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1.  Judging near and distant virtue and vice ☆ 
We propose that people judge immoral acts as more offensive and moral acts as more virtuous when the acts are psychologically distant than near. This is because people construe more distant situations in terms of moral principles, rather than attenuating situation-specific considerations. Results of four studies support these predictions. Study 1 shows that more temporally distant transgressions (e.g., eating one's dead dog) are construed in terms of moral principles rather than contextual information. Studies 2 and 3 further show that morally offensive actions are judged more severely when imagined from a more distant temporal (Study 2) or social (Study 3) perspective. Finally, Study 4 shows that moral acts (e.g., adopting a disabled child) are judged more positively from temporal distance. The findings suggest that people more readily apply their moral principles to distant rather than proximal behaviors.
doi:10.1016/j.jesp.2008.03.012
PMCID: PMC2701315  PMID: 19554217
Psychological distance; Moral judgment; Construal level theory
2.  Action planning as predictor of health protective and health risk behavior: an investigation of fruit and snack consumption 
Background
Large discrepancies between people's intention to eat a healthy diet and actual dietary behavior indicate that motivation is not a sufficient instigator for healthy behavior. Research efforts to decrease this 'intention - behavior gap' have centered on aspects of self-regulation, most importantly self-regulatory planning. Most studies on the impact of self-regulatory planning in health and dietary behavior focus on the promotion of health protective behaviors. This study investigates and compares the predictive value of action planning in health protective behavior and the restriction of health risk behavior.
Methods
Two longitudinal observational studies were performed simultaneously, one focusing on fruit consumption (N = 572) and one on high-caloric snack consumption (N = 585) in Dutch adults. Structural equation modeling was used to investigate and compare the predictive value of action planning in both behaviors, correcting for demographics and the influence of motivational factors and past behavior. The nature of the influence of action planning was investigated by testing mediating and moderating effects.
Results
Action planning was a significant predictor of fruit consumption and restricted snack consumption beyond the influence of motivational factors and past behavior. The strength of the predictive value of action planning did not differ between the two behaviors. Evidence for mediation of the intention - behavior relationship was found for both behaviors. Positive moderating effects of action planning were demonstrated for fruit consumption, indicating that individuals who report high levels of action planning are significantly more likely to translate their intentions into actual behavior.
Conclusion
The results indicate that the planning of specific preparatory actions predicts the performance of healthy dietary behavior and support the application of self-regulatory planning in both health protective and health risk behaviors. Future interventions in dietary modification may turn these findings to advantage by incorporating one common planning protocol to increase the likelihood that good intentions are translated into healthy dietary behavior.
doi:10.1186/1479-5868-6-69
PMCID: PMC2770554  PMID: 19825172
3.  The Origins of 12-Month Attachment: A Microanalysis of 4-Month Mother-Infant Interaction 
Attachment & human development  2010;12(0):3-141.
A detailed microanalysis of 4-month mother-infant face-to-face communication revealed a fine-grained specification of essential communication processes that predicted 12-month insecure attachment outcomes, particularly resistant and disorganized classifications. An urban community sample of 84 dyads were videotaped at 4 months during a face-to-face interaction, and at 12 months during the Ainsworth Strange Situation. Four-month mother and infant communication modalities of attention, affect, touch, and spatial orientation were coded from split-screen videotape on a 1s time base; mother and infant facial-visual “engagement” variables were constructed. We used contingency measures (multi-level time-series modeling) to examine the dyadic temporal process over time, and specific rates of qualitative features of behavior to examine the content of behavior. Self-contingency (auto-correlation) measured the degree of stability/lability within an individual’s own rhythms of behavior; interactive contingency (lagged cross-correlation) measured adjustments of the individual’s behavior that were correlated with the partner’s previous behavior.
We documented that both self- and interactive contingency, as well as specific qualitative features, of mother and infant behavior were mechanisms of attachment formation by 4 months, distinguishing 12-month insecure, resistant, and disorganized attachment classifications from secure; avoidant were too few to test. All communication modalities made unique contributions. The separate analysis of different communication modalities identified intermodal discrepancies or conflict, both intrapersonal and interpersonal, that characterized insecure dyads. Contrary to dominant theories in the literature on face-to-face interaction, measures of maternal contingent coordination with infant yielded the fewest associations with 12-month attachment, whereas mother and infant self-contingency, and infant contingent coordination with mother, yielded comparable numbers of findings. Rather than the more usual hypothesis that more contingency is “better,” we partially supported our hypothesis that 12-month insecurity is associated with both higher and lower 4-month self- and interactive contingency values than secure, as a function of mother vs. infant and communication modality. Thus, in the origins of attachment security, more contingency is not necessarily better.
A remarkable degree of differentiation was identified in the 4-month patterns of “future” C and D infants, classified as resistant and disorganized, respectively, at 12 months. Only future D infants were emotionally distressed, with simultaneous positive and negative discrepant affect; only their mothers showed difficulty in sharing infant affect, particularly distress, and lowered their contingent coordination with infant facial-visual engagement. This lowered contingent coordination makes it more difficult for infants to come to expect that their emotional/attentional states can influence mothers to coordinate with them and thus compromises the infant’s sense of interactive efficacy. Only future C dyads showed the spatial approach/avoid pattern of “chase and dodge;” only mothers of future D infants showed the spatial intrusion pattern of “looming” into the infant’s face. Both future C and D dyads showed patterns of touch dysregulation. Future C infants inhibited their emotional coordination with mothers’ less affectionate touch, as if tuning it out. Future D dyads showed a dyadic touch dysregulation, in which mothers lowered their coordination with infant touch, while infants had a lowered ability to use their own touch. Both mothers of future C and D infants disturbed the stability of the spatial “frame” of the encounter by transitioning among upward, forward and loom orientations in less predictable ways than mothers of future B infants. Only mothers of future D infants disturbed the attentional “frame” as well, by looking and looking away from the infant’s face in less predictable ways than mothers of future B infants. Only mothers of future D infants showed methods of managing their own state which distanced them from their infants, such as extensive looking away and “closing up” their faces.
The intact interactive contingency of the mother of the future C infant overall safeguards the infant’s interactive agency, and the infant’s expectation that mother will match the direction of infant affective change, sharing infant states. However, we proposed that the future C infant will have difficulty feeling sensed and known by mother during her spatial/tactile intrusions.
The central feature of future D dyads is intrapersonal and interpersonal discordance or conflict in the context of intensely distressed infants. Lowered maternal contingent coordination, and failures of maternal affective correspondence, constitute maternal emotional withdrawal from distressed infants, compromising infant interactive agency and emotional coherence. The level of dysregulation in future D dyads is thus of an entirely different order than that of future C dyads. We proposed that the future D infant represents not being sensed and known by the mother, particularly in states of distress. We proposed that the emerging internal working model of future D infants includes confusion about their own basic emotional organization, about their mothers’ emotional organization, and about their mothers’ response to their distress, setting a trajectory in development which may disturb the fundamental integration of the person.
The findings have rich implications for clinical intervention, with remarkable specificity for different kinds of mother and infant distress. The concepts of heightened and lowered self- and interactive contingency, in different modalities, as well as the specific behavioral qualities identified, provide a more differentiated set of concepts to guide clinical intervention.
doi:10.1080/14616730903338985
PMCID: PMC3763737  PMID: 20390524
4.  Representations of the Self in the Near and Distant Future 
Seven studies provide evidence that representations of the self at a distant-future time point are more abstract and structured than are representations of the self at a near-future time point and that distant-future behaviors are more strongly related to general self-conceptions. Distant-future self-representations incorporate broader, more superordinate identities than do near-future self-representations (Study 1) and are characterized by less complexity (Study 2), more cross-situational consistency (Study 3), and a greater degree of schematicity (Study 4). Furthermore, people’s behavioral predictions of their distant-future (vs. near-future) behavior are more strongly related to their general self-characteristics (Study 5), distant-future behaviors are seen as more self-expressive (Study 6), and distant-future behaviors that do not match up with acknowledged self-characteristics are more strongly rejected as reflections of the self (Study 7). Implications for understanding both the nature of the self-concept and the way in which distance may influence a range of self-processes are discussed.
doi:10.1037/a0012939
PMCID: PMC3153422  PMID: 18808258
self-concept; distance; time; construal; self-structure
5.  Antiviral Resistance and the Control of Pandemic Influenza 
PLoS Medicine  2007;4(1):e15.
Background
The response to the next influenza pandemic will likely include extensive use of antiviral drugs (mainly oseltamivir), combined with other transmission-reducing measures. Animal and in vitro studies suggest that some strains of influenza may become resistant to oseltamivir while maintaining infectiousness (fitness). Use of antiviral agents on the scale anticipated for the control of pandemic influenza will create an unprecedented selective pressure for the emergence and spread of these strains. Nonetheless, antiviral resistance has received little attention when evaluating these plans.
Methods and Findings
We designed and analyzed a deterministic compartmental model of the transmission of oseltamivir-sensitive and -resistant influenza infections during a pandemic. The model predicts that even if antiviral treatment or prophylaxis leads to the emergence of a transmissible resistant strain in as few as 1 in 50,000 treated persons and 1 in 500,000 prophylaxed persons, widespread use of antivirals may strongly promote the spread of resistant strains at the population level, leading to a prevalence of tens of percent by the end of a pandemic. On the other hand, even in circumstances in which a resistant strain spreads widely, the use of antivirals may significantly delay and/or reduce the total size of the pandemic. If resistant strains carry some fitness cost, then, despite widespread emergence of resistance, antivirals could slow pandemic spread by months or more, and buy time for vaccine development; this delay would be prolonged by nondrug control measures (e.g., social distancing) that reduce transmission, or use of a stockpiled suboptimal vaccine. Surprisingly, the model suggests that such nondrug control measures would increase the proportion of the epidemic caused by resistant strains.
Conclusions
The benefits of antiviral drug use to control an influenza pandemic may be reduced, although not completely offset, by drug resistance in the virus. Therefore, the risk of resistance should be considered in pandemic planning and monitored closely during a pandemic.
Emergence of oseltamivir-resistant influenza strains during a pandemic is likely given the heightened selective pressure if the drug is widely used. Marc Lipsitch and colleagues suggest that resistance would reduce but not completely offset the drug's benefits for pandemic control.
Editors' Summary
Background.
Governments and health authorities worldwide are planning how they would best prepare for and deal with a future influenza pandemic. Seasonal influenza is thought to affect between 5% and 15% of the population worldwide each year. Most people who get influenza recover within a couple of weeks without lasting effects, but a small proportion of patients, mostly young children and elderly people, experience serious complications that can be fatal. An influenza pandemic happens when new variants of the influenza virus emerge against which little immunity exists in the general population. Pandemic influenza strains are transmitted more rapidly than seasonal strains, often sweep across several countries or continents, and make more people ill. There are drugs that can treat and prevent influenza. One of them, oseltamivir (Tamiflu) is an antiviral drug that works by preventing viral particles from being released by infected human cells. Stockpiling large amounts of oseltamivir and related drugs with the intent to treat a large fraction of the population is a key part of pandemic preparedness of many countries. However, it is known that influenza viruses can develop resistance to these drugs.
Why Was This Study Done?
It is not clear how the emergence of oseltamivir-resistant influenza strains would affect the course of any future influenza pandemic. Much research in this area has focused on how likely the new strains are to emerge in the first place, rather than on how they might spread once they had emerged. In the context of an influenza pandemic, antiviral drugs would be used in a large proportion of the population, likely driving the selection and spread of resistant viruses. For this study, the researchers wanted to estimate the likely impact of resistant strains during an influenza pandemic.
What Did the Researchers Do and Find?
These researchers set up a mathematical model (i.e., simulations done on a computer) to mimic the spread of influenza. They then fed a set of assumptions into the computer. These included information about the rate of transmission of influenza from one person to another; what proportion of people would receive antiviral drugs for prophylaxis or treatment; how likely the drugs would be to successfully treat or prevent infection; and in what proportion of people the virus might become resistant to drugs. The modeling led to three main predictions. First, it predicted that widespread use of antiviral drugs such as oseltamivir could quickly lead to the spread of resistant viruses, even if resistant strains emerged only rarely. Second, even with resistant strains circulating, prophylaxis and treatment with oseltamivir would still delay the spread of the pandemic and reduce its total size. Third, nondrug interventions (such as social isolation and school closures) would further reduce the number of cases, but a higher proportion of cases would be caused by resistant strains if these control measures were used.
What Do These Findings Mean?
These findings suggest that, in the event of a future influenza pandemic for which antiviral drugs are used, there is a risk of resistance emerging and resistant strains causing illness in a substantial number of people. This would counteract the benefits of antiviral drugs but not eliminate those benefits entirely. Like all modeling studies, this one relies on realistic assumptions being entered into the model, and it is hard to know closely the model will mimic a real-life situation until the properties of an actual pandemic strain are known. Most studies, including this one, suggest that in the event of a pandemic, antiviral drugs will have an overall beneficial impact on reducing death rates and adverse health outcomes. However, given the sizeable effects of resistance suggested here, its role should be considered in pandemic planning. This includes surveillance that can detect emergence and spread of resistant strains.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/doi:10.1371/journal.pmed.0040015.
World Health Organization: information on pandemic preparedness
World Health Organization: fact sheets on influenza
Information from the UK Health Protection Agency on pandemic influenza
US government website on both pandemic flu and avian flu (information provided by the US Department of Health and Human Services)
doi:10.1371/journal.pmed.0040015
PMCID: PMC1779817  PMID: 17253900
6.  Intentions to Maintain Adherence to Mammography 
Journal of Women's Health  2008;17(7):1133-1141.
Abstract
Objective
Recent attention has focused on moving women from having initial mammograms to maintaining adherence to regular mammography schedules. We examined behavioral intentions to maintain mammography adherence, which include the likelihood of performing a behavior, and implementation intentions, specific action plans to obtain mammograms. Potential predictors were Theory of Planned Behavior constructs, previous barriers, previous mammography maintenance, and age.
Methods
Respondents were 2062 currently adherent women due for their next mammograms in 3–4 months according to American Cancer Society recommendations for annual screening. Statistical models were used to examine predictors of behavioral and two implementation intentions, including having thought about where women would get their next mammograms and having thought about making appointments.
Results
With the exception of pros, cons, and subjective norms, all variables predicted behavioral intentions (p ≤ 0.05). Stronger perceived control, previous mammography maintenance, and one barrier (vs. none) predicted being more likely to have thought about where to get their next mammograms. Previous maintenance and no barriers (vs. two) predicted being more likely to have thought about making appointments.
Conclusions
Our findings suggest that among women currently adherent to mammography, volitional factors, such as barriers, may be better predictors of implementation intentions than motivational factors, such as attitudes. Implementation variables may be useful in understanding how women move from intentions to action. Future research should examine how such factors relate to mammography maintenance behaviors and can be integrated into behavior change interventions.
doi:10.1089/jwh.2007.0600
PMCID: PMC2575244  PMID: 18657041
7.  Spontaneous trait inference and construal level theory: Psychological distance increases nonconscious trait thinking 
Can psychological distance affect how much perceivers form spontaneous trait inferences (STI) from others’ behaviors? On the basis of construal level theory (CLT) which posits that distant (vs. near) entities are represented more in terms of their abstract, global, and decontextualized features, we predicted that perceived distance would increase the tendency for perceivers to draw spontaneous trait inferences from behavioral information about actors. In two experiments, participants learned about people who were perceived as being distant or proximal to the self, and STI formation was subsequently assessed. We found that perceivers were more likely to form STIs about distant vs. near actors from the same behavioral information. These findings generalized across two distance dimensions: space and time. In addition, we found that priming individuals to adopt a high-level (vs. low-level) construal mindset also resulted in increased STI (Experiment 3). In sum, psychological distance facilitates STI formation, and this occurs via high-level construal of actors and their behaviors.
doi:10.1016/j.jesp.2009.06.015
PMCID: PMC3150821  PMID: 21822331
Person perception; Social cognition; Trait inference; Construal; Psychological distance
8.  Survey mode and asking about future intentions did not impact self-reported colorectal cancer screening accuracy 
Background
Self-reported colorectal cancer (CRC) screening behavior is often subject to over-reporting bias. We examined how the inclusion of a future intention to screen item (viz. asking about future intentions to get screened before asking about past screening) and mode of survey administration impacted the accuracy of self-reported CRC screening.
Methods
The target population was men and women between 49 and 85 years of age who lived in Olmsted County, MN, for at least 10 years at the time of the study. Eligible residents were randomized into four groups representing the presence or absence the future intention to screen item in the questionnaire and administration mode (mail vs. telephone). A total of 3,638 cases were available for analysis with 914, 838, 956, and 930 in the mail/future intention, mail/no future intention, telephone/future intention, and telephone/no future intention conditions, respectively. False positives were defined as self-reporting being screened among those with no documented history of screening in medical records and false negatives as not self-reporting screening among those with history of screening.
Results
Comparing false positive and false negative reporting rates for each specific screening test among the responders at the bivariate level, regardless of mode, there were no statistically significant differences by the presence or absence of a preceding future intention question. When considering all tests combined, the percentage of false negatives within the telephone mode was slightly higher for those with the future intention question (6.7% vs 4.2%, p = 0.04). Multivariate models that considered the independent impact of the future intention question and mode, affirmed the results observed at the bivariate level. However, individuals in the telephone arm (compared to mail) were slightly (though not significantly) more likely to report a false positive (36.4% vs 31.8%, OR = 1.11, p = 0.55).
Conclusion
It may be that in the context of a questionnaire that is clearly focused on CRC and with specific descriptions of the various CRC screening tests, certain design features such as including intention to screen items or mode of administration will have very little impact on the accuracy of self-reported CRC screening.
doi:10.1186/1471-2288-14-19
PMCID: PMC3918109  PMID: 24499399
Data collection; survey methodology; cancer screening; self-report accuracy; mail surveys; telephone surveys
9.  Athletic Trainers' Beliefs Toward Working With Special Olympics Athletes 
Journal of Athletic Training  2009;44(3):279-285.
Context:
Certified athletic trainers (ATs) are often the first health care providers to treat injured athletes. However, few researchers have studied ATs' beliefs concerning working with Special Olympics athletes.
Objectives:
To examine ATs' beliefs toward working with Special Olympics athletes by using the theory of planned behavior model and to examine the influence of moderator variables.
Design:
Cross-sectional survey.
Setting:
Athletic Trainers' Beliefs Toward Special Olympics Athletes survey instruments were mailed to 147 directors of Commission on Accreditation of Allied Health Education Programs–accredited athletic training education programs (ATEPDs) in 43 states and 120 cities.
Patients or Other Participants:
One hundred twenty ATEPDs (44 women, 76 men).
Main Outcome Measure(s):
We used stepwise multiple regression analysis to determine whether attitude toward the behavior, subjective norm, and perceived behavioral control predicted intention and to determine which moderator variables predicted attitude toward the behavior, subjective norm, and perceived behavioral control. Pearson product moment correlations were used to determine ATEPDs' beliefs about how competent they felt working with Special Olympics athletes and whether they were currently working with these athletes.
Results:
We found that subjective norm, attitude toward the behavior, and perceived behavioral control predicted intention (R  =  0.697, R2  =  0.486, F3,112  =  35.3, P < .001) and that intention predicted ATEPDs' actual behaviors (R  =  0.503, R2  =  0.253, F1,118  =  39.995, P < .001). Moderator variables that predicted attitude toward the behavior included more years of experience working with Special Olympics athletes, completion of 1 or more courses in adapted physical activity, ATEPDs' competence, completion of 1 or more special education courses, and sex (R  =  0.589, R2  =  0.347, F5,111  =  11.780, P < .001). Moderator variables that predicted subjective norm included more experience working with Special Olympics athletes and more Special Olympics certifications (R  =  0.472, R2  =  0.222, F2,112  =  16.009, P < .001). Moderator variables that predicted perceived behavioral control included ATEPDs' competence, more years of experience working with Special Olympics athletes, and a higher educational degree (R  =  0.642, R2  =  0.412, F4,113  =  19.793, P < .001).
Conclusions:
Certified athletic trainers had favorable attitudes about the behavior beliefs toward working with Special Olympics athletes; however, their subjective norm, perceived behavioral control, and intention beliefs were unfavorable. The ATEPDs reported they did not feel competent to work with Special Olympics athletes.
PMCID: PMC2681214  PMID: 19478841
disability sport injury; intellectual disabilities; autism; theory of planned behavior; attitude research
10.  Use of Syndromic Surveillance Information for Expanded Assessment of Wildfire Disaster 
Objective
This presentation describes how syndromic surveillance information was combined with fire emission information and spatio-temporal fire occurrence data to evaluate, model and forecast climate change impacts on future fire scenarios.
Introduction
Syndromic surveillance information can be a useful for the early recognition of outbreaks, acute public health events and in response to natural disasters. Inhalation of particulate matter from wildland fire smoke has been linked to various acute respiratory and cardiovascular health effects. Historically, wildfire disasters occur across Southern California on a recurring basis. During 2003 and 2007, wildfires ravaged San Diego County and resulted in historic levels of population evacuation, significant impact on air quality and loss of lives and infrastructure. In 2011, the National Institutes of Health-National Institute of Environmental Health Sciences awarded Michigan Tech Research Institute a grant to address the impact of fire emissions on human health, within the context of a changing climate. San Diego County Public Health Services assisted on this project through assessment of population health impacts and provisioning of syndromic surveillance data for advanced modeling.
Methods
Various historical data sets were used during this study. These included: emergency department syndromic surveillance from 17 hospitals, as well as air quality and particulate matter, meteorological, wildland burn fuel, and atmospheric dispersion data. The study area was San Diego County. These data were linked temporally and spatially to create statistical models based on selected modeling approaches including generalized additive modeling. Future fire frequency was modeled for the entire region to determine the impacts of climate change on future fire and health outcomes. Modeling based upon previous fire occurrence was used to develop models for future fire indexes, risk of ignition, potential burning, and fire weather.
Results
Several models were developed to produce expected respiratory health impacts under future climate conditions for the San Diego County region. Model results showed that at peak fire particulate concentrations, the odds of a person seeking emergency care increased by approximately 50% compared to non-fire conditions. Also developed was a model to forecast future fire occurrence based on regional climate model predictions. This forecast covering the next the next three decades reveals that San Diego County will experience approximately two extreme fire seasons each decade by 2040.
Conclusions
Syndromic surveillance data are useful during disasters for situational awareness. These data may also provide value for post-disaster analytic work and predictive modeling for future disasters. This study demonstrates utility of syndromic data for collaborative work resulting in better understanding of environmental interactions on human health. We do know that wildfire occurs with some degree of historic regularity and these results may be useful for preparedness planning. We also know the conditions which must be present for medium to high wildland fire impact upon the population. This study further supports the notion that agencies should be able to strategically deploy resources and messaging immediately preceding the fire period with the goal of reducing human health risk factors and encouraging changes in community behaviors before, during and after a fire. Future fire model shows San Diego County will experience approximately two extreme fire seasons each decade by 2040. This project also promoted collaboration between public health and environmental health entities to better understand determinants of health during a disaster. In addition to developing a better understanding of the consequences of climate change on fire-induced respiratory illness, the project funding has provided support for San Diego County to improve their syndromic surveillance capacity and infrastructure.
PMCID: PMC3692945
Syndromic; Disaster; Forecasting; Wildfire; San Diego
11.  Impact and Process Evaluation of Integrated Community and Clinic-Based HIV-1 Control: A Cluster-Randomised Trial in Eastern Zimbabwe 
PLoS Medicine  2007;4(3):e102.
Background
HIV-1 control in sub-Saharan Africa requires cost-effective and sustainable programmes that promote behaviour change and reduce cofactor sexually transmitted infections (STIs) at the population and individual levels.
Methods and Findings
We measured the feasibility of community-based peer education, free condom distribution, income-generating projects, and clinic-based STI treatment and counselling services and evaluated their impact on the incidence of HIV-1 measured over a 3-y period in a cluster-randomised controlled trial in eastern Zimbabwe. Analysis of primary outcomes was on an intention-to-treat basis. The income-generating projects proved impossible to implement in the prevailing economic climate. Despite greater programme activity and knowledge in the intervention communities, the incidence rate ratio of HIV-1 was 1.27 (95% confidence interval [CI] 0.92–1.75) compared to the control communities. No evidence was found for reduced incidence of self-reported STI symptoms or high-risk sexual behaviour in the intervention communities. Males who attended programme meetings had lower HIV-1 incidence (incidence rate ratio 0.48, 95% CI 0.24–0.98), and fewer men who attended programme meetings reported unprotected sex with casual partners (odds ratio 0.45, 95% CI 0.28–0.75). More male STI patients in the intervention communities reported cessation of symptoms (odds ratio 2.49, 95% CI 1.21–5.12).
Conclusions
Integrated peer education, condom distribution, and syndromic STI management did not reduce population-level HIV-1 incidence in a declining epidemic, despite reducing HIV-1 incidence in the immediate male target group. Our results highlight the need to assess the community-level impact of interventions that are effective amongst targeted population sub-groups.
In cluster-randomised trial in Zimbabwe integrated peer education, condom distribution, and management of sexually transmitted infections did not reduce incidence of population-level HIV-1.
Editors' Summary
Background.
Sub-Saharan Africa has been hit heavily by HIV/AIDS, and Zimbabwe in particular has been very badly affected, with over one-fifth of its adult population infected with HIV. However, this proportion has been declining slowly in recent years, and the same trend has also been seen in a few other African countries. It is not clear whether these trends are related to changes in the way people behave, perhaps as a result of public health and prevention campaigns, or rather are due to changes in the natural spread of the HIV epidemic. However, there is considerable uncertainty about how we should carry out campaigns that try to get people to change their behavior. One possible approach for achieving behavior change involves peer education: that is, education carried out within the community, by at-risk community members themselves. Another approach involves tying together a set of related programs that deliver information and education through health clinics and directly in the community. Such programs are termed “integrated community and clinic-based HIV prevention.”
Why Was This Study Done?
The researchers wanted to find out whether providing integrated community and clinic-based strategies for HIV prevention in Eastern Zimbabwe could reduce the proportion of people within the community infected with HIV. If successful, then the strategies could be effective elsewhere, for example in other African countries where behavior patterns and the HIV epidemic are similar to the situation studied here.
What Did the Researchers Do and Find?
The research was done as a cluster-randomized trial. This means that different communities were assigned by chance to one of two trial arms, either an “intervention arm”, where the community and clinic-based strategies would be delivered, or a “control” arm which would not have additional services. Six pairs of communities in Eastern Zimbabwe were compared, each of which had its own health center. Control communities received the standard government services for preventing HIV. The other communities received a package of various additional strategies. These included education and condom distribution amongst sex workers and their clients; better services at sexually transmitted infection (STI) clinics (STIs can increase the risk of HIV infection); and educational HIV/AIDS open days at health centers. The researchers planned to compare, between the two arms, the number of people who became infected with HIV over the course of the trial. They found that there was no statistical difference in the number of people in the intervention arm who became infected with HIV over the course of the trial, as compared to people in the control arm. Men in the intervention communities were more likely to have effective treatment for STIs, but women were more likely to show risky behaviors, such as having sex at a younger age, and having unprotected sex. However, men in the intervention communities were more knowledgeable about HIV/AIDS than men in the control communities. One strategy in the intervention arm (delivery of education and condom distribution among sex workers and their clients) may have been less successful because of the economic situation at the time, which meant that the income-generating projects that were supposed to support this initiative were impossible.
What Do These Findings Mean?
Some of the results from this trial are encouraging, for example an improvement in male participants' knowledge and behavior. However, overall, the intervention did not have an impact on the HIV infection rate in the community. Some other trials have also shown similar results. These results mean that other strategies need to be developed, and tested, which will encourage people to change their behavior patterns and reduce the risk of getting HIV. However, trials such as this are very difficult to design, carry out, and interpret. In particular, if a complex intervention such as this fails, it is often hard to tell whether it did so because the intervention was not delivered successfully, or because it did not work.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040102.
Information from Avert, an international HIV/AIDS charity, on HIV and AIDS in Zimbabwe
Information from UNAIDS, the United Nations Programme on HIV/AIDS, on strategies for HIV prevention
HIV/AIDS minisite from the World Health Organization
The Web site of the Manicaland HIV/STD Prevention Project discusses this project
doi:10.1371/journal.pmed.0040102
PMCID: PMC1831737  PMID: 17388666
12.  Neural Correlates of Self-Appraisals in the Near and Distant Future: An Event-Related Potential Study 
PLoS ONE  2013;8(12):e84332.
To investigate perceptual and neural correlates of future self-appraisals as a function of temporal distance, event-related potentials (ERPs) were recorded while participants (11 women, eight men) made judgments about the applicability of trait adjectives to their near future selves (i.e., one month from now) and their distant future selves (i.e., three years from now). Behavioral results indicated people used fewer positive adjectives, more negative adjectives, recalled more specific events coming to mind and felt more psychologically connected to the near future self than the distant future self. Electrophysiological results demonstrated that negative trait adjectives elicited more positive ERP deflections than did positive trait adjectives in the interval between 550 and 800 ms (late positive component) within the near future self condition. However, within the same interval, there were no significant differences between negative and positive traits adjectives in the distant future self condition. The results suggest that negative emotional processing in future self-appraisals is modulated by temporal distance, consistent with predictions of construal level theory.
doi:10.1371/journal.pone.0084332
PMCID: PMC3869860  PMID: 24376803
13.  The influence of rural clinical school experiences on medical students’ levels of interest in rural careers 
Human Resources for Health  2014;12(1):48.
Background
Australian Rural Clinical School (RCS) programmes have been designed to create experiences that positively influence graduates to choose rural medical careers. Rural career intent is a categorical evaluation measure and has been used to assess the Australian RCS model. Predictors for rural medical career intent have been associated with extrinsic values such as students with a rural background. Intrinsic values such as personal interest have not been assessed with respect to rural career intent. In psychology, a predictor of the motivation or emotion for a specific career or career location is the level of interest. Our primary aims are to model over one year of Australian RCS training, change in self-reported interest for future rural career intent. Secondary aims are to model student factors associated with rural career intent while attending an RCS.
Methods
The study participants were medical students enrolled in a RCS in the year 2013 at the University of New South Wales (UNSW) and who completed the newly developed self-administered UNSW Undergraduate Destinations Study (UDS) questionnaire. Data were collected at baseline and after one year of RCS training on preferred location for internship, work and intended specialty. Interest for graduate practice location (career intent) was assessed on a five-variable Likert scale at both baseline and at follow-up. A total of 165 students completed the UDS at baseline and 150 students after 1 year of follow-up.
Results
Factors associated with intent to practise in a rural location were rural background (χ2 = 28.4, P < 0.001), two or more previous years at an RCS (χ2 = 9.0, P = 0.003), and preference for a rural internship (χ2 = 17.8, P < 0.001). At follow-up, 41% of participants who originally intended to work in a metropolitan location at baseline changed their preference and indicated a preference for a rural location. The level of interest in intended practice location was significantly higher for those intending to work in a rural area than those with intention to work in a metropolitan (urban area) location (t = -3.1, P = 0.002). Initial rural career location intention was associated with increased interest levels after 1 year of follow-up (paired t = -2.3, P = 0.02).
Conclusion
When evaluating the success of RCS outcomes with respect to rural workforce destination, both rural practice intentions and level of interest are key factors related to projected career destination. RCS experience can positively influence practice intent (toward rural practice) and interest levels (toward greater interest in rural practice).
doi:10.1186/1478-4491-12-48
PMCID: PMC4159525  PMID: 25169650
Rural career intention; Interest level; Australian Rural Clinical School (RCS)
14.  The role of action planning and plan enactment for smoking cessation 
BMC Public Health  2013;13:393.
Background
Several studies have reemphasized the role of action planning. Yet, little attention has been paid to the role of plan enactment. This study assesses the determinants and the effects of action planning and plan enactment on smoking cessation.
Methods
One thousand and five participants completed questionnaires at baseline and at follow-ups after one and six months. Factors queried were part of the I-Change model. Descriptive analyses were used to assess which plans were enacted the most. Multivariate linear regression analyses were used to assess whether the intention to quit smoking predicted action planning and plan enactment, and to assess which factors would predict quitting behavior. Subsequently, both multivariate and univariate regression analyses were used to assess which particular action plans would be most effective in predicting quitting behavior. Similar analyses were performed among a subsample of smokers prepared to quit within one month.
Results
Smokers who intended to quit smoking within the next month had higher levels of action planning than those intending to quit within a year. Additional predictors of action planning were being older, being female, having relatively low levels of cigarette dependence, perceiving more positive and negative consequences of quitting, and having high self-efficacy toward quitting. Plan enactment was predicted by baseline intention to quit and levels of action planning. Regression analysis revealed that smoking cessation after six months was predicted by low levels of depression, having a non-smoking partner, the intention to quit within the next month, and plan enactment. Only 29% of the smokers who executed relatively few plans had quit smoking versus 59% of the smokers who executed many plans. The most effective preparatory plans for smoking cessation were removing all tobacco products from the house and choosing a specific date to quit.
Conclusion
Making preparatory plans to quit smoking is important because it also predicts plan enactment, which is predictive of smoking cessation. Not all action plans were found to be predictive of smoking cessation. The effects of planning were not very much different between the total sample and smokers prepared to quit within one month.
doi:10.1186/1471-2458-13-393
PMCID: PMC3644281  PMID: 23622256
Smoking cessation; Action planning; Preparatory planning; Plan enactment; Planned quit attempts
15.  Global and Local Concerns: What Attitudes and Beliefs Motivate Farmers to Mitigate and Adapt to Climate Change? 
PLoS ONE  2012;7(12):e52882.
In response to agriculture's vulnerability and contribution to climate change, many governments are developing initiatives that promote the adoption of mitigation and adaptation practices among farmers. Since most climate policies affecting agriculture rely on voluntary efforts by individual farmers, success requires a sound understanding of the factors that motivate farmers to change practices. Recent evidence suggests that past experience with the effects of climate change and the psychological distance associated with people's concern for global and local impacts can influence environmental behavior. Here we surveyed farmers in a representative rural county in California's Central Valley to examine how their intention to adopt mitigation and adaptation practices is influenced by previous climate experiences and their global and local concerns about climate change. Perceived changes in water availability had significant effects on farmers' intention to adopt mitigation and adaptation strategies, which were mediated through global and local concerns respectively. This suggests that mitigation is largely motivated by psychologically distant concerns and beliefs about climate change, while adaptation is driven by psychologically proximate concerns for local impacts. This match between attitudes and behaviors according to the psychological distance at which they are cognitively construed indicates that policy and outreach initiatives may benefit by framing climate impacts and behavioral goals concordantly; either in a global context for mitigation or a local context for adaptation.
doi:10.1371/journal.pone.0052882
PMCID: PMC3530505  PMID: 23300805
16.  Explaining clinical behaviors using multiple theoretical models 
Background
In the field of implementation research, there is an increased interest in use of theory when designing implementation research studies involving behavior change. In 2003, we initiated a series of five studies to establish a scientific rationale for interventions to translate research findings into clinical practice by exploring the performance of a number of different, commonly used, overlapping behavioral theories and models. We reflect on the strengths and weaknesses of the methods, the performance of the theories, and consider where these methods sit alongside the range of methods for studying healthcare professional behavior change.
Methods
These were five studies of the theory-based cognitions and clinical behaviors (taking dental radiographs, performing dental restorations, placing fissure sealants, managing upper respiratory tract infections without prescribing antibiotics, managing low back pain without ordering lumbar spine x-rays) of random samples of primary care dentists and physicians. Measures were derived for the explanatory theoretical constructs in the Theory of Planned Behavior (TPB), Social Cognitive Theory (SCT), and Illness Representations specified by the Common Sense Self Regulation Model (CSSRM). We constructed self-report measures of two constructs from Learning Theory (LT), a measure of Implementation Intentions (II), and the Precaution Adoption Process. We collected data on theory-based cognitions (explanatory measures) and two interim outcome measures (stated behavioral intention and simulated behavior) by postal questionnaire survey during the 12-month period to which objective measures of behavior (collected from routine administrative sources) were related. Planned analyses explored the predictive value of theories in explaining variance in intention, behavioral simulation and behavior.
Results
Response rates across the five surveys ranged from 21% to 48%; we achieved the target sample size for three of the five surveys. For the predictor variables, the mean construct scores were above the mid-point on the scale with median values across the five behaviors generally being above four out of seven and the range being from 1.53 to 6.01. Across all of the theories, the highest proportion of the variance explained was always for intention and the lowest was for behavior. The Knowledge-Attitudes-Behavior Model performed poorly across all behaviors and dependent variables; CSSRM also performed poorly. For TPB, SCT, II, and LT across the five behaviors, we predicted median R2 of 25% to 42.6% for intention, 6.2% to 16% for behavioral simulation, and 2.4% to 6.3% for behavior.
Conclusions
We operationalized multiple theories measuring across five behaviors. Continuing challenges that emerge from our work are: better specification of behaviors, better operationalization of theories; how best to appropriately extend the range of theories; further assessment of the value of theories in different settings and groups; exploring the implications of these methods for the management of chronic diseases; and moving to experimental designs to allow an understanding of behavior change.
doi:10.1186/1748-5908-7-99
PMCID: PMC3500222  PMID: 23075284
17.  A Cognitive-Social Model of Fertility Intentions 
Population and development review  2013;39(3):459-485.
We examine the use and value of fertility intentions against the backdrop of theory and research in the cognitive and social sciences. First, we draw on recent brain and cognition research to contextualize fertility intentions within a broader set of conscious and unconscious mechanisms that contribute to mental function. Next, we integrate this research with social theory. Our conceptualizations suggest that people do not necessarily have fertility intentions; they form them only when prompted by specific situations. Intention formation draws on the current situation and on schemas of childbearing and parenthood learned through previous experience, imbued by affect, and organized by self-representation. Using this conceptualization, we review apparently discordant knowledge about the value of fertility intentions in predicting fertility. Our analysis extends and deepens existing explanations for the weak predictive validity of fertility intentions at the individual level and provides a social-cognitive explanation for why intentions predict as well as they do. When focusing on the predictive power of intentions at the aggregate level, our conceptualizations lead us to focus on how social structures frustrate or facilitate intentions and how the structural environment contributes to the formation of reported intentions in the first place. Our analysis suggests that existing measures of fertility intentions are useful but to varying extents and in many cases despite their failure to capture what they seek to measure.
doi:10.1111/j.1728-4457.2013.00612.x
PMCID: PMC4132897  PMID: 25132695
18.  Understanding Determinants of Consumer Mobile Health Usage Intentions, Assimilation, and Channel Preferences 
Background
Consumer use of mobile devices as health service delivery aids (mHealth) is growing, especially as smartphones become ubiquitous. However, questions remain as to how consumer traits, health perceptions, situational characteristics, and demographics may affect consumer mHealth usage intentions, assimilation, and channel preferences.
Objective
We examine how consumers’ personal innovativeness toward mobile services (PIMS), perceived health conditions, health care availability, health care utilization, demographics, and socioeconomic status affect their (1) mHealth usage intentions and extent of mHealth assimilation, and (2) preference for mHealth as a complement or substitute for in-person doctor visits.
Methods
Leveraging constructs from research in technology acceptance, technology assimilation, consumer behavior, and health informatics, we developed a cross-sectional online survey to study determinants of consumers’ mHealth usage intentions, assimilation, and channel preferences. Data were collected from 1132 nationally representative US consumers and analyzed by using moderated multivariate regressions and ANOVA.
Results
The results indicate that (1) 430 of 1132 consumers in our sample (37.99%) have started using mHealth, (2) a larger quantity of consumers are favorable to using mHealth as a complement to in-person doctor visits (758/1132, 66.96%) than as a substitute (532/1132, 47.00%), and (3) consumers’ PIMS and perceived health conditions have significant positive direct influences on mHealth usage intentions, assimilation, and channel preferences, and significant positive interactive influences on assimilation and channel preferences. The independent variables within the moderated regressions collectively explained 59.70% variance in mHealth usage intentions, 60.41% in mHealth assimilation, 34.29% in preference for complementary use of mHealth, and 45.30% in preference for substitutive use of mHealth. In a follow-up ANOVA examination, we found that those who were more favorable toward using mHealth as a substitute for in-person doctor visits than as a complement indicated stronger intentions to use mHealth (F 1,702=20.14, P<.001) and stronger assimilation of mHealth (F 1,702=41.866, P<.001).
Conclusions
Multiple predictors are shown to have significant associations with mHealth usage intentions, assimilation, and channel preferences. We suggest that future initiatives to promote mHealth should shift targeting of consumers from coarse demographics to nuanced considerations of individual dispositions toward mobile service innovations, complementary or substitutive channel use preferences, perceived health conditions, health services availability and utilization, demographics, and socioeconomic characteristics.
doi:10.2196/jmir.2635
PMCID: PMC3742412  PMID: 23912839
mobile health; consumer preferences; adoption; health information technology; multivariate analyses
19.  Been there before? Examining “familiarity” as a moderator for discriminating between true and false intentions 
Prospection is thinking about possible future states of the world. Commitment to perform a future action—commonly referred to as intention—is a specific type of prospection. This knowledge is relevant when trying to assess whether a stated intention is a lie or the truth. An important observation is that thinking of, and committing to, future actions often evoke vivid and detailed mental images. One factor that affects how specific a person experiences these simulations is location-familiarity. The purpose of this study was to examine to what extent location-familiarity moderates how liars and truth tellers describe a mental image in an investigative interview. Liars were instructed to plan a criminal act and truth tellers were instructed to plan a non-criminal act. Before they could carry out these acts, the participants were intercepted and interviewed about the mental images they may have had experienced in this planning phase. Truth tellers told the truth whereas liars used a cover story to mask their criminal intentions. As predicted, the results showed that the truth tellers reported a mental image significantly more often than the liars. If a mental image was reported, the content of the descriptions did not differ between liars and truth tellers. In a post interview questionnaire, the participants rated the vividness (i.e., content and clarity) of their mental images. The ratings revealed that the truth tellers had experienced their mental images more vividly during the planning phase than the liars. In conclusion, this study indicates that both prototypical and specific representations play a role in prospection. Although location-familiarity did not moderate how liars and truth tellers describe their mental images of the future, this study allows some interesting insights into human future thinking. How these findings can be helpful for distinguishing between true and false intentions will be discussed.
doi:10.3389/fpsyg.2014.00677
PMCID: PMC4083357  PMID: 25071648
deception detection; episodic future thinking; familiarity; mental images; true and false intentions; prototypical prospection
20.  The Global Coherence Initiative: Creating a Coherent Planetary Standing Wave 
ABSTRACT
The much anticipated year of 2012 is now here. Amidst the predictions and cosmic alignments that many are aware of, one thing is for sure: it will be an interesting and exciting year as the speed of change continues to increase, bringing both chaos and great opportunity. One benchmark of these times is a shift in many people from a paradigm of competition to one of greater cooperation. All across the planet, increasing numbers of people are practicing heart-based living, and more groups are forming activities that support positive change and creative solutions for manifesting a better world. The Global Coherence Initiative (GCI) is a science-based, co-creative project to unite people in heart-focused care and intention. GCI is working in concert with other initiatives to realize the increased power of collective intention and consciousness.
The convergence of several independent lines of evidence provides strong support for the existence of a global information field that connects all living systems and consciousness. Every cell in our bodies is bathed in an external and internal environment of fluctuating invisible magnetic forces that can affect virtually every cell and circuit in biological systems. Therefore, it should not be surprising that numerous physiological rhythms in humans and global collective behaviors are not only synchronized with solar and geomagnetic activity, but disruptions in these fields can create adverse effects on human health and behavior.
The most likely mechanism for explaining how solar and geomagnetic influences affect human health and behavior are a coupling between the human nervous system and resonating geomagnetic frequencies, called Schumann resonances, which occur in the earth-ionosphere resonant cavity and Alfvén waves. It is well established that these resonant frequencies directly overlap with those of the human brain and cardiovascular system. If all living systems are indeed interconnected and communicate with each other via biological, electromagnetic, and nonlocal fields, it stands to reason that humans can work together in a co-creative relationship to consciously increase the coherence in the global field environment, which in turn distributes this information to all living systems within the field.
GCI was established to help facilitate the shift in global consciousness from instability and discord to balance, cooperation, and enduring peace. A primary goal of GCI is to test the hypothesis that large numbers of people when in a heart-coherent state and holding a shared intention can encode information on the earth's energetic and geomagnetic fields, which act as carrier waves of this physiologically patterned and relevant information. In order to conduct this research, a global network of 12 to 14 ultrasensitive magnetic field detectors specifically designed to measure the earth's magnetic resonances is being installed strategically around the planet. More important is GCI's primary goal to motivate as many people as possible to work together in a more coherent and collaborative manner to increase the collective human consciousness.
If we are persuaded that not only external fields of solar and cosmic origins but also human attention and emotion can directly affect the physical world and the mental and emotional states of others (consciousness), it broadens our view of what interconnectedness means and how it can be intentionally utilized to shape the future of the world we live in. It implies that our attitudes, emotions, and intentions matter and that coherent, cooperative intent can have positive effects.
GCI hypothesizes that when enough individuals and social groups increase their coherence baseline and utilize that increased coherence to intentionally create a more coherent standing reference wave in the global field, it will help increase global consciousness. This can be achieved when an increasing number of people move towards more balanced and self-regulated emotions and responses. This in turn can help facilitate cooperation and collaboration in innovative problem solving and intuitive discernment for addressing society's significant social, environmental, and economic problems. In time, as more individuals stabilize the global field and families, workplaces, and communities move to increased social coherence, it will lead to increased global coherence. This will be indicated by countries adopting a more coherent planetary view so that social and economic oppression, warfare, cultural intolerance, crime, and disregard for the environment can be addressed meaningfully and successfully.
doi:10.7453/gahmj.2012.1.1.013
PMCID: PMC3833489  PMID: 24278803
Global Coherence Initiative; geomagnetic; Schumann resonances; coherence; heart-based living; global health
21.  Inferring on the Intentions of Others by Hierarchical Bayesian Learning 
PLoS Computational Biology  2014;10(9):e1003810.
Inferring on others' (potentially time-varying) intentions is a fundamental problem during many social transactions. To investigate the underlying mechanisms, we applied computational modeling to behavioral data from an economic game in which 16 pairs of volunteers (randomly assigned to “player” or “adviser” roles) interacted. The player performed a probabilistic reinforcement learning task, receiving information about a binary lottery from a visual pie chart. The adviser, who received more predictive information, issued an additional recommendation. Critically, the game was structured such that the adviser's incentives to provide helpful or misleading information varied in time. Using a meta-Bayesian modeling framework, we found that the players' behavior was best explained by the deployment of hierarchical learning: they inferred upon the volatility of the advisers' intentions in order to optimize their predictions about the validity of their advice. Beyond learning, volatility estimates also affected the trial-by-trial variability of decisions: participants were more likely to rely on their estimates of advice accuracy for making choices when they believed that the adviser's intentions were presently stable. Finally, our model of the players' inference predicted the players' interpersonal reactivity index (IRI) scores, explicit ratings of the advisers' helpfulness and the advisers' self-reports on their chosen strategy. Overall, our results suggest that humans (i) employ hierarchical generative models to infer on the changing intentions of others, (ii) use volatility estimates to inform decision-making in social interactions, and (iii) integrate estimates of advice accuracy with non-social sources of information. The Bayesian framework presented here can quantify individual differences in these mechanisms from simple behavioral readouts and may prove useful in future clinical studies of maladaptive social cognition.
Author Summary
The ability to decode another person's intentions is a critical component of social interactions. This is particularly important when we have to make decisions based on someone else's advice. Our research proposes that this complex cognitive skill (social learning) can be translated into a mathematical model, which prescribes a mechanism for mentally simulating another person's intentions. This study demonstrates that this process can be parsimoniously described as the deployment of hierarchical learning. In other words, participants learn about two quantities: the intentions of the person they interact with and the veracity of the recommendations they offer. As participants become more and more confident about their representation of the other's intentions, they make decisions more in accordance with the advice they receive. Importantly, our modeling framework captures individual differences in the social learning process: The estimated “learning fingerprint” can predict other aspects of participants' behavior, such as their perspective-taking abilities and their explicit ratings of the adviser's level of trustworthiness. The present modeling approach can be further applied in the context of psychiatry to identify maladaptive learning processes in disorders where social learning processes are particularly impaired, such as schizophrenia.
doi:10.1371/journal.pcbi.1003810
PMCID: PMC4154656  PMID: 25187943
22.  Imagining the future: Degraded representations of future rewards and events in schizophrenia 
Journal of abnormal psychology  2011;120(2):483-489.
Over the course of life, most people work towards temporally distant rewards such as university degrees or work-related promotions. In contrast, many people with schizophrenia show deficits in behavior oriented toward long-term rewards, although they function adequately when rewards are more immediately present. Moreover, when asked about possible future events, individuals with schizophrenia show foreshortened future time perspectives relative to healthy individuals. Here, we take the view that these deficits are related and can be explained by cognitive deficits. We compared participants with schizophrenia (N=39) and healthy participants' (N=25) performance on tasks measuring reward discounting and future event representations. Consistent with previous research, we found that relative to healthy participants, those with schizophrenia discounted the value of future rewards more steeply. Furthermore, when asked about future events, their responses were biased toward events in the near future, relative to healthy participants' responses. Interestingly, although discounting and future representations were unrelated in healthy participants, we found significant correlations across the tasks among participants with schizophrenia, as well as correlations with cognitive variables and symptoms. Further analysis showed that statistically controlling working memory eliminated group differences in task performance. Together these results suggest that the motivational deficits characteristic of schizophrenia relate to cognitive deficits affecting the ability to represent and/or evaluate distant outcomes, a finding with important implications for promoting recovery from schizophrenia.
doi:10.1037/a0021810
PMCID: PMC3091996  PMID: 21171727
Schizophrenia; reward; time perspectives; delay discounting; cognitive function
23.  Characteristics and Impact of Drug Detailing for Gabapentin 
PLoS Medicine  2007;4(4):e134.
Background
Sales visits by pharmaceutical representatives (“drug detailing”) are common, but little is known about the content of these visits or about the impact of visit characteristics on prescribing behavior. In this study, we evaluated the content and impact of detail visits for gabapentin by analyzing market research forms completed by physicians after receiving a detail visit for this drug.
Methods and Findings
Market research forms that describe detail visits for gabapentin became available through litigation that alleged that gabapentin was promoted for “off-label” uses. Forms were available for 97 physicians reporting on 116 detail visits between 1995 and 1999. Three-quarters of recorded visits (91/116) occurred in 1996. Two-thirds of visits (72/107) were 5 minutes or less in duration, 65% (73/113) were rated of high informational value, and 39% (42/107) were accompanied by the delivery or promise of samples. During the period of this study, gabapentin was approved by the US Food and Drug Administration only for the adjunctive treatment of partial seizures, but in 38% of visits (44/115) the “main message” of the visit involved at least one off-label use. After receiving the detail visit, 46% (50/108) of physicians reported the intention to increase their prescribing or recommending of gabapentin in the future. In multivariable analysis, intent to increase future use or recommendation of gabapentin was associated with receiving the detail in a small group (versus one-on-one) setting and with low or absent baseline use of the drug, but not with other factors such as visit duration, discussion of “on-label” versus “off-label” content, and the perceived informational value of the presentation.
Conclusions
Detail visits for gabapentin were of high perceived informational value and often involved messages about unapproved uses. Despite their short duration, detail visits were frequently followed by physician intentions to increase their future recommending or prescribing of the drug.
Visits from pharmaceutical representatives regarding gabapentin "detailing" were frequently followed by physician intentions to increase their future activity with the drug.
Editors' Summary
Background.
In the US, before a pharmaceutical company can market a drug to doctors for use in a specific “indication” (meaning the treatment for a particular disease and group of patients), the drug has to be approved as safe and effective for that use by a government agency, the Food and Drug Administration. Once approved, doctors are allowed to use a drug for whatever nonapproved indications they think are appropriate, but the drug company cannot actively promote the drug for anything other than its approved use. However, many people are concerned that drug companies indirectly try to promote use of drugs for indications that are not approved. Such illegal activity would help a drug company increase its market share and sell more drugs. One tactic that drug companies use to sell drugs is “detailing.” Detailing involves direct visits from drug company representatives to individual doctors, during which the representative would provide information about their company's drugs. However, not a great deal is known about detail visits and the effect that they have on doctors' attitudes towards the drugs that are being promoted.
Why Was This Study Done?
The researchers carrying out this study wanted to learn more about what happens during detail visits and what impact these visits have on prescribing behavior. An opportunity for researching this came about as a result of a lawsuit during which drug company documents were subpoenaed (i.e., required by the court to be made available). In that lawsuit, it was alleged that a drug company, Parke-Davis, had promoted a drug, gabapentin, for many nonapproved uses. The company that subsequently took over Parke-Davis eventually made an out-of-court settlement. During the relevant time period, the only approved use of gabapentin was for treatment of partial seizures in adults with epilepsy, in combination with other drugs. However, gabapentin was used for many other conditions such as treatment of psychiatric disorders and management of pain. These researchers therefore used the documents available as a result of the lawsuit to research detailing and what impact detailing had on doctors' attitudes towards the drug being promoted.
What Did the Researchers Do and Find?
The documents analyzed in this study were produced by Verispan, a market research company. Verispan asked doctors who had been visited by Parke-Davis sales representatives to fill out a standard form after each detail visit. These forms were then subpoenaed as part of the lawsuit against Parke-Davis. The researchers here focused specifically on data relating to visits made by a single sales representative to a doctor or small group of doctors, and collected 116 forms. The data available from these forms included the doctors' ratings and comments regarding the main message associated with the products; the informational value of the visit; the quality of the presentation; and whether the doctor currently prescribed or planned to prescribe the product. The researchers classified the information available from the forms, identifying whether the “main message” related to approved uses of the drug or not; and extracting data relating to whether doctors planned to increase, maintain, or decrease their use of the drug. The majority of the visits studied were to doctors who were not neurologists, and would therefore be unlikely to prescribe gabapentin for its approved use. Doctors reported that a substantial proportion of the detail visits contained messages relating to nonapproved uses of gabapentin. Nearly half the doctors stated in the forms that their use of gabapentin would increase in the future, and no doctors said that their use would decrease following the visit. Doctors' intention to increase their use of gabapentin in the future was similar regardless of whether the message of the visit involved an approved or unapproved use.
What Do These Findings Mean?
This study shows that in the case of gabapentin, detail visits by drug company representatives frequently promoted nonapproved uses of the drug; these visits often resulted in doctors planning to increase their use of gabapentin. However, it is not clear whether these findings are also true for other drugs and drug companies, in part because these data came about as a result of a unique opportunity granted by the lawsuit against Parke-Davis.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040134.
Medline Plus (provided by the US National Library of Medicine) has an entry about gabapentin
Introductory information is available from the US FDA Center for Drug Evaluation and Research about the drug approvals process in the USA
Wikipedia has an entry on pharmaceutical marketing (Note that Wikipedia is an internet encyclopedia anyone can edit)
The Drug Industry Document Archive is available at University of California, San Francisco; this internet archive holds documents relating to the lawsuit against Parke-Davis and from which the data presented in this paper derives
Guidance is available from the International Federation of Pharmaceutical Manufacturers and Associations regarding ethical promotion of medicines
doi:10.1371/journal.pmed.0040134
PMCID: PMC1855692  PMID: 17455990
24.  Protection Motivation Theory in Predicting Intention to Engage in Protective Behaviors against Schistosomiasis among Middle School Students in Rural China 
Background
Among millions of people who suffer from schistosomiasis in China, adolescents are at increased risk to be infected. However, there is a lack of theory-guided behavioral prevention intervention programs to protect these adolescents. This study attempted to apply the Protection Motivation Theory (PMT) in predicting intentions to engage in protective behaviors against schistosomiasis infection.
Methods
The participants were selected using the stratified cluster sampling method. Survey data were collected using anonymous self-reported questionnaire. The advanced structural equation modeling (SEM) method was utilized to assess the complex relationship among schistosomiasis knowledge, previous risk exposure and protective measures in predicting intentions to engage in protective behavior through the PMT constructs.
Principal Findings
Approximately 70% of participants reported they were always aware of schistosomiasis before exposure to water with endemic schistosomiasis, 6% of the participants reported frequency of weekly or monthly prior exposure to snail-conditioned water. 74% of participants reported having always engaged in protective behaviors in the past three months. Approximately 7% were unlikely or very unlikely to avoid contact with snail-conditioned water, and to use protective behaviors before exposure. Results from SEM analysis indicated that both schistosomiasis knowledge and prior exposure to schistosomiasis were indirectly related to behavior intentions through intrinsic rewards and self-efficacy; prior protective behaviors were indirectly related to behavior intentions through severity, intrinsic rewards and self-efficacy, while awareness had an indirect relationship with behavior intentions through self-efficacy. Among the seven PMT constructs, severity, intrinsic rewards and self-efficacy were significantly associated with behavior intentions.
Conclusions
The PMT can be used to predict the intention to engage in protective behaviors against schistosomiasis. Schistosomiasis intervention programs should focus on the severity, intrinsic rewards and self-efficacy of protection motivation, and also increase the awareness of infection, and enrich the contents of schistosomiasis education.
Author Summary
In China, millions of population suffer from schistosomiasis infection and adolescents tend to have higher infection rates than adults. The Knowledge-Attitude-Practice (KAP) Theory has traditionally been used as guidance to schistosomiasis prevention in China. However, despite increases in knowledge among residents in the epidemic areas due to KAP theory-based schistosomiasis health education, no significant reduction in water-contact behavior was evident. Therefore, it is of crucial importance to seek alternative health behavior change theories/models that are more effective than the KAP theory to promote purposeful behavioral change. The Protection Motivation Theory (PMT) as a social cognitive model may be an alternative to the KAP theory. In this study, we found that the PMT can be used to predict intention to engage in protective behaviors against schistosomiasis infection among middle school students in rural China. Based on the PMT, in addition to enhancing awareness of schistosomiasis infection, intervention programs should focus on the severity, intrinsic rewards and self-efficacy of protection motivation.
doi:10.1371/journal.pntd.0003246
PMCID: PMC4199519  PMID: 25329829
25.  Comparative Efficacy of Seven Psychotherapeutic Interventions for Patients with Depression: A Network Meta-Analysis 
PLoS Medicine  2013;10(5):e1001454.
Jürgen Barth and colleagues use network meta-analysis - a novel methodological approach - to reexamine the comparative efficacy of seven psychotherapeutic interventions for adults with depression.
Please see later in the article for the Editors' Summary
Background
Previous meta-analyses comparing the efficacy of psychotherapeutic interventions for depression were clouded by a limited number of within-study treatment comparisons. This study used network meta-analysis, a novel methodological approach that integrates direct and indirect evidence from randomised controlled studies, to re-examine the comparative efficacy of seven psychotherapeutic interventions for adult depression.
Methods and Findings
We conducted systematic literature searches in PubMed, PsycINFO, and Embase up to November 2012, and identified additional studies through earlier meta-analyses and the references of included studies. We identified 198 studies, including 15,118 adult patients with depression, and coded moderator variables. Each of the seven psychotherapeutic interventions was superior to a waitlist control condition with moderate to large effects (range d = −0.62 to d = −0.92). Relative effects of different psychotherapeutic interventions on depressive symptoms were absent to small (range d = 0.01 to d = −0.30). Interpersonal therapy was significantly more effective than supportive therapy (d = −0.30, 95% credibility interval [CrI] [−0.54 to −0.05]). Moderator analysis showed that patient characteristics had no influence on treatment effects, but identified aspects of study quality and sample size as effect modifiers. Smaller effects were found in studies of at least moderate (Δd = 0.29 [−0.01 to 0.58]; p = 0.063) and large size (Δd = 0.33 [0.08 to 0.61]; p = 0.012) and those that had adequate outcome assessment (Δd = 0.38 [−0.06 to 0.87]; p = 0.100). Stepwise restriction of analyses by sample size showed robust effects for cognitive-behavioural therapy, interpersonal therapy, and problem-solving therapy (all d>0.46) compared to waitlist. Empirical evidence from large studies was unavailable or limited for other psychotherapeutic interventions.
Conclusions
Overall our results are consistent with the notion that different psychotherapeutic interventions for depression have comparable benefits. However, the robustness of the evidence varies considerably between different psychotherapeutic treatments.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Depression is a very common condition. One in six people will experience depression at some time during their life. People who are depressed have recurrent feelings of sadness and hopelessness and might feel that life is no longer worth living. The condition can last for months and often includes physical symptoms such as headaches, sleeping problems, and weight gain or loss. Treatment of depression can include non-drug treatments (psychotherapy), antidepressant drugs, or a combination of the two. Especially for people with mild or intermediate depression, psychotherapy is often considered the preferred first option. Psychotherapy describes a range of different psychotherapies, and a number of established types of psychotherapies have all shown to work for at least some patients.
Why Was This Study Done?
While it is broadly accepted that psychotherapy can help people with depression, the question of which type of psychotherapy works best for most patients remains controversial. While many scientific studies have compared one psychotherapy with control conditions, there have been few studies that directly compared multiple treatments. Without such direct comparisons, it has been difficult to establish the respective merits of the different types of psychotherapy. Taking advantage of a recently developed method called “network meta-analysis,” the authors re-examine the evidence on seven different types of psychotherapy to see how well they have been shown to work and whether some work better than others.
What Did the Researchers Do and Find?
The researchers looked at seven different types of psychotherapy, which they defined as follows. “Interpersonal psychotherapy” is short and highly structured, using a manual to focus on interpersonal issues in depression. “Behavioral activation” raises the awareness of pleasant activities and seeks to increase positive interactions between the patient and his or her environment. “Cognitive behavioral therapy” focuses on a patient's current negative beliefs, evaluates how they affect current and future behavior, and attempts to restructure the beliefs and change the outlook. “Problem solving therapy” aims to define a patient's problems, propose multiple solutions for each problem, and then select, implement, and evaluate the best solution. “Psychodynamic therapy” focuses on past unresolved conflicts and relationships and the impact they have on a patient's current situation. In “social skills therapy,” patients are taught skills that help to build and maintain healthy relationships based on honesty and respect. “Supportive counseling” is a more general therapy that aims to get patients to talk about their experiences and emotions and to offer empathy without suggesting solutions or teaching new skills.
The researchers started with a systematic search of the medical literature for relevant studies. The search identified 198 articles that reported on such clinical trials. The trials included a total of 15,118 patients and compared one of the seven psychotherapies either with another one or with a common “control intervention”. In most cases, the control (no psychotherapy) was deferral of treatment by “wait-listing” patients or continuing “usual care.” With network meta-analysis they were able to summarize the results of all these trials in a meaningful way. They did this by integrating direct comparisons of several psychotherapies within the same trial (where those were available) with indirect comparisons across all trials (using no psychotherapy as a control intervention).
Based on the combined trial results, all seven psychotherapies tested were better than wait-listing or usual care, and the differences were moderate to large, meaning that the average person in the group that received therapy was better off than about half of the patients in the control group. When comparing the therapies with each other, the researchers saw small or no differences, meaning that none of them really stood out as much better or much worse than the others. They also found that the treatments worked equally well for different patient groups with depression (younger or older patients, or mothers who had depression after having given birth). Similarly, they saw no big differences when comparing individual with group therapy, or person-to-person with internet-based interactions between therapist and patient.
However, they did find that smaller and less rigorous studies generally found larger benefits of psychotherapies, and most of the studies included in the analysis were small. Only 36 of the studies had at least 50 patients who received the same treatment. When they restricted their analysis to those studies, the researchers still saw clear benefits of cognitive-behavioral therapy, interpersonal therapy, and problem-solving therapy, but not for the other four therapies.
What Do these Findings Mean?
Similar to earlier attempts to summarize and make sense of the many study results, this one finds benefits for all of the seven psychotherapies examined, and none of them stood as being much better than some or all others. The scientific support for being beneficial was stronger for some therapies, mostly because they had been tested more often and in larger studies.
Treatments with proven benefits still do not necessarily work for all patients, and which type of psychotherapy might work best for a particular patient likely depends on that individual. So overall this analysis suggests that patients with depression and their doctors should consider psychotherapies and explore which of the different types might be best suited for a particular patient.
The study also points to the need for further research. Whereas depression affects large numbers of people around the world, all of the trials identified were conducted in rich countries and Western societies. Trials in different settings are essential to inform treatment of patients worldwide. In addition, large high-quality studies should further explore the potential benefits of some of therapies for which less support currently exists. Where possible, future studies should compare psychotherapies with one another, because all of them have benefits, and it would not be ethical to withhold such beneficial treatment from patients.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001454.
The US National Institute of Mental Health provides information on all aspects of depression (in English and Spanish); information on psychotherapy includes information on its most common forms
The UK National Health Service Choices website also provides detailed information about depression and includes personal stories about depression
The UK nonprofit Mind provides information on depression, including an explanation of the most common psychotherapies in the UK
MedlinePlus provides links to other resources about depression (in English and Spanish)
The UK nonprofit healthtalkonline.org has a unique database of personal and patient experiences on depression
doi:10.1371/journal.pmed.1001454
PMCID: PMC3665892  PMID: 23723742

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