low risk for HIV. Peer influence to engage in MCSP exacerbated the problem among adolescents. Poor communication with sexual partners and parents and societal indifference to multiple sexual partnerships increased permissive attitudes toward infidelity. The unclear adolescent sexual and reproductive health policies hampered access to services, and transactional sexual relationships with older (polygamous) sexual partners increased the HIV risk. Adolescents were found to be more concerned about unplanned pregnancies than HIV risk.Discussion: From the empirical evidence, adolescent health programs in Uganda should incorporate comprehensive sexual health education on HIV and teenage pregnancy risk-reduction strategies. Programs should strengthen parental and community support through enhanced collaborative training on communication with and for adolescents. Forming strategic partnerships with various stakeholders for concerted efforts to address the MCSP problem among adolescents is critical.

International audience; Engagement in electronic health (eHealth) and mobile health (mHealth) behavior change interventions is thought to be important for intervention effectiveness, though what constitutes engagement and how it enhances efficacy has been somewhat unclear in the literature. Recently published detailed definitions and conceptual models of engagement have helped to build consensus around a definition of engagement and improve our understanding of how engagement may influence effectiveness. This work has helped to establish a clearer research agenda. However, to test the hypotheses generated by the conceptual modules, we need to know how to measure engagement in a valid and reliable way. The aim of this viewpoint is to provide an overview of engagement measurement options that can be employed in eHealth and mHealth behavior change intervention evaluations, discuss methodological considerations, and provide direction for future research. To identify measures, we used snowball sampling, starting from systematic reviews of engagement research as well as those utilized in studies known to the authors. A wide range of methods to measure engagement were identified, including qualitative measures, self-report questionnaires, ecological momentary assessments, system usage data, sensor data, social media data, and psychophysiological measures. Each measurement method is appraised and examples are provided to illustrate possible use in eHealth and mHealth behavior change research. Recommendations for future research are provided, based on the limitations of current methods and the heavy reliance on system usage data as the sole assessment of engagement. The validation and adoption of a wider range of engagement measurements and their thoughtful application to the study of engagement are encouraged.

Objectives: To examine the bidirectional association of sleep duration with proportions of time spent in physical behaviors among Dutch adolescents. Methods: Adolescents (n = 294, 11–15 years) completed sleep diaries and wore an accelerometer (ActiGraph) over 1 week. With linear mixed-effects models, the authors estimated the association of sleep categories (short, optimal, and long) with the following day’s proportion in physical behaviors. With generalized linear mixed models with binomial distribution, the authors estimated the association of physical behavior proportions on sleep categories. Physical behavior proportions were operationalized using percentages of wearing time and by applying a compositional approach. All analyses were stratified by gender accounting for differing developmental stages. Results: For males (number of observed days: 345, n = 83), short as compared with optimal sleep was associated with the following day’s proportion spent in sedentary (−2.57%, p = .03, 95% confidence interval [CI] [−4.95, −0.19]) and light-intensity activities (1.96%, p = .02, 95% CI [0.27, 3.65]), which was not significant in the compositional approach models. Among females (number of observed days: 427, n = 104), long sleep was associated with the proportions spent in moderate- to vigorous-intensity physical activity (1.69%, p < .001, 95% CI [0.75, 2.64]) and in sedentary behavior (−3.02%, p n = 204). Conclusions: Results indicate partial associations between sleep and the following day’s physical behaviors, and no associations between physical behaviors and the following night’s sleep.

BACKGROUND: Metabolic health in people with obesity is determined by body composition. In this study, we examined the influence of a combined strength exercise and motivational programme -embedded in the school curriculum- on adolescents body composition and daily physical activity.METHODS: A total of 695 adolescents (11-15y) from nine Dutch secondary schools participated in a one year cluster randomised controlled trial (RCT). In the intervention schools, physical education teachers were instructed to spend 15-30 min of all physical education lessons (2× per week) on strength exercises. Monthly motivational lessons were given to stimulate students to be more physically active. Control schools followed their usual curriculum. The primary outcome measure was body composition assessed by the deuterium dilution technique. Daily physical activity and sedentary behaviour measured by accelerometry served as a secondary outcome.RESULTS: After 1 year, a 1.6% fat mass difference was found in favour of the intervention group (p = .007). This reflected a 0.9 kg difference in fat free mass (intervention>control; p = .041) and 0.7 kg difference in fat mass (interventionCONCLUSION: In 11-15 year olds, the combination of strength exercises plus motivational lessons contributed to an improvement in body composition and a smaller decrease in physical activity level. TRIAL REGISTRATION ID: ( NTR5676 - retrospectively registered 8 February 2016; enrolment of first participant: 2 March 2015).

Background/aim Proxies of patients with COPD are often unable to identify the patients' most important problematic activities of daily life (ADLs). The aim was to explore causes of perceptual differences between patients with COPD and their proxies about the problematic ADLs of the patient. Methods Ten open structured interviews were conducted in the presence of both the patient and proxy. Patients' five most important problematic ADLs identified by the couple were compared and discussed. For data analysis, open coding, axial coding and selective coding were conducted. Results Ten main causes were identified: differences in the level of satisfaction, or acceptance; estimation of own capabilities; problematic ADL goes unnoticed; proxy is not present during problematic ADL; problematic ADL is not performed (often or anymore), or not (longer) talked about; masked by another problematic ADL; value judgement; solution for problematic ADL. Conclusion The causes of perceptual differences between patients and proxies about patients' problematic ADLs were related to both the patient's and the proxy's perception.