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1.  Evaluation of a Serious Self-Regulation Game Intervention for Overweight-Related Behaviors (“Balance It”): A Pilot Study 
Serious games have the potential to promote health behavior. Because overweight is still a major issue among secondary vocational education students in the Netherlands, this study piloted the effects of “Balance It,” a serious self-regulation game intervention targeting students’ overweight-related behaviors: dietary intake and physical activity (PA).
We aimed to pilot the effects of Balance It on secondary vocational education students’ dietary intake and PA.
In total, 501 secondary vocational education students participated at baseline (intervention: n=250; control: n=251) in this pre-post cluster randomized trial. After 4 weeks, at immediate posttest, 231 students filled in the posttest questionnaire (intervention: n=105; control: n=126). The sample had a mean age of 17.28 (SD 1.26, range 15-21) years, 62.8% (145/231) were female, and 26.8% (62/231) had a non-Dutch background. Body mass index (BMI kg/m2) ranged from 14.4 to 31.1 (mean 21.1, SD 3.3). The intervention and control groups were compared on the primary (behavioral) outcomes of dietary intake (fruit and vegetable consumption, snack consumption, and soft drink consumption) and PA (moderate and vigorous). Additionally, we explored (1) differences between the intervention and control groups in determinants of dietary intake and PA, including attitude, self-efficacy, intention, barrier identification, action planning, and action control, and (2) differences between active (intervention) users and the control group in dietary intake, PA, and associated determinants.
After corrections for multiple testing, we did not find significant differences between the intervention group and control group in terms of dietary intake, PA, and determinants of dietary intake and PA. Exploratory research indicated that only 27.6% (29/105) of the intervention group reported actual intervention use (ie, active users). For exploratory reasons, we compared the active users (n=29) with the control group (n=124) and corrected for multiple testing. Results showed that active users’ snack consumption decreased more strongly (active users: mean change=–0.20; control group: mean change=–0.08; beta=–0.36, P=.01, R2 change=.05), and their use of active transport had a stronger increase (active users: mean change=0.92; control group=–0.12; beta=1.58, P=.02, R2 change=.03) than the control group. Results also revealed significant differences in action planning (active users: mean change=0.42; control group: mean change=0.07; beta=0.91, P=.01, R2 change=.04) and action control (active users: mean change=0.63; control group: mean change=–0.05; beta=1.25, P=.001, R2 change=.08) in terms of unhealthy eating.
The Balance It intervention did not show favorable effects on dietary intake and PA compared to the control condition. However, only a small number of people in the intervention condition actually used Balance It (27.6%). Exploratory analyses did suggest that, if used as planned, Balance It could contribute to changing dietary intake and PA behaviors, albeit it remains debatable whether this would be sufficient to prevent overweight.
PMCID: PMC5057062  PMID: 27670222
Balance It; effect evaluation; serious game; self-regulation; prevention and control; health promotion; dietary intake; physical activity
2.  Associations between parental impulsivity and child body mass index 
SpringerPlus  2016;5(1):1422.
The aim of this study was to examine the association between parental impulsivity and (12–15 year old) child body mass index (BMI).
In total, 300 parents completed a survey regarding their own impulsivity level (Barratt impulsiveness scale) and that of their child (impulsivity scale of the temperament in middle childhood questionnaire), and supplied details of their own and their child’s height and weight. Partial correlations were computed to assess relationships between both parental and child impulsiveness scores and child BMI z-scores, independent of parental BMI. Mediation analyses were performed to assess the potential mediating role of child impulsivity on the relationship between parental impulsivity and child BMI z-score.
For daughters, parental impulsivity was significantly correlated with BMI z-score. Parent-reported child impulsivity was not related to child BMI z-score, and no evidence was found for a mediating effect of parent-reported child impulsivity on the relationship between parental impulsivity and child BMI z-score.
There is a stronger association between parental impulsivity and child BMI z-score than between child impulsivity and child BMI z-score. The relationship between parental impulsivity and-child BMI z-score could possibly be explained by parenting styles and practices. The potentially mediating role of parenting should be taken into account in future studies investigating the role of personality in children becoming overweight or obese.
Electronic supplementary material
The online version of this article (doi:10.1186/s40064-016-3048-x) contains supplementary material, which is available to authorized users.
PMCID: PMC5001965  PMID: 27625976
Adolescents; Body mass index; Child; Impulsivity; Parents
3.  Design of the FemCure study: prospective multicentre study on the transmission of genital and extra-genital Chlamydia trachomatis infections in women receiving routine care 
BMC Infectious Diseases  2016;16:381.
In women, anorectal infections with Chlamydia trachomatis (CT) are about as common as genital CT, yet the anorectal site remains largely untested in routine care. Anorectal CT frequently co-occurs with genital CT and may thus often be treated co-incidentally. Nevertheless, post-treatment detection of CT at both anatomic sites has been demonstrated. It is unknown whether anorectal CT may play a role in post-treatment transmission. This study, called FemCure, in women who receive routine treatment (either azithromycin or doxycycline) aims to understand the post-treatment transmission of anorectal CT infections, i.e., from their male sexual partner(s) and from and to the genital region of the same woman. The secondary objective is to evaluate other reasons for CT detection by nucleic acid amplification techniques (NAAT) such as treatment failure, in order to inform guidelines to optimize CT control.
A multicentre prospective cohort study (FemCure) is set up in which genital and/or anorectal CT positive women (n = 400) will be recruited at three large Dutch STI clinics located in South Limburg, Amsterdam and Rotterdam. The women self-collect anorectal and vaginal swabs before treatment, and at the end of weeks 1, 2, 4, 6, 8, 10, and 12. Samples are tested for presence of CT-DNA (by NAAT), load (by quantitative polymerase chain reaction -PCR), viability (by culture and viability PCR) and CT type (by multilocus sequence typing). Sexual exposure is assessed by online self-administered questionnaires and by testing samples for Y chromosomal DNA. Using logistic regression models, the impact of two key factors (i.e., sexual exposure and alternate anatomic site of infection) on detection of anorectal and genital CT will be assessed.
The FemCure study will provide insight in the role of anorectal chlamydia infection in maintaining the CT burden in the context of treatment, and it will provide practical recommendations to reduce avoidable transmission. Implications will improve care strategies that take account of anorectal CT.
Trial registration Identifier: NCT02694497.
PMCID: PMC4977887  PMID: 27502928
Chlamydia trachomatis; Anorectal; Genital; Transmission; Heterosexual
4.  A taxonomy of behaviour change methods: an Intervention Mapping approach 
Health Psychology Review  2015;10(3):297-312.
In this paper, we introduce the Intervention Mapping (IM) taxonomy of behaviour change methods and its potential to be developed into a coding taxonomy. That is, although IM and its taxonomy of behaviour change methods are not in fact new, because IM was originally developed as a tool for intervention development, this potential was not immediately apparent. Second, in explaining the IM taxonomy and defining the relevant constructs, we call attention to the existence of parameters for effectiveness of methods, and explicate the related distinction between theory-based methods and practical applications and the probability that poor translation of methods may lead to erroneous conclusions as to method-effectiveness. Third, we recommend a minimal set of intervention characteristics that may be reported when intervention descriptions and evaluations are published. Specifying these characteristics can greatly enhance the quality of our meta-analyses and other literature syntheses. In conclusion, the dynamics of behaviour change are such that any taxonomy of methods of behaviour change needs to acknowledge the importance of, and provide instruments for dealing with, three conditions for effectiveness for behaviour change methods. For a behaviour change method to be effective: (1) it must target a determinant that predicts behaviour; (2) it must be able to change that determinant; (3) it must be translated into a practical application in a way that preserves the parameters for effectiveness and fits with the target population, culture, and context. Thus, taxonomies of methods of behaviour change must distinguish the specific determinants that are targeted, practical, specific applications, and the theory-based methods they embody. In addition, taxonomies should acknowledge that the lists of behaviour change methods will be used by, and should be used by, intervention developers. Ideally, the taxonomy should be readily usable for this goal; but alternatively, it should be clear how the information in the taxonomy can be used in practice. The IM taxonomy satisfies these requirements, and it would be beneficial if other taxonomies would be extended to also meet these needs.
PMCID: PMC4975080  PMID: 26262912
Taxonomy; behaviour change; meta-analysis; meta-analyses; review; interventions
5.  Innovatively Supporting Teachers’ Implementation of School-Based Sex Education: Developing A Web-Based Coaching Intervention From Problem to Solution 
Full program implementation is crucial for effectiveness but is often overlooked or insufficiently considered during development of behavioral change interventions. For school-based health promotion programs, teachers are key players in program implementation, but teacher support in this phase is mostly limited to technical support and information. To ensure optimal implementation of the Dutch school-based sexual health program Long Live Love, a Web-based coaching website was developed to support teachers in completeness and fidelity of program implementation.
The aim of this paper is to provide insight into the process of systematic development of a Web-based coaching intervention to support teachers in their implementation of a school-based sexual health program.
The intervention mapping (IM) protocol was applied for the development of a theory- and evidence-based intervention. The IM process begins with (1) a needs assessment, followed by (2) the formulation of change objectives, (3) the selection of theory-based intervention methods and practical applications that take the parameters for effectiveness into consideration, (4) integration of practical applications into an organized program, (5) planning for adoption, implementation, and sustainability of the program, and finally, (6) generating an evaluation plan to measure program effectiveness.
Teacher’s implementation behavior was characterized by inconsistently selecting parts of the program and not delivering (all) lessons as intended by program developers. Teachers, however, did not perceive this behavior as problematic, revealing the discrepancy between teacher’s actual and perceived need for support in delivering Long Live Love lessons with completeness and fidelity. Teachers did, however, acknowledge different difficulties they encountered which could potentially negatively influence the quality of implementation. With the IM protocol, this Web-based coaching intervention was developed based on a concept of unobtrusive coaching, by and for teachers, to bring about change in teachers’ implementation behavior.
This paper provides an example of a Web-based intervention to bring about behavioral change in a target group of intermediaries who lack intrinsic motivation for coaching and who’s perceptions differ from their actual problematic behavior. The IM protocol is a useful tool for guiding the scientific development of interventions and making them compatible with the needs and preferences of the target group.
PMCID: PMC4961878  PMID: 27405241
implementation; web-based coaching; intervention mapping; sexual education; unobtrusive; fidelity; teachers
6.  Stigma by association and family burden among family members of people with mental illness: the mediating role of coping 
When someone has a mental illness, family members may share the experience of stigma. Past research has established that family members’ experiences of stigma by association predict psychological distress and lower quality-of-life.
The present study, conducted with 503 family members of people with mental illness examined the prevalence of 14 different coping strategies. Of greater importance, we examined the role of these coping strategies as mediators of the relationships between stigma by association and family burden, on the one hand, and outcomes, such as psychological distress and quality-of-life, on the other.
The results showed that both perceived stigma by association and family burden are associated with greater psychological distress and lower quality-of-life, and that most coping strategies mediate these relationships.
Adaptive coping strategies were related to reduced negative outcomes, while most maladaptive coping strategies were related to enhanced negative outcomes. Implications for intervention development are discussed.
PMCID: PMC5025495  PMID: 27357819
Stigma by association; Family burden; Psychological distress; Quality-of-life; Coping; Mental illness
7.  Identifying Psychosocial Variables That Predict Safer Sex Intentions in Adolescents and Young Adults 
Young people are especially vulnerable to sexually transmitted infections (STIs). The triad of deliberate and effective safer sex behavior encompasses condom use, combined with additional information about a partner’s sexual health, and the kind of sex acts usually performed. To identify psychosocial predictors of young people’s intentions to have safer sex, as related to this triad, we conducted an online study with 211 sexually active participants aged between 18 and 24 years. Predictors [i.e., perceived behavioral control (PBC), subjective norms, and intention] taken from Fishbein and Ajzen’s Reasoned Action Approach (RAA), were combined with more distal variables (e.g., behavioral inhibition, sensation seeking, parental monitoring, and knowledge about STIs). Beyond the highly predictive power of RAA variables, additional variance was explained by the number of instances of unprotected sexual intercourse (SI) during the last 12 months and reasons for using barrier protection during first SI. In particular, past condom non-use behavior moderated PBC related to intended condom use. Further, various distal variables showed significant univariate associations with intentions related to the three behaviors of interest. It may, therefore, be helpful to include measures of past behavior as well as certain additional distal variables in future safer sex programs designed to promote health-sustaining sexual behavior.
PMCID: PMC4837163  PMID: 27148520
public health; adolescence; sexual risk behavior; adolescent behavior; RAA; sexuality; safer sex motivation; HIV/AIDS
8.  A needs assessment of people living with diabetes and diabetic retinopathy 
BMC Research Notes  2016;9:56.
The Kilimanjaro Diabetic Programme was initiated in response to the needs of people living with diabetes (PWLD) to identify barriers to uptake of screening for diabetic retinopathy, to improve management of diabetes, and establish an affordable, sustainable eye screening and treatment programme for diabetic retinopathy. Intervention Mapping was used as the framework for the needs assessment.
A mixed methods approach was used. Five psychometric measures, Diabetes Knowledge Questionnaire, Diabetes Health Beliefs, Self-Efficacy scale, Problem Areas in Diabetes scale, and Hopkins Scale Checklist-25 and a structured interview relating to self-efficacy, addressing disclosure of living with diabetes and life-style changes were used to triangulate the quantitative findings. These were administered to 26 PWLD presenting to rural district hospitals.
The interviewees demonstrated low levels of perceived stigma regarding disclosure of living with diabetes and high levels of self-efficacy in raising community awareness of diabetes, seeking on going treatment from Western medicine over traditional healers and in seeking care on sick days. Self-efficacy was high for adjusting diet, although comprehensive dietary knowledge was poor. Negative emotions expressed at diagnosis, changes in life style and altered quality of life were reflected in high levels of anxiety and depression.
Low levels of stigma surrounding living with diabetes were linked to a desire to raise community awareness of diabetes, help others live with diabetes and to secure social support to access hospital services. Confusion over what constituted a healthy diet showed the importance of comprehensive, accessible diabetes education, essential to ensuring good glycaemic control, and preventing diabetic complications, including diabetic retinopathy. Low levels of self-efficacy along with high levels of anxiety and depression may have a negative impact on the uptake of screening for Diabetic Retinopathy. The findings of this needs assessment led to the planning and delivery of a comprehensive health intervention programme for PLWD in Kilimanjaro Region. The programme has provided them with support, resources, education, and screening for diabetic retinopathy at the regional hospital and at district level with mobile digital retinal cameras, an electronic diabetic database and computerised follow up to ensure continuity of care.
PMCID: PMC4736166  PMID: 26829927
Diabetic retinopathy; Screening; Self-efficacy; Social stigma; Diabetes mellitus; Diabetes complications; Needs assessment; Evidence based healthcare
9.  Predictors of Chlamydia Trachomatis testing: perceived norms, susceptibility, changes in partner status, and underestimation of own risk 
BMC Public Health  2016;16:55.
It is hard to convince people to participate in chlamydia screening programs outside the clinical setting. In two earlier studies (BMC Public Health. 2013;13:1091; J Med Internet Res. 2014;16(1):e24), we identified explicit and implicit determinants of chlamydia screening behavior and attempted, unsuccessfully, to improve participation rates by optimizing the recruitment letter. In the present study, we examined the links between a number of social-cognitive determinants (e.g., stereotypical beliefs about a person with chlamydia, intentions, changes in partner status), and self-reported chlamydia testing behavior six months after the initial study.
The present study is a follow-up to our first study (T0). We assessed self-reported testing behavior 6 months after the first measure by means of an online questionnaire (T1; N = 269). Furthermore, at T1, we measured the social-cognitive determinants in more detail, and explored the influence of stereotypical beliefs and any changes in partner status during this six month period.
In total, 25 (9.1 %) of the participants tested for chlamydia at some point during the six months between baseline (T0) and follow up (T1). Testing behavior was influenced by testing intentions in combination with changes in risk behavior. The higher the participants’ own numbers of partners ever, the higher they estimated the number of partners of the stereotypical person with chlamydia. Testing intentions were most strongly predicted by perceived norms and susceptibility, and having had multiple partners in the last 6 months (R2 = .41).
The most relevant determinants for testing intentions and behavior were susceptibility, subjective norms and changes in partner status. We found a systematic tendency for individuals to underestimate their own risk, especially the risk of inconsistent condom use. Future research should focus on more promising alternatives to population-based interventions, such as online interventions, screening in primary care, the rescreening of positives, and clinic-based interventions. This future research should also focus on making testing easier and reducing barriers to testing, as well as using social and sexual networks in order to reach more people.
Electronic supplementary material
The online version of this article (doi:10.1186/s12889-016-2689-6) contains supplementary material, which is available to authorized users.
PMCID: PMC4719691  PMID: 26790411
STD; STI; Screening; Stereotypical beliefs; Risk perception; Sexual behavior
10.  Online Support Program for Parents of Children With a Chronic Kidney Disease Using Intervention Mapping: A Development and Evaluation Protocol 
JMIR Research Protocols  2016;5(1):e1.
The care for children with a chronic kidney disease (CKD) is complex. Parents of these children may experience high levels of stress in managing their child’s disease, potentially leading to negative effects on their child’s health outcomes. Although the experienced problems are well known, adequate (online) support for these parents is lacking.
The objective of the study is to describe the systematic development of an online support program for parents of children with CKD, and how this program will be evaluated.
Intervention Mapping (IM) was used for the development of the program. After conducting a needs assessment, defining program objectives, searching for theories, and selecting practical applications, the online program e-Powered Parents was developed. e-Powered Parents consist of three parts: (1) an informative part with information about CKD and treatments, (2) an interactive part where parents can communicate with other parents and health care professionals by chat, private messages, and a forum, and (3) a training platform consisting of four modules: Managing stress, Setting limits, Communication, and Coping with emotions. In a feasibility study, the potential effectiveness and effect size of e-Powered Parents will be evaluated using an explorative randomized controlled trial with parents of 120 families. The outcomes will be the child’s quality of life, parental stress and fatigue, self-efficacy in the communication with health care professionals, and family management. A process evaluation will provide insight in parents’ experiences, including their experienced level of support.
Study results are expected to be published in the summer of 2016.
Although the development of e-Powered Parents using IM was time-consuming, IM has been a useful protocol. IM provided us with a systematic framework for structuring the development process. The participatory planning group was valuable as well; knowledge, experiences, and visions were shared, ensuring us that parents and health care professionals support the program.
Trial Registration
Dutch Trial Registration: NTR4808; (Archived by WebCite at
PMCID: PMC4730104  PMID: 26764218
child; chronic kidney failure; family health; health promotion; intervention mapping; parents; program development; telemedicine
11.  Vaccination decision-making of immigrant parents in the Netherlands; a focus group study 
BMC Public Health  2015;15:1229.
Although the vaccination coverage in most high income countries is high, variations in coverage rates on the national level among different ethnic backgrounds are reported. A qualitative study was performed to explore factors that influence decision-making among parents with different ethnic backgrounds in the Netherlands.
Six focus groups were conducted with 33 mothers of Moroccan, Turkish and other ethnic backgrounds with at least one child aged 0–4 years. Data were analysed using thematic analysis.
Parents had a positive attitude towards childhood vaccination and a high confidence in the advices of Child Vaccine Providers (CVPs). Vaccinating their children was perceived as self-evident and important. Parents do perceive a language barrier in understanding the provided NIP-information, and they had a need for more NIP- information, particularly about the targeted diseases. Another barrier parents perceived was the distance to the Child Welfare Center (CWC), especially when the weather was bad and when they had no access to a car.
More information about targeted diseases and complete information regarding benefits and drawbacks of the NIP should be provided to the parents. To fulfill parents’ information needs, NIP information meetings can be organized at CWCs in different languages. Providing NIP information material in Turkish, Arabic and Berber language with easy access is also recommended. Providing information tailored to these parents’ needs is important to sustain high vaccination participation, and to ensure acceptance of future vaccinations.
PMCID: PMC4676170  PMID: 26654538
Childhood vaccination; Decision-making; Non-Western; Ethnic background
12.  Patient and Provider Perspectives on HIV and HIV-Related Stigma in Dutch Health Care Settings 
AIDS Patient Care and STDs  2014;28(12):652-665.
Ensuring that people living with HIV (PLWH) feel accepted in health care settings is imperative. This mixed methods study explored the perspectives of PLWH and health professionals on their interactions. A total of 262 predominantly gay men of Dutch origin participated in a survey study of possible negative interactions with health professionals, and semi-structured interviews were subsequently conducted with 22 PLWH and 14 health professionals. Again, most PLWH were gay men of Dutch origin. All health professionals were Dutch. PLWH reported negative experiences with health professionals including awkward interactions, irrelevant questions, rude treatment, blame, pity, excessive or differential precautions, care refusal, unnecessary referrals, delayed treatment, poor support, and confidentiality breaches. They also reported positive experiences including equal treatment, being valued as a partner in one's health, social support provision, and confidentiality assurances. Health professionals reported having little experience with PLWH and only basic knowledge of HIV. They contended that PLWH are treated equally and that HIV is no longer stigmatized, but also reported fear of occupational infection, resulting in differential precautions. Additionally, they conveyed labeling PLWH's files to warn others, and curiosity regarding how patients acquired HIV. The findings suggest that there is a gap in perception between PLWH and health professionals regarding the extent to which negative interactions occur, and that these interactions should be improved. Implications for stigma reduction and care optimization are discussed.
PMCID: PMC4250939  PMID: 25459231
14.  Aerobic and strength exercises for youngsters aged 12 to 15: what do parents think? 
BMC Public Health  2015;15:994.
Although strength exercises evidently have both physiological and psychological health benefits across all ages, they are erroneously considered to adversely affect health status in youngsters. The aim of this study was to examine parental attitudes towards their child’s physical activity in general, as well as aerobic and strength exercises in particular.
In total, 314 parents from an online panel representative of the Dutch population completed an online survey about their own physical activity and that of their child (12–15 years old). The study also explored reasons for non-participation, and attitudes about the parents’ own and their child’s physical activity level.
Parents consistently reported a positive attitude towards aerobic exercises, but a less positive attitude regarding strength exercises. Parents were more likely to indicate that their child was not allowed to participate in strength exercises (29.6 %) than aerobic exercises (4.0 %). They thought that strength exercises could interfere with optimal physical development.
This study consistently shows that parents have a positive attitude towards aerobic exercises, but a less positive attitude regarding strength exercises. We suggest testing interventions to increase parental understanding of the advantages of and possibilities for (e.g., facilities) strength training on their child’s health.
Electronic supplementary material
The online version of this article (doi:10.1186/s12889-015-2328-7) contains supplementary material, which is available to authorized users.
PMCID: PMC4589906  PMID: 26423524
Resistance exercise; Adolescents; Attitude; Parenting; Physical activity; Intervention development
15.  A Web—Based Respondent Driven Sampling Pilot Targeting Young People at Risk for Chlamydia Trachomatis in Social and Sexual Networks with Testing: A Use Evaluation 
Background: With the aim of targeting high-risk hidden heterosexual young people for Chlamydia trachomatis (CT) testing, an innovative web-based screening strategy using Respondent Driven Sampling (RDS) and home-based CT testing, was developed, piloted and evaluated. Methods: Two STI clinic nurses encouraged 37 CT positive heterosexual young people (aged 16–25 years), called index clients, to recruit peers from their social and sexual networks using the web-based screening strategy. Eligible peers (young, living in the study area) could request a home-based CT test and recruit other peers. Results: Twelve (40%) index clients recruited 35 peers. Two of these peers recruited other peers (n = 7). In total, 35 recruited peers were eligible for participation; ten of them (29%) requested a test and eight tested. Seven tested for the first time and one (13%) was positive. Most peers were female friends (80%). Nurses were positive about using the strategy. Conclusions: The screening strategy is feasible for targeting the hidden social network. However, uptake among men and recruitment of sex-partners is low and RDS stopped early. Future studies are needed to explore the sustainability, cost-effectiveness, and impact of strategies that target people at risk who are not effectively reached by regular health care.
PMCID: PMC4555318  PMID: 26308015
Chlamydia trachomatis; web-based respondent driven sampling; peer-referral; social networks; sexual networks; partner notification; home-based test kits
16.  Acceptance of Home-Based Chlamydia Genital and Anorectal Testing Using Short Message Service (SMS) in Previously Tested Young People and Their Social and Sexual Networks 
PLoS ONE  2015;10(7):e0133575.
Control strategies for Chlamydia trachomatis (CT) are most effective when targeting people at highest risk. We assessed test acceptance of home-collection test kits offered by short messaging services (SMS) texts, in high-risk young people, i.e. those who had previously tested CT positive (positive indices), or negative reporting more than 3 sex partners (negative indices), and their sexual and social networks.
Young (16 to 25 years old) heterosexuals who previously tested positive (n=536) or negative (n=536) in our STI clinic received, 3 to 20 months after their initial screening, an SMS inviting them to re-test. They were offered a free home-collection test kit including a genital (men and women) and anorectal (women only) test, and a test kit to pass on to a friend or sex partner (peer). SMS reminders were sent in case of non-response. We assessed proportions of tests requested and returned, peers tested, and positivity. Associations with the individual’s initial screening result and other factors were explored using logistic regression.
Of 1072 people invited to retest, 34.4% (n=369) requested a test. Of these, 55.8% (n=206) retested. Overall, retest participation was higher in positive (22%) than in negative indices (16%) (p<0.001); it was also higher in women and in those aged >22 years. Positivity was 13% and 7% in positive and negative indices, respectively. One in 3 retesters also had a peer tested. Of tested peers (n=87), 84% were friends, 31% were first-time testers, and 7% tested positive.
Acceptance of a relatively low-cost strategy for genital and anorectal testing, i.e. using SMS and home-collection test kits, was highest in individuals who previously tested CT positive suggesting that implementation for this group may be considered. By further including a peer-led testing component, undetected CT positives can be identified in the social networks surrounding a high-risk individual.
PMCID: PMC4539363  PMID: 26230085
17.  Chlamydia trachomatis testing among young people: what is the role of stigma? 
BMC Public Health  2015;15:651.
To reach young people for Chlamydia trachomatis (CT) testing, new web-based strategies are used to offer testing via young people’s sexual and social networks. The success of such peer-driven strategies depends on whether individuals disclose their own testing and encourage others to get tested. We assessed whether public- and self-stigma would hamper these behaviours, by comparing anticipations and experiences relating to these issues in young men and women who already tested or never tested for CT.
Participants were recruited at an STI clinic and two schools in the Netherlands. Semi-structured interviews were analysed from 23 sexually active heterosexual young people between 16–24 years using qualitative content analysis with a framework approach.
Both tested and never tested participants perceived public stigma and anticipated shame and self-stigma in relation to testing. Maintaining good health was identified as main reason for testing. Never tested and tested participants anticipated that they would feel shame and receive stigmatizing reactions from people outside their trusted network if they would disclose their testing, or encourage them to test. From a selected group of trusted peers, they anticipated social support and empathy. When tested participants disclosed their testing to trusted peers they did not experience stigma. Due to the fact that no one disclosed their testing behaviour to peers outside their trusted network, stigma was avoided and therefore tested participants reported no negative reactions. Similarly, regarding the encouragement of others to test, most tested participants did not experience negative reactions from sex partners and friends.
Young people perceive public stigma and anticipate self-stigma and shame in relation to CT testing, disclosure and encouraging others to test. People do test for CT, including those who anticipate stigma. To avoid stigmatizing reactions, stigma management strategies are applied, such as selective disclosure and the selective encouragement of others to test (i.e. only in a small trusted peer network). Care strategies that deploy sexual and social networks of individuals can reach into small networks surrounding a person. These strategies could be improved by exploring methods to reach high-risk network members outside the small trusted circle of a person.
PMCID: PMC4499893  PMID: 26169173
Chlamydia; Stigma; Stigma management; Testing; Disclosure; Encouragement
18.  Disease Detection or Public Opinion Reflection? Content Analysis of Tweets, Other Social Media, and Online Newspapers During the Measles Outbreak in the Netherlands in 2013 
In May 2013, a measles outbreak began in the Netherlands among Orthodox Protestants who often refuse vaccination for religious reasons.
Our aim was to compare the number of messages expressed on Twitter and other social media during the measles outbreak with the number of online news articles and the number of reported measles cases to answer the question if and when social media reflect public opinion patterns versus disease patterns.
We analyzed measles-related tweets, other social media messages, and online newspaper articles over a 7-month period (April 15 to November 11, 2013) with regard to topic and sentiment. Thematic analysis was used to structure and analyze the topics.
There was a stronger correlation between the weekly number of social media messages and the weekly number of online news articles (P<.001 for both tweets and other social media messages) than between the weekly number of social media messages and the weekly number of reported measles cases (P=.003 and P=.048 for tweets and other social media messages, respectively), especially after the summer break. All data sources showed 3 large peaks, possibly triggered by announcements about the measles outbreak by the Dutch National Institute for Public Health and the Environment and statements made by well-known politicians. Most messages informed the public about the measles outbreak (ie, about the number of measles cases) (93/165, 56.4%) followed by messages about preventive measures taken to control the measles spread (47/132, 35.6%). The leading opinion expressed was frustration regarding people who do not vaccinate because of religious reasons (42/88, 48%).
The monitoring of online (social) media might be useful for improving communication policies aiming to preserve vaccination acceptability among the general public. Data extracted from online (social) media provide insight into the opinions that are at a certain moment salient among the public, which enables public health institutes to respond immediately and appropriately to those public concerns. More research is required to develop an automatic coding system that captures content and user’s characteristics that are most relevant to the diseases within the National Immunization Program and related public health events and can inform official responses.
PMCID: PMC4468573  PMID: 26013683
Internet; Web 2.0; measles; infectious disease outbreak; Netherlands; vaccination
19.  Identifying Effective Methods for Teaching Sex Education to Individuals With Intellectual Disabilities: A Systematic Review 
Journal of Sex Research  2014;52(4):412-432.
Sex education for individuals with intellectual disabilities is important. However, our knowledge about effective methods for teaching sex education to this population is limited. We report the results of a systematic review identifying methods for sex education programs aimed at individuals with intellectual disabilities. In all, 20 articles were included that met the criteria set in terms of topic—the effectiveness of sex education programs—and population of interest—individuals with intellectual disabilities. In these articles, methods for increasing knowledge and for improving skills and attitudes were reported. However, the studies revealed that generalization of skills to real-life situations was often not achieved. There are indications that the maintenance of knowledge and skills still needs extra attention. Moreover, detailed descriptions of the program materials, program goals, and methods used in the programs were often lacking in the reports. Although there is some evidence for methods that may improve knowledge, attitudes, and skills with regard to sex education aimed at individuals with intellectual disabilities, due to the lack of detailed descriptions provided it is unclear under which conditions these methods work. We therefore suggest that authors provide additional detail about methods in future publications or in online supplements.
PMCID: PMC4409057  PMID: 25085114
20.  Medical students’ attitude towards influenza vaccination 
BMC Infectious Diseases  2015;15:185.
Influenza vaccination is recommended for all healthcare personnel (HCP) and most institutions offer vaccination for free and on site. However, medical students do not always have such easy access, and the predictors that might guide the motivation of medical students to get vaccinated are largely unknown.
We conducted a cross-sectional survey study among pre-clinical medical students in a German University hospital to assess the social cognitive predictors of influenza vaccination, as well as reasons for refusal and acceptance of the vaccine.
Findings show that pre-clinical medical students have comparable knowledge gaps and negative attitudes towards influenza vaccination that have previously been reported among HCP. Lower injunctive norms and higher feelings of autonomy contribute to no intention to get vaccinated against influenza, while a positive instrumental attitude and higher feelings of autonomy contribute to a high intention to get vaccinated. The variables in the regression model explained 20% of the variance in intention to get vaccinated.
The identified factors should be addressed early in medical education, and hospitals might benefit from a more inclusive vaccination program and accessibility of free vaccines for their medical students.
PMCID: PMC4419496  PMID: 25884906
Medical students; Hospital; Influenza vaccination; Social-cognitive predictors
21.  Barriers to and facilitators of partner notification for chlamydia trachomatis among health care professionals 
Partner notification (PN) is an essential case-finding tool in the management of sexually transmitted infections (STIs). Yet, data on the effectiveness and factors impacting implementation of PN in the Netherlands are lacking. With the aim of further exploring and improving the PN process, the current study assessed perceived barriers and facilitators among health care professionals in the STI clinical setting. In particular, we explored the management of PN in young heterosexual patients diagnosed with Chlamydia trachomatis (Ct).
We conducted semi-structured interviews among 22 health care professionals (response rate 52%) from 5 of the 8 national STI clinics in the Netherlands. We carried out qualitative content analysis using a framework approach. All participants were nurses, aged mid 20’s to late 50’s, and all but one were female.
All health care professionals felt comfortable discussing PN. Other perceived facilitators for PN included: time, one-on-one consultations, interviewing skills (i.e. Motivational Interviewing) and a proactive helping style. Important barriers were identified as: sub-optimal guidelines, inaccurate sexual history, a lack of feedback regarding the motivational strategies that were used, and the lack of feedback regarding overall PN effectiveness. The health care professionals placed an emphasis on the care and treatment of the individual index patient rather than on discussion of PN, or on motivating and helping patients to engage in PN.
Health care professionals identified several barriers that need to be overcome, and facilitators which need to be maintained. Future efforts should concentrate on introducing PN protocols, providing feedback on both the effectiveness of strategies used by health care professionals, and on the PN process as a whole, and educating health care professionals about Motivational Interviewing strategies. Moreover, the possible implementation of an Internet-based PN system should be explored.
PMCID: PMC4279885  PMID: 25526679
Partner notification; Chlamydia trachomatis; Barriers; Facilitators; Public health
22.  Supporting Health Care Professionals to Improve the Processes of Shared Decision Making and Self-Management in a Web-Based Intervention: Randomized Controlled Trial 
Research to assess the effect of interventions to improve the processes of shared decision making and self-management directed at health care professionals is limited. Using the protocol of Intervention Mapping, a Web-based intervention directed at health care professionals was developed to complement and optimize health services in patient-centered care.
The objective of the Web-based intervention was to increase health care professionals’ intention and encouraging behavior toward patient self-management, following cardiovascular risk management guidelines.
A randomized controlled trial was used to assess the effect of a theory-based intervention, using a pre-test and post-test design. The intervention website consisted of a module to help improve professionals’ behavior, a module to increase patients’ intention and risk-reduction behavior toward cardiovascular risk, and a parallel module with a support system for the health care professionals. Health care professionals (n=69) were recruited online and randomly allocated to the intervention group (n=26) or (waiting list) control group (n=43), and invited their patients to participate. The outcome was improved professional behavior toward health education, and was self-assessed through questionnaires based on the Theory of Planned Behavior. Social-cognitive determinants, intention and behavior were measured pre-intervention and at 1-year follow-up.
The module to improve professionals’ behavior was used by 45% (19/42) of the health care professionals in the intervention group. The module to support the health professional in encouraging behavior toward patients was used by 48% (20/42). The module to improve patients’ risk-reduction behavior was provided to 44% (24/54) of patients. In 1 of every 5 patients, the guideline for cardiovascular risk management was used. The Web-based intervention was poorly used. In the intervention group, no differences in social-cognitive determinants, intention and behavior were found for health care professionals, compared with the control group. We narrowed the intervention group and no significant differences were found in intention and behavior, except for barriers. Results showed a significant overall difference in barriers between the intervention and the control group (F 1=4.128, P=.02).
The intervention was used by less than half of the participants and did not improve health care professionals’ and patients’ cardiovascular risk-reduction behavior. The website was not used intensively because of time and organizational constraints. Professionals in the intervention group experienced higher levels of barriers to encouraging patients, than professionals in the control group. No improvements were detected in the processes of shared decision making and patient self-management. Although participant education level was relatively high and the intervention was pre-tested, it is possible that the way the information was presented could be the reason for low participation and high dropout. Further research embedded in professionals’ regular consultations with patients is required with specific emphasis on the processes of dissemination and implementation of innovations in patient-centered care.
Trial Registration
Netherlands Trial Register Number (NTR): NTR2584; (Archived by WebCite at
PMCID: PMC4259881  PMID: 25337988
Web-based intervention; health professionals; RCT; self-management; barriers
23.  Long Live Love. The implementation of a school-based sex-education program in the Netherlands 
Health Education Research  2014;29(4):583-597.
Implementation of health education programs is often inadequately considered or not considered at all in planning, developing and evaluating interventions. With the focus being predominantly on the adoption stage, little is known about the factors influencing the implementation and continuation stages of the diffusion process. This study contributes to the understanding of factors that promote or impede each stage of the diffusion process in the school setting using the sex education program Long Live Love (LLL) as an example. A survey integrating different diffusion-related concepts was completed by 130 teachers. Results showed that teacher curriculum-related beliefs were associated with all stages in the diffusion process. Although adoption of LLL was predominantly related to teacher curriculum-related beliefs, implementation completeness and fidelity and continued use of LLL were also enhanced by contextual factors, namely teacher training and interactive context variables (school policy, governing body support and student response), respectively. The results of this study can be used to optimize the adoption, implementation and continuation of school-based (sexual) health promotion programs.
PMCID: PMC4101186  PMID: 24817522
24.  “I don’t see an added value for myself”: a qualitative study exploring the social cognitive variables associated with influenza vaccination of Belgian, Dutch and German healthcare personnel 
BMC Public Health  2014;14:407.
Health Authorities recommend influenza vaccination of healthcare personnel (HCP) to decrease the transmission of influenza to vulnerable patients. Recent studies have almost exclusively used quantitative questionnaires in order to identify determinants of vaccination behaviour. Interviews enable HCP to express freely why they think they are (not) willing to get vaccinated against influenza.
By means of semi-structured one-on-one interviews with 123 Belgian, Dutch and German HCP, reasons for and against vaccination, experiences with influenza vaccination, intention to get vaccinated and possible barriers, as well as willingness to advice influenza vaccination to patients were investigated. Data were processed with QSR NVivo 8.0 and analysed using a combination of a deductive and a general inductive approach.
Across countries, self-protection, patient protection, and protection of family members were reported as most important reasons to get vaccinated against influenza. Reasons to not get vaccinated against influenza were fear of side effects caused by the vaccine, a low risk-perception, the disbelief in the effectiveness of influenza vaccination, organizational barriers, misconceptions, and undefined negative emotions.
The social cognitive variables underlying the decision of HCP to get vaccinated against influenza (or not) seem to be similar in Belgium, Germany, and the Netherlands, even though some differences surfaced. A quantitative investigation of those social cognitive variables is needed in order to determine the importance of the social cognitive variables in explaining the intention to get vaccinated and the importance of the similarities and differences between countries that have been found in this study.
PMCID: PMC4021212  PMID: 24775096
Influenza vaccination; Healthcare personnel; Hospital; Qualitative research; Social cognitive determinants
25.  Process evaluation of school-based peer education for HIV prevention among Yemeni adolescents 
Sahara J  2013;10(1):55-64.
In 2005, a survey was conducted among all the 27 high schools of Aden, which revealed low levels of knowledge on major prevention measures, and a high level of stigma and discrimination towards people living with HIV (PLWH). The results served as a baseline for implementing a school-based peer education intervention for HIV prevention in the 27 schools of Aden. In 2008, and after 3 years of implementation, a quasi-experimental evaluation was conducted, which revealed that the peer education intervention has succeeded in improving HIV knowledge and skills; and in decreasing stigmatization of PLWH. This process evaluation aims to give a deeper understanding of the quasi-experimental evaluation which was conducted in the 27 high schools of Aden, and to highlight the factors that facilitated or inhibited school peer education in such a conservative Muslim setting. Qualitative methodologies were pursued, where 12 focus group discussions and 12 in-depth interviews were conducted with peer educators, targeted students, school principals, social workers, and parents of peer educators. Results revealed that school-peer education was well received. There was an apparent positive effect on the life skills of peer educators, but the intervention had a lesser effect on targeted students. Key enabling factors have been the high quality of training for peer educators, supportive school principals, and acceptance of the intervention by parents. These findings are important for improving the life skills and peer education intervention at the school level, and in better planning and implementation of life skills and peer programmes at a national scale.
PMCID: PMC3914420  PMID: 23777570
school-based intervention; peer education; HIV prevention; process evaluation; Diffusion of Innovation; Yemen; programme au sein de l'école; l'éducation donnée par les pairs; la prévention du VIH; l'évaluation du processus éducatif; la diffusion des innovations; le Yémen

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