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1.  Physical activity counseling intervention at a federally qualified health center: improves autonomy-supportiveness, but not patients’ perceived competence 
Patient education and counseling  2013;92(3):10.1016/j.pec.2013.06.031.
Objective
To assess the effect of a pilot intervention to promote clinician-patient communication about physical activity on patient ratings of their perceived competence for physical activity and their clinicians’ autonomy-supportiveness.
Methods
Family medicine clinicians (n=13) at two urban community health centers were randomized to early or delayed (8 months later) communication training groups. The goal of the training was to teach the 5As (Ask, Advise, Agree, Assist, Arrange) for physical activity counseling. Outcome measures were changes in patient perceptions of autonomy support (modified Health Care Climate Questionnaire, mHCCQ) and perceived competence (Perceived Competence Scale for physical activity, PCS) completed via surveys at baseline, post-intervention and six-month follow-up.
Results
Patients (n=326) were mostly female (70%) and low income. Using a generalized estimating equations model (GEE) with patients nested within clinician, patient perceived autonomy support increased at post-intervention compared to baseline (mean HCCQ scores 3.68 to 4.06, p=0.03). There was no significant change in patient perceived competence for physical activity.
Conclusions
A clinician-directed intervention increased patient perceptions of clinician autonomy support but not patient perceived competence for physical activity.
Practice Implications
Clinicians working with underserved populations can be taught to improve their autonomy supportiveness, according to patient assessments of their clinicians.
doi:10.1016/j.pec.2013.06.031
PMCID: PMC3862290  PMID: 23932756
2.  Predicting fruit consumption: the role of habits, previous behavior and mediation effects 
BMC Public Health  2014;14:730.
Background
This study assessed the role of habits and previous behavior in predicting fruit consumption as well as their additional predictive contribution besides socio-demographic and motivational factors. In the literature, habits are proposed as a stable construct that needs to be controlled for in longitudinal analyses that predict behavior. The aim of this study is to provide empirical evidence for the inclusion of either previous behavior or habits.
Methods
A random sample of 806 Dutch adults (>18 years) was invited by an online survey panel of a private research company to participate in an online study on fruit consumption. A longitudinal design (N = 574) was used with assessments at baseline and after one (T2) and two months (T3). Multivariate linear regression analysis was used to assess the differential value of habit and previous behavior in the prediction of fruit consumption.
Results
Eighty percent of habit strength could be explained by habit strength one month earlier, and 64% of fruit consumption could be explained by fruit consumption one month earlier. Regression analyses revealed that the model with motivational constructs explained 41% of the behavioral variance at T2 and 38% at T3. The addition of previous behavior and habit increased the explained variance up to 66% at T2 and to 59% at T3. Inclusion of these factors resulted in non-significant contributions of the motivational constructs. Furthermore, our findings showed that the effect of habit strength on future behavior was to a large extent mediated by previous behavior.
Conclusions
Both habit and previous behavior are important as predictors of future behavior, and as educational objectives for behavior change programs. Our results revealed less stability for the constructs over time than expected. Habit strength was to a large extent mediated by previous behavior and our results do not strongly suggest a need for the inclusion of both constructs. Future research needs to assess the conditions that determine direct influences of both previous behavior and habit, since these influences may differ per type of health behavior, per context stability in which the behavior is performed, and per time frame used for predicting future behavior.
doi:10.1186/1471-2458-14-730
PMCID: PMC4223379  PMID: 25037859
Fruit consumption; Habit; Previous behavior; SRHI
3.  The use of a proactive dissemination strategy to optimize reach of an internet-delivered computer tailored lifestyle intervention 
BMC Public Health  2013;13:721.
Background
The use of reactive strategies to disseminate effective Internet-delivered lifestyle interventions restricts their level of reach within the target population. This stresses the need to invest in proactive strategies to offer these interventions to the target population. The present study used a proactive strategy to increase reach of an Internet-delivered multi component computer tailored intervention, by embedding the intervention in an existing online health monitoring system of the Regional Public Health Services in the Netherlands.
Methods
The research population consisted of Dutch adults who were invited to participate in the Adult Health Monitor (N = 96,388) offered by the Regional Public Health Services. This Monitor consisted of an online or a written questionnaire. A prospective design was used to determine levels of reach, by focusing on actual participation in the lifestyle intervention. Furthermore, adequacy of reach among the target group was assessed by composing detailed profiles of intervention users. Participants’ characteristics, like demographics, behavioral and mental health status and quality of life, were included in the model as predictors.
Results
A total of 41,155 (43%) people participated in the Adult Health Monitor, of which 41% (n = 16,940) filled out the online version. More than half of the online participants indicated their interest (n = 9169; 54%) in the computer tailored intervention and 5168 participants (31%) actually participated in the Internet-delivered computer tailored intervention. Males, older respondents and individuals with a higher educational degree were significantly more likely to participate in the intervention. Furthermore, results indicated that especially participants with a relatively healthier lifestyle and a healthy BMI were likely to participate.
Conclusions
With one out of three online Adult Health Monitor participants actually participating in the computer tailored lifestyle intervention, the employed proactive dissemination strategy succeeded in ensuring relatively high levels of reach. Reach among at-risk individuals (e.g. low socioeconomic status and unhealthy lifestyle) was modest. It is therefore essential to further optimize reach by putting additional effort into increasing interest in the lifestyle intervention among at-risk individuals and to encourage them to actually use the intervention.
Trial registration
Dutch Trial Register (NTR1786) and Medical Ethics Committee of Maastricht University and the University Hospital Maastricht (NL2723506809/MEC0903016).
doi:10.1186/1471-2458-13-721
PMCID: PMC3750934  PMID: 23914991
Internet-delivered interventions; Online interventions; Reach; Computer tailoring; Lifestyle; User characteristics; Proactive dissemination
4.  Internet-Based Computer Tailored Feedback on Sunscreen Use 
Background
Skin cancer incidence rates signify the need for effective programs for the prevention of skin cancer and for helping skin cancer patients. Internet and computer tailored (CT) technology fosters the development of highly individualized health communication messages. Yet, reactions to Internet CT programs may differ per level of involvement and education level and remain understudied.
Objective
First, we identified perceptions concerning sunscreen use in Dutch adults and assessed differences in differences between the general public and skin cancer patients, and between low and high educated respondents. Second, we assessed program evaluations of these groups about a new Dutch CT Internet-based program promoting sunscreen use, and potential differences between groups
Methods
A cross-sectional research design was used. In total, 387 respondents participated and filled out an online questionnaire based on the I-Change Model assessing socio-demographics, history of skin cancer, sunscreen use, and beliefs about sunscreen use. The responses were fed into a computer program that generated personal tailored feedback on screen; next we assessed their program evaluations
Results
Of the 132 patients, 92 were female (69.7%) and 40 were male (30.3%). In the general population (N = 225), 139 (54.5%) respondents were female and 116 (45.5%) were male. Men (50.9 years) were 8 years older than women (43.1 years). Most patients were diagnosed with basal cell carcinoma (N = 65; 49.2%), followed by melanoma (N = 28; 21.2%) and squamous cell carcinoma (N = 10; 7.6%); 22% (N = 29) did not remember their skin cancer type. Patients had higher knowledge levels, felt significantly more at risk, were more convinced of the pros of sunscreen, experienced more social support to use sunscreen, had higher self-efficacy, and made more plans to use sunscreen than respondents without skin cancer (N=255; all P’s< .01). Low (N=196) educated respondents scored lower on knowledge (P<.003) but made more action plans (P<.03) than higher educated respondents (N=191). The CT feedback was evaluated positively by all respondents, and scored a 7.8 on a 10 point scale. Yet, patients evaluated the CT program slightly more (P<.05) positive (8.1) than non-patients. (7.6). Lower educated respondents were significantly (P<.05) more positive about the advantages of the program.
Conclusions
First, involvement with skin cancer was reflected in more positive beliefs toward sunscreen use in patients in comparison with non-patients. Second, the CT Internet program was well accepted by both patients and non-patients, and low and high educated respondents, perhaps because higher educated respondents were more knowledgeable about sunscreen use and skin cancer. Third, a pro-active approach as conducted in our study is very well suited to reach various groups of people and is more likely to be successful than a reactive approach
doi:10.2196/jmir.1902
PMCID: PMC3376524  PMID: 22547528
Health communication, Computer tailoring; Web-based interventions, Internet
5.  Program Completion of a Web-Based Tailored Lifestyle Intervention for Adults: Differences between a Sequential and a Simultaneous Approach 
Background
Unhealthy lifestyle behaviors often co-occur and are related to chronic diseases. One effective method to change multiple lifestyle behaviors is web-based computer tailoring. Dropout from Internet interventions, however, is rather high, and it is challenging to retain participants in web-based tailored programs, especially programs targeting multiple behaviors. To date, it is unknown how much information people can handle in one session while taking part in a multiple behavior change intervention, which could be presented either sequentially (one behavior at a time) or simultaneously (all behaviors at once).
Objectives
The first objective was to compare dropout rates of 2 computer-tailored interventions: a sequential and a simultaneous strategy. The second objective was to assess which personal characteristics are associated with completion rates of the 2 interventions.
Methods
Using an RCT design, demographics, health status, physical activity, vegetable consumption, fruit consumption, alcohol intake, and smoking were self-assessed through web-based questionnaires among 3473 adults, recruited through Regional Health Authorities in the Netherlands in the autumn of 2009. First, a health risk appraisal was offered, indicating whether respondents were meeting the 5 national health guidelines. Second, psychosocial determinants of the lifestyle behaviors were assessed and personal advice was provided, about one or more lifestyle behaviors.
Results
Our findings indicate a high non-completion rate for both types of intervention (71.0%; n = 2167), with more incompletes in the simultaneous intervention (77.1%; n = 1169) than in the sequential intervention (65.0%; n = 998). In both conditions, discontinuation was predicted by a lower age (sequential condition: OR = 1.04; P < .001; CI = 1.02-1.05; simultaneous condition: OR = 1.04; P < .001; CI = 1.02-1.05) and an unhealthy lifestyle (sequential condition: OR = 0.86; P = .01; CI = 0.76-0.97; simultaneous condition: OR = 0.49; P < .001; CI = 0.42-0.58). In the sequential intervention, being male (OR = 1.27; P = .04; CI = 1.01-1.59) also predicted dropout. When respondents failed to adhere to at least 2 of the guidelines, those receiving the simultaneous intervention were more inclined to drop out than were those receiving the sequential intervention.
Conclusion
Possible reasons for the higher dropout rate in our simultaneous intervention may be the amount of time required and information overload. Strategies to optimize program completion as well as continued use of computer-tailored interventions should be studied.
Trial Registration
Dutch Trial Register NTR2168
doi:10.2196/jmir.1968
PMCID: PMC3376514  PMID: 22403770
Internet; dropout; computer tailoring; multiple health behavior change intervention; sequential; simultaneous; lifestyle
6.  The Influence of User Characteristics and a Periodic Email Prompt on Exposure to an Internet-Delivered Computer-Tailored Lifestyle Program 
Background
The Internet is a promising medium in the field of health promotion for offering tailored and targeted lifestyle interventions applying computer-tailored (CT) techniques to the general public. Actual exposure to CT interventions is not living up to its high expectations, as only a (limited) proportion of the target group is actually using these programs.
Objective
To investigate exposure to an Internet-delivered, CT lifestyle intervention, targeting physical activity, fruit and vegetable intake, smoking behavior, and alcohol intake, we focused on three processes: first use, prolonged use, and sustained use. The first objectives were to identify user characteristics that predict initiation of an online CT lifestyle program (first use) and completion of this program (prolonged use). Furthermore, we studied the effect of using a proactive strategy, consisting of periodic email prompts, on program revisits (sustained use).
Methods
The research population for this study consisted of Dutch adults participating in the Adult Health Monitor, offered by the regional public health services. We used a randomized controlled trial design to assess predictors of first use, prolonged use, and sustained use. Demographics and behavioral characteristics, as well as the strategy used for revisiting, were included as predictors in the model.
Results
A total of 9169 participants indicated their interest in the new program and 5168 actually logged in to the program. Participants significantly more likely to initiate one of the CT modules were male, older, and employed, and had a lower income, higher body mass index, and relatively unhealthy lifestyle. Participants significantly more likely to complete one of the CT modules were older and had a higher income and a relatively healthier lifestyle. Finally, using a proactive strategy influenced sustained use, with people from the prompting condition being more likely to revisit the program (odds ratio 28.92, 95% confidence interval 10.65–78.52; P < .001).
Conclusions
Older, male, and employed participants, and those with a lower income, higher body mass index, and a relatively unhealthy lifestyle were more likely to initiate a CT module. Module completers predominantly had a higher income and age. The current program therefore succeeded in reaching those people who benefit most from online lifestyle interventions. However, these people tended to disengage from the program. This underlines the importance of additional research into program adjustments and strategies that can be used to stimulate prolonged program use. Furthermore, sending periodic email prompts significantly increased revisits to the program. Though promising, this effect was modest and needs to be further examined, in order to maximize the potential of periodic email prompting.
Trial Registration
Nederlands Trial Register (NTR: 1786) and Medical Ethics Committee of Maastricht University and the University Hospital Maastricht (NL2723506809/MEC0903016); http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1786 (Archived by WebCite at http://www.webcitation.org/65hBXA6V7)
doi:10.2196/jmir.1939
PMCID: PMC3376522  PMID: 22382037
Internet interventions; computer tailoring; lifestyle; behavior change; program use; user characteristics; diffusion; proactive strategy; prompts
7.  Identifying Factors for Optimal Development of Health-Related Websites: A Delphi Study Among Experts and Potential Future Users 
Background
The Internet has become a popular medium for offering tailored and targeted health promotion programs to the general public. However, suboptimal levels of program use in the target population limit the public health impact of these programs. Optimizing program development is considered as one of the main processes to increase usage rates.
Objective
To distinguish factors potentially related to optimal development of health-related websites by involving both experts and potential users. By considering and incorporating the opinions of experts and potential users in the development process, involvement in the program is expected to increase, consequently resulting in increased appreciation, lower levels of attrition, and higher levels of sustained use.
Methods
We conducted a systematic three-round Delphi study through the Internet. Both national and international experts (from the fields of health promotion, health psychology, e-communication, and technical Web design) and potential users were invited via email to participate. During this study an extensive list of factors potentially related to optimal development of health-related websites was identified, by focusing on factors related to layout, general and risk information provision, questionnaire use, additional services, and ease of use. Furthermore, we assessed the extent to which experts and potential users agreed on the importance of these factors. Differences as well as similarities among experts and potentials users were deduced.
Results
In total, 20 of 62 contacted experts participated in the first round (32% response rate); 60 of 200 contacted experts (30% response rate) and 210 potential users (95% response rate) completed the second-round questionnaire, and 32 of 60 contacted experts completed the third round (53% response rate). Results revealed important factors consented upon by experts and potential users (eg, ease of use, clear structure, and detailed health information provision), as well as differences regarding important factors consented upon by experts (eg, visual aids, self-monitoring tool, and iterative health feedback) or by potential users only (eg, bread crumb navigation and prevention of receiving spam).
Conclusions
This study is an important first step in determining the agreed-upon factors that should be taken into account when developing online health promotion programs. The public health impact of these programs will be improved by optimizing the development process in line with these factors.
doi:10.2196/jmir.1863
PMCID: PMC3374541  PMID: 22357411
Health promotion; Internet interventions; health behavior change; optimal development; Delphi study; experts; users
8.  Does action planning moderate the intention-habit interaction in the exercise domain? A three-way interaction analysis investigation 
Journal of Behavioral Medicine  2011;35(5):509-519.
Both habit strength and action planning have been found to moderate the intention-exercise behaviour relationship, but no research exists that has investigated how habit strength and action planning simultaneously influence this relationship. The present study was designed to explore this issue in a prospective sample of undergraduate students (N = 415): action planning, habit strength, intention, attitudes, subjective norms and perceived behavioural control were assessed at baseline and exercise behaviour was assessed 2 weeks later. Both habit strength and action planning moderated the intention-exercise relationship, with stronger relationship at higher levels of planning or habit strength. Decomposing a significant action planning × habit strength × intention interaction showed that the strength of the intention-exercise relationship progressed linearly through levels of action planning and habit strength. These novel results show that action planning strengthens the intention-habit strength interaction in the exercise domain: exercise interventions should therefore focus on simultaneously bolstering action planning and habit strength.
doi:10.1007/s10865-011-9380-2
PMCID: PMC3439603  PMID: 21979328
Exercise behaviour; Intention-exercise relationship; Habit strength; Action planning; Interaction
9.  Optimizing diffusion of an online computer tailored lifestyle program: a study protocol 
BMC Public Health  2011;11:480.
Background
Although the Internet is a promising medium to offer lifestyle interventions to large amounts of people at relatively low costs and effort, actual exposure rates of these interventions fail to meet the high expectations. Since public health impact of interventions is determined by intervention efficacy and level of exposure to the intervention, it is imperative to put effort in optimal dissemination. The present project attempts to optimize the dissemination process of a new online computer tailored generic lifestyle program by carefully studying the adoption process and developing a strategy to achieve sustained use of the program.
Methods/Design
A prospective study will be conducted to yield relevant information concerning the adoption process by studying the level of adoption of the program, determinants involved in adoption and characteristics of adopters and non-adopters as well as satisfied and unsatisfied users. Furthermore, a randomized control trial will be conducted to the test the effectiveness of a proactive strategy using periodic e-mail prompts in optimizing sustained use of the new program.
Discussion
Closely mapping the adoption process will gain insight in characteristics of adopters and non-adopters and satisfied and unsatisfied users. This insight can be used to further optimize the program by making it more suitable for a wider range of users, or to develop adjusted interventions to attract subgroups of users that are not reached or satisfied with the initial intervention. Furthermore, by studying the effect of a proactive strategy using period prompts compared to a reactive strategy to stimulate sustained use of the intervention and, possibly, behaviour change, specific recommendations on the use and the application of prompts in online lifestyle interventions can be developed.
Trial registration
Dutch Trial Register NTR1786 and Medical Ethics Committee of Maastricht University and the University Hospital Maastricht (NL2723506809/MEC0903016).
doi:10.1186/1471-2458-11-480
PMCID: PMC3130675  PMID: 21689412
10.  Testing a Dutch web-based tailored lifestyle programme among adults: a study protocol 
BMC Public Health  2011;11:108.
Background
Smoking, high alcohol consumption, unhealthy eating habits and physical inactivity often lead to (chronic) diseases, such as cardiovascular diseases and cancer. Tailored online interventions have been proven to be effective in changing health behaviours. The aim of this study is to test and compare the effectiveness of two different tailoring strategies for changing lifestyle compared to a control group using a multiple health behaviour web-based approach.
Methods
In our Internet-based tailored programme, the five lifestyle behaviours of smoking, alcohol intake, fruit consumption, vegetable consumption, and physical activity are addressed. This randomized controlled trial, conducted among Dutch adults, includes two experimental groups (i.e., a sequential behaviour tailoring condition and a simultaneous behaviour tailoring condition) and a control group. People in the sequential behaviour tailoring condition obtain feedback on whether their lifestyle behaviours meet the Dutch recommendations. Using a step-by-step approach, they are stimulated to continue with a computer tailored module to change only one unhealthy behaviour first. In the course of the study, they can proceed to change a second behaviour. People in the simultaneous behaviour tailoring condition receive computer tailored feedback about all their unhealthy behaviours during their first visit as a stimulation to change all unhealthy behaviours. The experimental groups can re-visit the website and can then receive ipsative feedback (i.e., current scores are compared to previous scores in order to give feedback about potential changes). The (difference in) effectiveness of the different versions of the programme will be tested and compared to a control group, in which respondents only receive a short health risk appraisal. Programme evaluations will assess satisfaction with and appreciation and personal relevance of the intervention among the respondents. Finally, potential subgroup differences pertaining to gender, age and socioeconomic status regarding the behaviour effects and programme evaluation will be assessed.
Discussion
Research regarding multiple behaviour change is in its infancy. We study how to offer multiple behaviour change interventions optimally. Using these results could strengthen the effectiveness of web-based computer-tailoring lifestyle programmes. This study will yield new results about the need for differential lifestyle approaches using Internet-based expert systems and potential differences in subgroups concerning the effectiveness and appreciation.
Trial registration
Dutch Trial Register NTR2168.
doi:10.1186/1471-2458-11-108
PMCID: PMC3050747  PMID: 21324181
11.  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

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