Mediating processes underlying the associations between maternal obesity and the likelihood of cesarean birth.

BACKGROUND: Pregnant women with obesity are more likely to experience cesarean birth compared to women without obesity. Yet, little is known about the underlying mechanisms. The objective of this study was therefore to evaluate how mediators contribute to the association between obesity and prelabor/intrapartum cesarean birth. METHODS: We retrospectively analyzed Swiss cohort data from 394,812 singleton, cephalic deliveries between 2005 and 2020. Obesity (BMI ≥ 30 kg/m2 ) was defined as the exposure and prelabor or intrapartum cesarean birth as the outcomes. Hypothesized mediators included gestational comorbidities, large-for-gestational-age infant, pregnancy duration >410/7 weeks, slower labor progress, labor induction, and history of cesarean birth. We performed path analyses using generalized structural equation modeling and assessed mediation by a counterfactual approach. RESULTS: Women with obesity had a cesarean birth rate of 39.36% vs. 24.12% in women without obesity. The path models mainly showed positive direct and indirect associations between obesity and cesarean birth. In the total sample, the mediation models explained up to 39.47% (95% CI 36.92-42.02) of the association between obesity and cesarean birth, and up to 57.13% (95% CI 54.10-60.16) when including history of cesarean birth as mediator in multiparous women. Slower labor progress and history of cesarean birth were found to be the most clinically significant mediators. CONCLUSIONS: This study provides empirical insights into how obesity may increase cesarean birth rates through mediating processes. Particularly allowing for a slower labor progress in women with obesity might reduce cesarean birth rates and prevent subsequent repeat cesarean births in multiparous women.

Perspectives of patients and clinicians on older patient mobility on acute medical wards: a qualitative study.

BACKGROUND: Low mobility during an acute care medical hospitalization is frequent and associated with adverse outcomes, particularly among older patients. Better understanding barriers and facilitators to improve mobility during hospitalization could help develop effective interventions. The goal of this study was to assess barriers and facilitators to older medical patients' hospital mobility, from the point of view of patients and clinicians, to develop a framework applicable in clinical practice. METHODS: We conducted a qualitative study in one university and two non-university hospitals of two different language and cultural regions of Switzerland, including 13 focus groups (FGs; five with patients, eight with clinicians). We included 24 adults aged 60 years or older hospitalized on an acute general internal medicine ward of one of the three participating hospitals during the previous years, and 34 clinicians (15 physicians, nine nurses/nursing assistants, 10 physiotherapists) working on those wards. The FG guides included open-ended questions exploring mobility experiences, expectations, barriers and facilitators to mobility, consequences of low mobility and knowledge on mobility. We applied an inductive thematic analysis. RESULTS: We identified four themes of barriers and facilitators to mobility: 1) patient-related factors; 2) clinician-related factors; 3) social interactions; and 4) non-human factors. Clinician-related factors were only mentioned in clinician FGs. Otherwise, subthemes identified from patient and clinician FGs were similar and codes broadly overlapped. Subthemes included motivation, knowledge, expectations, mental and physical state (theme 1); process, knowledge - skills, mental state - motivation (theme 2); interpersonal relationships, support (theme 3); hospital setting - organization (theme 4). CONCLUSIONS: From patients' and clinicians' perspectives, a broad spectrum of human and structural factors influences mobility of older patients hospitalized on an acute general internal medicine ward. New factors included privacy issues and role perception. Many of those factors are potentially actionable without additional staff resources. This study is a first step in participatory research to improve mobility of older medical inpatients.

Barriers and facilitators to mobility of patients hospitalised on an acute medical ward: a systematic review.

BACKGROUND: low patient mobility is common during hospitalisation and is associated with adverse outcomes. To change practice, interventions should address barriers and facilitators to mobility. Our aim was to systematically review the literature to provide a synthesised overview of patient-, health care professional (HCP)- and environment-/system-related barriers and facilitators to mobility of patients hospitalised on an acute care medical ward. METHODS: we searched Medline, Embase, PsycInfo, Web of Science Core Collection, Cochrane CENTRAL, CINHAHL and Google Scholar (inception to 18 October 2021) to identify studies reporting barriers and/or facilitators to mobility of adults hospitalised on an acute medical ward. We applied a deductive and inductive thematic analysis to classify barriers and facilitators into themes and subthemes relevant for clinical practice. RESULTS: among 26 studies (16 qualitative, 7 quantitative and 3 mixed methods), barriers and facilitators were categorised into 10 themes: patient situation, knowledge, beliefs, experiences, intentions, emotions, social influences, role/identity, implementation/organisation and environment/resources. Barriers included patient characteristics (e.g. impaired cognitive/physical status) and symptoms, HCPs prioritising other tasks over mobility, HCPs labelling patients as 'too sick', fear of injury, lack of time, lack of clarity about responsibility, patient medical devices and non-encouraging environment. Facilitators included knowledge of mobility importance, HCP skills, interdisciplinarity, documentation and unit expectations, encouraging staff, goal individualisation, activity programme, family/visitor/volunteer support and availability of equipment. CONCLUSION: this synthesised overview of patient-, HCP- and environment-/system-related barriers and facilitators to mobility of adults hospitalised on an acute medical ward can help researchers and clinicians focus on what can realistically be influenced to improve mobility. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021285954.

Understanding Between-Person Interventions With Time-Intensive Longitudinal Outcome Data: Longitudinal Mediation Analyses.

BACKGROUND: Mediation analysis is an important tool for understanding the processes through which interventions affect health outcomes over time. Typically the temporal intervals between X, M, and Y are fixed by design, and little focus is given to the temporal dynamics of the processes. PURPOSE: In this article, we aim to highlight the importance of considering the timing of the causal effects of a between-person intervention X, on M and Y, resulting in a deeper understanding of mediation. METHODS: We provide a framework for examining the impact of a between-person intervention X on M and Y over time when M and Y are measured repeatedly. Five conceptual and analytic steps involve visualizing the effects of the intervention on Y, M, the relationship of M and Y, and the mediating process over time and selecting an appropriate analytic model. RESULTS: We demonstrate how these steps can be applied to two empirical examples of health behavior change interventions. We show that the patterns of longitudinal mediation can be fit with versions of longitudinal multilevel structural equation models that represent how the magnitude of direct and indirect effects vary over time. CONCLUSIONS: We urge researchers and methodologists to pay more attention to temporal dynamics in the causal analysis of interventions.

Compensatory health beliefs and unhealthy snack consumption in daily life.

Compensatory health beliefs (CHBs) are beliefs that an unhealthy behavior (unhealthy eating) can be compensated for by engaging in a healthy behavior (physical activity). Previous research focused on CHBs as rather stable beliefs (trait). Some studies indicated that situation-specific CHBs (state) might be important in situations, in which people are confronted with an unhealthy snack. This study aims to investigate the association between CHBs and unhealthy snack consumption in daily life with a special focus on the distinction between trait and state CHBs. Overall, N = 45 participants (66.7% female; age: 18-45 years, M = 21.9) received a link to an online questionnaire five times daily for seven consecutive days (n = 1575 possible diary entries). They reported unhealthy snack consumption, state and trait CHBs concerning the compensation with subsequent eating behavior and physical activity. The results showed that trait and state CHBs were significantly positively related to unhealthy snack consumption in daily life. Different effects appeared for CHBs concerning the compensation with subsequent eating behavior compared to the compensation with physical activity. This study demonstrates that both, state and trait CHBs are important for unhealthy snack consumption in daily life. Findings emphasize the need for further daily diary approaches to understand the temporal sequence of state CHBs that could further explain the use of CHBs as a maladaptive strategy for unhealthy eating.

Compensation and transfer effects of eating behavior change in daily life: Evidence from a randomized controlled trial.

Pursuing specific eating goals may lead to the adoption of other healthy behaviors (transfer) or compensation with unhealthy behaviors. Previous research has mostly investigated such processes using non-experimental studies focusing on interindividual differences. To investigate transfer or compensation of eating behavior in daily life, we analyzed data from a 2 (eating goal: more fruit and vegetables [FV] vs. fewer unhealthy snacks) x 2 (intervention vs. control group) factorial randomized trial. Adopting a within-person perspective, we studied potential transfer and compensation 1) between different eating behaviors and physical activity (PA), and 2) in response to an eating behavior change intervention. Participants (N = 203) received either goals to increase FV intake or decrease unhealthy snack intake and completed a daily e-diary. Eating more unhealthy snacks predicted 0.16 less FV portions (ß = -0.07; p < 0.001) and 18% less unhealthy snack intake the next day (p < 0.001). Eating more FV predicted 0.42 less FV portions the next day (ß = -0.07; p < 0.001). Participants with the FV eating goal intervention decreased unhealthy snacks (p = 0.012) and PA (p = 0.019) by 8% compared to controls, respectively. Similar but non-significant patterns were observed for participants with the decreasing unhealthy snack goal intervention (p > 0.05). Results indicated both compensation and transfer processes in daily life. Relationships mostly occur within the same behavior and rather support compensatory effects. In turn, a behavior change intervention to promote FV intake potentially enhances non-assigned eating behaviors, indicating transfer, but may lower PA.

A Research Agenda for the Future of Urban Water Management: Exploring the Potential of Nongrid, Small-Grid, and Hybrid Solutions.

Recent developments in high- and middle-income countries have exhibited a shift from conventional urban water systems to alternative solutions that are more diverse in source separation, decentralization, and modularization. These solutions include nongrid, small-grid, and hybrid systems to address such pressing global challenges as climate change, eutrophication, and rapid urbanization. They close loops, recover valuable resources, and adapt quickly to changing boundary conditions such as population size. Moving to such alternative solutions requires both technical and social innovations to coevolve over time into integrated socio-technical urban water systems. Current implementations of alternative systems in high- and middle-income countries are promising, but they also underline the need for research questions to be addressed from technical, social, and transformative perspectives. Future research should pursue a transdisciplinary research approach to generating evidence through socio-technical "lighthouse" projects that apply alternative urban water systems at scale. Such research should leverage experiences from these projects in diverse socio-economic contexts, identify their potentials and limitations from an integrated perspective, and share their successes and failures across the urban water sector.

The role of Compensatory Health Beliefs in eating behavior change: A mixed method study.

Compensatory Health Beliefs (CHBs), defined as beliefs that an unhealthy behavior can be compensated for by engaging in another healthy behavior, are assumed to hinder health behavior change. The aim of the present study was to investigate the role of CHBs for two distinct eating behaviors (increased fruit and vegetable consumption and eating fewer unhealthy snacks) with a mixed method approach. Participants (N = 232, mean age = 27.3 years, 76.3% women) were randomly assigned to a fruit and vegetable or an unhealthy snack condition. For the quantitative approach, path models were fitted to analyze the role of CHBs within a social-cognitive theory of health behavior change, the Health Action Process Approach (HAPA). With a content analysis, the qualitative approach investigated the occurrence of CHBs in smartphone chat groups when pursuing an eating goal. Both analyses were conducted for each eating behavior separately. Path models showed that CHBs added predictive value for intention, but not behavior over and above HAPA variables only in the unhealthy snack condition. CHBs were significantly negatively associated with intention and action planning. Content analysis revealed that people generated only a few CHB messages. However, CHBs were more likely to be present and were also more diverse in the unhealthy snack condition compared to the fruit and vegetable condition. Based on a mixed method approach, this study suggests that CHBs play a more important role for eating unhealthy snacks than for fruit and vegetable consumption.

Mind the Gap? An Intensive Longitudinal Study of Between-Person and Within-Person Intention-Behavior Relations.

BACKGROUND: Despite their good intentions, people often do not eat healthily. This is known as the intention-behavior gap. Although the intention-behavior relationship is theorized as a within-person process, most evidence is based on between-person differences. PURPOSE: The purpose of the present study is to investigate the within-person intention-behavior association for unhealthy snack consumption. METHODS: Young adults (N = 45) participated in an intensive longitudinal study. They reported intentions and snack consumption five times daily for 7 days (n = 1068 observations analyzed). RESULTS: A within-person unit difference in intentions was associated with a halving of the number of unhealthy snacks consumed in the following 3 h (CI95 27-70 %). Between-person differences in average intentions did not predict unhealthy snack consumption. CONCLUSIONS: Consistent with theory, the intention-behavior relation for healthy eating is best understood as a within-person process. Interventions to reduce unhealthy snacking should target times of day when intentions are weakest.

Social-cognitive factors mediating intervention effects on handwashing: a longitudinal study.

Handwashing with soap effectively prevents diarrhoea, a leading cause of death in infants. Theory-based interventions are expected to promote handwashing more successfully than standard approaches. The present article investigates the underlying change processes of theory-based handwashing interventions. A nonrandomised field study compared a standard approach to two theory-based interventions that were tailored to the target population, the inhabitants of four villages in southern Ethiopia (N = 408). Data were collected before and after interventions by structured interviews and analysed by mediation analysis. In comparison to the standard approach (i.e., education only), education with public commitment and reminder was slightly more effective in changing social-cognitive factors and handwashing. Education with an infrastructure promotion and reminder was most effective in promoting handwashing through enhancing social-cognitive factors. The results confirm the relevance of testing interventions' underlying change processes.

Implications of the COVID-19 trajectory for the evaluation of hand hygiene interventions: Secondary analysis of the Soapp trial.

Hand hygiene behavior is crucial to counter the spread of infectious diseases. However, its adoption during the early stages of the Coronavirus disease (COVID-19) pandemic showed temporal fluctuations associated with the trajectory of the pandemic (e.g. new COVID-19 infections). Such associations can confound conclusions about the effectiveness of interventions aimed at promoting hand hygiene during a pandemic. In this study, we performed a secondary analysis of a dataset from the optimization phase of Soapp, an app to promote hand hygiene during the COVID-19 pandemic. We used a longitudinal study design to test whether the associations between the pandemic trajectory and hand hygiene behavior were still present one year after the outbreak (primary outcome) and whether they impacted conclusions about the effectiveness of Soapp (secondary outcome). Participants (N = 216) were randomized to different versions of Soapp and used an electronic diary to self-report their hand hygiene behavior multiple times during the study. We considered the following indicators of the COVID-19 pandemic from the country of Switzerland in the period between March and August 2021: total cases/deaths, increases in recent new cases/deaths, new cases/deaths, and number of administered doses of vaccine. Data were analyzed using a multilevel approach. Results suggested that there were no significant associations between hand hygiene and the indicators of the pandemic trajectory. However, models including total cases/deaths impacted the conclusions about Soapp's effectiveness. Implications from this study are that the development and evaluation of hand hygiene interventions during a pandemic context should account for the trajectory indicators to maximize their effectiveness and control for confounding effects.

Hand hygiene is an effective behavior for decreasing the transmission of infectious diseases, including Coronavirus disease (COVID-19). During the early stages of the COVID-19 pandemic, hand hygiene was in part related to how the pandemic evolved over time (pandemic trajectory), e.g., how many people were affected or the number of deaths. We argue that such associations can confound conclusions about the effectiveness of interventions aimed at promoting hand hygiene during a pandemic. To test this hypothesis, we estimated how indicators of the pandemic trajectory influenced the evaluation of a smartphone app developed to promote hand hygiene during COVID-19. Our analysis included 216 participants who used the app for 34 days between March and August 2021 and reported their hand hygiene behavior using an electronic diary. Information on the pandemic trajectory were extracted from the World Health Organization database. Results confirmed that hand hygiene behavior increased with the use of the app when accounting for most pandemic trajectory indicators. However, this effect disappeared when accounting specifically for the total number of cases and deaths since the beginning of the pandemic. These results underline the importance of considering the pandemic trajectory when evaluating the efficacy of behavior change interventions carried out during an ongoing pandemic.

The temporal trajectories of habit decay in daily life: An intensive longitudinal study on four health-risk behaviors.

Habits are cue-behavior associations learned through repetition that are assumed to be relatively stable. Thereby, unhealthy habits can pose a health risk due to facilitating relapse. In the absence of research on habit decay in daily life, we aimed to investigate how habit decreases over time when trying to degrade a habit and whether this differs by four health-risk behaviors (sedentary behavior, unhealthy snacking, alcohol consumption, and smoking). This 91-day intensive longitudinal study included four parallel non-randomized groups (one per behavior; N = 194). Habit strength was measured daily with the Self-Report Behavioral Automaticity Index (11,805 observations) and modelled over time with constant, linear, quadratic, cubic, asymptotic, and logistic models. Person-specific modelling revealed asymptotic and logistic models as the most common best-fitting models (54% of the sample). The time for habit decay to stabilize ranged from 1 to 65 days. Multilevel modelling indicated substantial between-person heterogeneity and suggested initial habit strength but not the decay process to vary by behavioral group. Findings suggest that habit decay when trying to degrade a habit typically follows a decelerating negative trend but that it is a highly idiosyncratic process. Recommendations include emphasizing the role of person-specific modelling and data visualization in habit research.

HabitWalk: A micro-randomized trial to understand and promote habit formation in physical activity.

Habit is a key psychological determinant for physical activity behavior change and maintenance. This study aims to deepen the understanding of habit formation in physical activity and identify promotion strategies. We examined the habit formation trajectory and its relationships with cue-behavior repetition (a cue-triggered 15-minute brisk walk) and unconditional physical activity (daily steps). We also tested whether the behavior change techniques (BCTs) 'commitment' and 'prompts and cues' promote habit, cue-behavior repetition, and daily steps within persons. This micro-randomized trial included a 7-day preparatory and a 105-day experimental phase delivered via the HabitWalk app. Participants (N = 24) had a 50% probability of receiving each BCT daily, leading to four conditions. Habit strength was assessed daily using the Self-Report Behavioral Automaticity Index, while cue-behavior repetition and steps were measured via an activity tracker. Person-specific growth functions indicated that habit strength trajectories were highly idiosyncratic. Multilevel models indicated a positive effect of cue-behavior repetition on habit strength, but not vice versa. The effect of habit strength on daily steps varied by the operationalization of cue-behavior repetition. Tentative findings suggest that commitment and prompts and cues are effective habit-promotion strategies when delivered together.

Interrelatedness of women's health-behaviour cognitions: A dyadic study of female family members on carrying heavy loads during pregnancy in Nepal.

OBJECTIVES: Decisions about reproductive health are often influenced by women's female family members, particularly in low-resource contexts. However, previous research has focused primarily on individual behavioural determinants. We investigated the interrelatedness of female family members' reproductive health behaviour with a dyadic version of an extended health action process approach. We investigated this for carrying heavy loads during pregnancy and postpartum, a risk factor for reproductive health in many low-income countries such as Nepal. DESIGN: This cross-sectional study included dyads of daughters-in-law and mothers-in-law in rural Nepal (N = 476, nested in 238 dyads). METHODS: Dyads of daughters- and mothers-in-law were surveyed about avoiding carrying heavy loads during pregnancy and postpartum. The effects of a woman's cognitions and her female dyadic partner's cognitions on their intention and behaviour about avoiding carrying loads were estimated using linear mixed models. RESULTS: The results showed that a mother-in-law's cognitions were related to her daughter-in-law's intentions and vice versa. The mother-in-law's cognitions were also related to the daughter-in-law's behaviour. The mother-in-law's self-efficacy and injunctive norms related to the daughter-in-law's intention and behaviour over and above the daughter-in-law's own self-efficacy and injunctive norms. CONCLUSION: Female Nepali family members' cognitions about carrying heavy loads during pregnancy and postpartum are interrelated. Including female family members in interventions to help women manage their reproductive health in low-resource populations seems promising. These novel findings add to the growing body of research indicating the importance of including a dyadic perspective when understanding and changing health behaviour.

Evaluating and Enhancing an Educational Intervention to Reduce Smallholder Farmers' Exposure to Pesticides in Uganda Through a Digital, Systematic Approach to Behavior Change: Protocol for a Cluster-Randomized Controlled Trial.

BACKGROUND: Smallholder farmers receive educational interventions on safe pesticide handling by governmental agencies, industries, or nongovernmental organizations to reduce exposure risks. However, existing educational interventions have limited effects on changing behaviors. Targeting psychosocial determinants of behavior change in educational interventions through theory- and evidence-based approaches may enhance their effectiveness. OBJECTIVE: We aim at describing the intervention development and study design of a 3-arm cluster-randomized controlled trial to assess the effects in improving safe pesticide handling and reducing pesticide exposure of (1) an existing educational intervention and (2) a newly developed SMS text messaging intervention based on the Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) behavior change approach. METHODS: We enrolled 539 Ugandan smallholder farmers in 12 clusters (subcounties). The clusters, each with 45 farmers, were randomly allocated to one of the three arms: (1) educational intervention, (2) educational intervention+RANAS-based SMS text messages, or (3) control group. The educational intervention comprised a 2-day workshop that targeted multiple aspects of safe pesticide handling, whereas the SMS text messages targeted the use of personal protective equipment (PPE) and were based on the RANAS approach. For intervention development in this study, this approach includes identifying psychosocial determinants of PPE use at baseline and selecting behavior change techniques to target them in SMS text messages. The primary outcomes of the study are (1) pesticide knowledge, attitude, and practice scores indicating performance throughout the educational intervention; and (2) frequency of PPE use. Secondary outcomes are the RANAS-based behavioral determinants of PPE use, the frequency of glove use, algorithm-based pesticide exposure intensity scores, and signs and symptoms of pesticide poisoning. The outcomes were assessed in structured interviews before the intervention (baseline) and at the 12-month follow-up. The effect of the interventions among the arms will be analyzed using the intervention arms and baseline measures as predictors and the follow-up measures as outcomes in linear multivariable mixed models including the clusters as random effects. The mediating psychosocial determinants of the interventions will be assessed in multiple mediation models. RESULTS: The study was conducted from 2020 to 2021-baseline interviews were conducted in October 2020, and the educational intervention was delivered in November 2020. The RANAS-based SMS text messages were developed based on the baseline data for relevant behavioral determinants of PPE use and sent between February 2021 and September 2021. Follow-up interviews were conducted in October 2021. Overall, 539 farmers were enrolled in the study at baseline; 8.3% (45/539) were lost to follow-up by the end of the study. CONCLUSIONS: This study will contribute to a better understanding of the effectiveness and behavior change mechanisms of educational interventions by using an experimental, cluster-randomized study design to improve pesticide handling among smallholder farmers. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number (ISRCTN) 18237656; https://doi.org/10.1186/ISRCTN18237656. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55238.

Predicting water consumption habits for seven arsenic-safe water options in Bangladesh.

BACKGROUND: In Bangladesh, 20 million people are at the risk of developing arsenicosis because of excessive arsenic intake. Despite increased awareness, many of the implemented arsenic-safe water options are not being sufficiently used by the population. This study investigated the role of social-cognitive factors in explaining the habitual use of arsenic-safe water options. METHODS: Eight hundred seventy-two randomly selected households in six arsenic-affected districts of rural Bangladesh, which had access to an arsenic-safe water option, were interviewed using structured face-to-face interviews in November 2009. Habitual use of arsenic-safe water options, severity, vulnerability, affective and instrumental attitudes, injunctive and descriptive norms, self-efficacy, and coping planning were measured. The data were analyzed using multiple linear regressions. RESULTS: Linear regression revealed that self-efficacy (B = 0.42, SE = .03, p < .001), the instrumental attitude towards the safe water option (B = 0.24, SE = .04, p < .001), the affective attitude towards contaminated tube wells (B = -0.04, SE = .02, p = .024), vulnerability (B = -0.20, SE = .02, p < .001), as well as injunctive (B = 0.08, SE = 0.04, p = .049) and descriptive norms (B = 0.34, SE = .03, p < .001) primarily explained the habitual use of arsenic-safe water options (R2 = 0.688). This model proved highly generalizable to all seven arsenic-safe water options investigated, even though habitual use of single options were predicted on the basis of parameters estimated without these options. CONCLUSIONS: This general model for the habitual use of arsenic-safe water options may prove useful to predict other water consumption habits. Behavior-change interventions are derived from the model to promote the habitual use of arsenic-safe water options.

Older adults' physical activity after lockdown: Testing the health action process approach and the moderating role of fear of Covid-19.

The coronavirus pandemic has influenced many lives, particularly older adults'. Although isolation protects from infection, health behaviors like physical activity (PA) are important to reinstate after lockdown. However, fear of Covid-19 may act as a barrier, for example, by preventing people from going outside. Based on the health action process approach (HAPA), we investigated whether and why older adults' PA changed after lockdown, and whether fear of Covid-19 moderates the intention-behavior relationship. Participants of this longitudinal study aged 65+ from German-speaking Europe completed an online questionnaire about their PA, fear of Covid-19, and HAPA factors in April and May 2020. Data were analyzed using multiple linear regressions. Results showed that moderate to vigorous activity (MVPA) remained stable after lockdown and that self-efficacy most robustly influenced the intention to be active. PA was not explained by any volitional factor but was strongly related to past PA. Interestingly, the relationship of past and future MVPA was attenuated by fear of Covid-19, but this finding was not robust when outliers were removed. In conclusion, self-efficacy is the most important motivator for PA in older adults after an interruption like a lockdown. Strong physical activity habits may facilitate PA after a period of isolation.

What do older adults think about when formulating implementation intentions for physical activity? Evidence from a qualitative study.

OBJECTIVES: Physical activity is an important health behaviour especially for older adults. Forming implementation intentions is an effective strategy to implement physical activity in daily life for young and middle-aged adults. However, evidence for older adults is inconclusive. This study explored the thoughts of older adults about implementation intentions and potential barriers and facilitators while formulating them. METHODS: Three samples of older adults from the United Kingdom (n = 8), Germany (n = 9) and Switzerland (n = 17) were prompted to think aloud while formulating implementation intentions to be more physically active. After the task, semi-structured interviews were conducted. Data were analysed thematically. RESULTS: Participants expressed pre-established thoughts about implementation intentions (e.g. they feel too restrictive). During the formulation of implementation intentions, several barriers to creating them were reported (e.g. problems with finding cues due to absence of recurring daily routines), but participants also mentioned that forming implementation intentions acted as a facilitator for physical activity (e.g. cues as useful reminders to be active, task itself triggering self-reflection about physical activity). After the task, participants reflected on circumstances that decrease the likelihood of enacting implementation intentions (e.g. spontaneous alternative activities, weather, health-related barriers, Covid-19-related barriers), which triggered spontaneous coping planning. CONCLUSIONS: The results on barriers and facilitators of implementation intentions and physical activity from older adults' perspectives provide starting points for improving instructions for older adults on how to create implementation intentions for physical activity. Future studies are needed to investigate whether the findings extend to implementation intentions for other behaviours.

Promoting Hand Hygiene During the COVID-19 Pandemic: Parallel Randomized Trial for the Optimization of the Soapp App.

BACKGROUND: Hand hygiene is an effective behavior for preventing the spread of the respiratory disease COVID-19 and was included in public health guidelines worldwide. Behavior change interventions addressing hand hygiene have the potential to support the adherence to public health recommendations and, thereby, prevent the spread of COVID-19. However, randomized trials are largely absent during a pandemic; therefore, there is little knowledge about the most effective strategies to promote hand hygiene during an ongoing pandemic. This study addresses this gap by presenting the results of the optimization phase of a Multiphase Optimization Strategy of Soapp, a smartphone app for promoting hand hygiene in the context of the COVID-19 pandemic. OBJECTIVE: This study aimed to identify the most effective combination and sequence of 3 theory- and evidence-based intervention modules (habit, motivation, and social norms) for promoting hand hygiene. To this end, 9 versions of Soapp were developed (conditions), and 2 optimization criteria were defined: the condition with the largest increase in hand hygiene at follow-up and condition with the highest engagement, usability, and satisfaction based on quantitative and qualitative analyses. METHODS: This study was a parallel randomized trial with 9 intervention conditions defined by the combination of 2 intervention modules and their sequence. The trial was conducted from March to August 2021 with interested participants from the Swiss general population (N=232; randomized). Randomization was performed using Qualtrics (Qualtrics International Inc), and blinding was ensured. The duration of the intervention was 34 days. The primary outcome was self-reported hand hygiene at follow-up, which was assessed using an electronic diary. The secondary outcomes were user engagement, usability, and satisfaction assessed at follow-up. Nine participants were further invited to participate in semistructured exit interviews. A set of ANOVAs was performed to test the main hypotheses, whereas a thematic analysis was performed to analyze the qualitative data. RESULTS: The results showed a significant increase in hand hygiene over time across all conditions. There was no interaction effect between time and intervention condition. Similarly, no between-group differences in engagement, usability, and satisfaction emerged. Seven themes (eg, "variety and timeliness of the task load" and "social interaction") were found in the thematic analysis. CONCLUSIONS: The effectiveness of Soapp in promoting hand hygiene laid the foundation for the next evaluation phase of the app. More generally, the study supported the value of digital interventions in pandemic contexts. The findings showed no differential effect of intervention conditions involving different combinations and sequences of the habit, motivation, and social norms modules on hand hygiene, engagement, usability, and satisfaction. In the absence of quantitative differences, we relied on the results from the thematic analysis to select the best version of Soapp for the evaluation phase. TRIAL REGISTRATION: ClinicalTrials.gov NCT04830761; https://clinicaltrials.gov/ct2/show/NCT04830761. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2021-055971.

Resilience characterized and quantified from physical activity data: A tutorial in R.

Consistent physical activity is key for health and well-being, but it is vulnerable to stressors. The process of recovering from such stressors and bouncing back to the previous state of physical activity can be referred to as resilience. Quantifying resilience is fundamental to assess and manage the impact of stressors on consistent physical activity. In this tutorial, we present a method to quantify the resilience process from physical activity data. We leverage the prior operationalization of resilience, as used in various psychological domains, as area under the curve and expand it to suit the characteristics of physical activity time series. As use case to illustrate the methodology, we quantified resilience in step count time series (length = 366 observations) for eight participants following the first COVID-19 lockdown as a stressor. Steps were assessed daily using wrist-worn devices. The methodology is implemented in R and all coding details are included. For each person's time series, we fitted multiple growth models and identified the best one using the Root Mean Squared Error (RMSE). Then, we used the predicted values from the selected model to identify the point in time when the participant recovered from the stressor and quantified the resulting area under the curve as a measure of resilience for step count. Further resilience features were extracted to capture the different aspects of the process. By developing a methodological guide with a step-by-step implementation, we aimed at fostering increased awareness about the concept of resilience for physical activity and facilitate the implementation of related research.