The ISAC Paradigm to Tame Oral Cancer in Saudi Arabia: A Quasi-experimental Study.

Late detection of oral cancer (OC) cases in Saudi Arabia is concerning. It reduces survival rate and complicates treatment. The ISAC intervention was developed to bridge the gaps observed in dentists' practice of OC examination and patient education. The ISAC stands for I, informing patients of OC screenings; S, screening for OC; A, advising high-risk patients to quit risk factors; and C, connecting patients to advanced services. This study tested the potential effect of the ISAC in influencing dentists' cognitive and behavioral skills, to enhance early detection and prevention of OC. A quasi-experimental study was conducted among dental interns (DIs) at dental setting to test the effect on comprehensive oral cancer examination score (COCE), awareness, self-efficacy, descriptive-norms, and self-reported behavior. Data were collected through triangulation of methods pre and post the intervention at two-months. Multiple linear mixed effects regression models were utilized for data analysis. Between October 2020 and April 2021, 47 DIs participated in the study. The final model showed the significant effects of time (ISAC) on COCE (95% CI = 25.12-29.42, P < .001). DIs had a significant improvement in awareness, self-efficacy, descriptive norms, and self-reported behavior. The findings showed promising effects of the intervention toward the early detection and prevention of OC. Dentists, dental organizations, and policymakers in areas with a high risk of OC could benefit from the current intervention which contributes to capacity building and improved community health. A pragmatic study with a robust design is needed to test the effectiveness of the intervention on a wider scale.

The Effects of Online Access to General Practice Medical Records Perceived by Patients: Longitudinal Survey Study.

BACKGROUND: Patient online access to medical records is assumed to facilitate patient empowerment and advance patient-centered health care. However, to date, the actual effects of online access to medical records perceived by patients and other outcomes are insufficiently empirically tested. OBJECTIVE: This study aimed to investigate the effects of online access to medical records on patient empowerment, informed decision-making, and the patient-provider relationship perceived by patients. METHODS: A nationwide, 2-wave, longitudinal survey study was conducted among Dutch adults (N=2402). Linear regression analyses were performed. In model 1, the perceived effects of online access to medical records (measured at T1 [first measurement; July 2021]) on 16 outcomes (measured at T2 [second measurement; January 2022]), which were associated with the use of online access to general practice medical records in previous research, were investigated. Model 2 included sociodemographic factors and patient characteristics as confounders. RESULTS: Users indicated more strongly than nonusers that online access to medical records would increase their participation in health care, improve the relationship with their general practitioner, and support informed decision-making. These results were robust when adjusted for the influence of confounders. Effect sizes were very small, with unstandardized regression coefficients (B) ranging between -0.39 and 0.28. Higher digital and health literacy were associated with higher ratings of almost all effects. CONCLUSIONS: Online access to medical records has the potential to empower patients and foster informed decision-making among patients. The effects in this study were small but might grow over time. Other factors, such as the attitude of general practitioners toward online access to medical records, might moderate these effects. The results indicate that the potential benefits of online access to medical records might be unevenly distributed. We suggest future exploration of the conditions under which online access to medical records can improve health care system functioning and efficiency without increasing health inequality.

Psychosocial determinants of consistent condom use among university students in Sudan: findings from a study using the Integrated Change Model.

Unprotected sex is common among university students in Sudan, thus increasing risks for sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV). As little is known about the psychosocial determinants of consistent condom use among this population, this study was designed to identify them. The Integrated Change Model (ICM) was applied in a cross-sectional design to identify in 218 students (aged 18-25 years) from Khartoum which items distinguish condom users from non-condom users. Condom users differed significantly from non-condom users in having more HIV and condom use-related knowledge, higher perception of susceptibility to HIV, reporting more exposure to condom use cues, having a less negative attitude towards condom use (attitude cons), experiencing social support and norms favouring condom use and having higher condom use self-efficacy. Binary logistic regression showed that peer norms favouring condom use in addition to HIV-related knowledge, condom use cues, negative attitude and self-efficacy were the factors uniquely associated with consistent condom use among university students in Sudan. Interventions seeking to promote consistent condom use among sexually active students could benefit from increasing knowledge about HIV transmission and prevention, raising HIV-risk perception, using condom use cues, addressing perceived condom disadvantages and enhancing students` self-efficacy to avoid unprotected sex. Moreover, such interventions should raise students` perceptions of their peers` beliefs and behaviours favouring condom use and seek health care professionals` and religious scholars` support for condom use.

Patient online access to general practice medical records: A qualitative study on patients' needs and expectations.

BACKGROUND: Patient online access to medical records is assumed to foster patient empowerment and advance patient-centred healthcare. Since July 2020, patients in the Netherlands have been legally entitled to electronically access their medical record in general practice. Experience from pioneering countries has shown that despite high patient interest, user rates often remain low. How to best support implementation depends on individual needs and expectations of patient populations, which are as yet unknown in the Dutch context. OBJECTIVE: To understand Dutch patients' needs and expectations with regard to online access to their medical record in general practice. METHOD: Twenty participants completed semi-structured individual interviews via video or telephone call. Transcripts of interviews underwent template analysis combining deductive and inductive coding using Atlas.ti software. RESULTS: Patients' needs and expectations ranged across three overlapping areas: (i) prerequisites for getting online access; (ii) using online access; and (iii) the impact on interaction with healthcare providers. Patients expected benefits from online access such as better overview, empowerment and improved communication with their general practitioner but identified needs regarding technological difficulties, data privacy and complex medical language in their record. CONCLUSION: The concerns and obstacles participants identified point towards the need for organisational changes in general practice, for example, adjusted documentation practices, and the key role of the general practitioner and staff in promoting and facilitating online access. IMPLICATIONS: Implementation strategies addressing needs identified in this study may help to unlock the full potential of online access to achieve desired outcomes of patient involvement and satisfaction.

Using tailored eHealth programmes to stimulate primary health care professionals' lifestyle counselling guideline adherence - Lessons learned from the STAR project.

BACKGROUND: Although individually tailored eHealth programmes have shown to be effective in changing patient and citizen health behaviours, they have so far not been applied to lifestyle counselling guideline adherence in primary health care professionals beyond our STAR project. The programme aimed to support general practice nurses adhering to national smoking cessation counselling guidelines and showed encouraging positive impacts on both nurse and patient level. OBJECTIVE: To identify lessons learned from our successful application of a tailored eHealth programme in primary health care. METHODS: Triangulation of information from different sources collected throughout the project run time (e.g., project meetings, discussions with experts in the fields of computer tailoring, smoking cessation and professional education and interactions with general practice nurses). RESULTS: We identify four lessons learned which developers and testers of tailored eHealth programmes in primary health care should consider, relating to 1) Choosing outcome measures, 2) Measuring outcomes, 3) Practical feedback application & Programme accessibility, and 4) Programme interaction. PRACTICE IMPLICATIONS: We share this information in the hope that we will see more applications of this promising intervention strategy - that can build on our work - in the future.

Active Ingredients of Interventions Improving Smoking Cessation Support by Dutch Primary Care Providers: A Systematic Review.

The objective was to assess active ingredients, change mechanisms, and fidelity in interventions aiming to increase the quality of smoking cessation care in the Dutch primary healthcare setting. We conducted a systematic review searching five scientific databases on August 2nd, 2019, updated on October 28th, 2021. We included effect data of behavioural interventions aiming at improving the provision of smoking cessation support by Dutch primary care providers to their patients. We excluded studies published before 2000 and those without a behavioural support intervention for primary care providers targeting smoking cessation in their patients. We found 1939 articles and included 15 distinct interventions in the review. We provided an overview of study characteristics, intervention effects, fidelity, active ingredients and change mechanisms using the Behaviour Change Techniques (BCT) Taxonomy and Mechanisms of Action (MoAs) protocols. Interventions seemed more effective when including a face-to-face component, using active learning strategies and providing a tool to help follow the guidelines in practice (e.g., physical cards with information). BCTs, MoAs, and fidelity were overall poorly reported on. To support the application of smoking cessation practices in Dutch primary care, we recommend implementation of face-to-face training programs incorporating active skill training elements combined with practical tools.

Effects of an Explicit Value Clarification Method With Computer-Tailored Advice on the Effectiveness of a Web-Based Smoking Cessation Decision Aid: Findings From a Randomized Controlled Trial.

BACKGROUND: Smoking continues to be a driver of mortality. Various forms of evidence-based cessation assistance exist; however, their use is limited. The choice between them may also induce decisional conflict. Offering decision aids (DAs) may be beneficial; however, insights into their effective elements are lacking. OBJECTIVE: This study tested the added value of an effective element (ie, an "explicit value clarification method" paired with computer-tailored advice indicating the most fitting cessation assistance) of a web-based smoking cessation DA. METHODS: A web-based randomized controlled trial was conducted among smokers motivated to stop smoking within 6 months. The intervention group received a DA with the aforementioned elements, and the control group received the same DA without these elements. The primary outcome measure was 7-day point prevalence abstinence 6 months after baseline (time point 3 [t=3]). Secondary outcome measures were 7-day point prevalence of abstinence 1 month after baseline (time point 2 [t=2]), evidence-based cessation assistance use (t=2 and t=3), and decisional conflict (immediately after DA; time point 1). Logistic and linear regression analyses were performed to assess the outcomes. Analyses were conducted following 2 (decisional conflict) and 3 (smoking cessation) outcome scenarios: complete cases, worst-case scenario (assuming that dropouts still smoked), and multiple imputations. A priori sample size calculation indicated that 796 participants were needed. The participants were mainly recruited on the web (eg, social media). All the data were self-reported. RESULTS: Overall, 2375 participants were randomized (intervention n=1164, 49.01%), of whom 599 (25.22%; intervention n=275, 45.91%) completed the DAs, and 276 (11.62%; intervention n=143, 51.81%), 97 (4.08%; intervention n=54, 55.67%), and 103 (4.34%; intervention n=56, 54.37%) completed time point 1, t=2, and t=3, respectively. More participants stopped smoking in the intervention group (23/63, 37%) than in the control group (14/52, 27%) after 6 months; however, this was only statistically significant in the worst-case scenario (crude P=.02; adjusted P=.04). Effects on the secondary outcomes were only observed for smoking abstinence after 1 month (15/55, 27%, compared with 7/46, 15%, in the crude and adjusted models, respectively; P=.02) and for cessation assistance uptake after 1 month (26/56, 46% compared with 18/47, 38% only in the crude model; P=.04) and 6 months (38/61, 62% compared with 26/50, 52%; crude P=.01; adjusted P=.02) but only in the worst-case scenario. Nonuse attrition was 34.19% higher in the intervention group than in the control group (P<.001). CONCLUSIONS: Currently, we cannot confidently recommend the inclusion of explicit value clarification methods and computer-tailored advice. However, they might result in higher nonuse attrition rates, thereby limiting their potential. As a lack of statistical power may have influenced the outcomes, we recommend replicating this study with some adaptations based on the lessons learned. TRIAL REGISTRATION: Netherlands Trial Register NL8270; https://www.trialregister.nl/trial/8270. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/21772.

Process Evaluation of a Comprehensive Intervention for the Early Detection and Prevention of Oral Cancer: A Mixed Methods Study.

Process evaluations help to understand and refine health interventions. The "ISAC" intervention targeted the enhancement of early detection and prevention of oral cancer (OC) through tobacco-cessation counseling, patient communications, and ISAC role-modeling. Over six months, throughout ISAC implementation in the Jazan region of Saudi Arabia, Linnan and Steckler's process evaluation framework's specified indicators were assessed, by mixed methods, on context, reach, dose delivered, dose received, fidelity, recruitment, and participant's satisfaction. Findings showed that 47 of 80 (58.75%) eligible dentists were reached and received all components. Thirty-six (76.6%) participants reported reading all intervention materials, visited the ISAC website, scored high on the perceived quality of provided information (M = 4.62 ± 0.63), and provided support (M = 4.67 ± 0.57). The fidelity was scored high across all intervention components. Role-modeling of the ISAC had the highest satisfaction score (M = 9.77 ± 0.58 out of 10). High perceived-effects were reported in relation to feeling confident in performing OC examination and training patients on OC self-examination (3.95 ± 0.22). The intervention attained high implementation levels for dose delivered, dose received, and fidelity. The intervention delivery was associated with high satisfaction and perceived effects. Using multiple data sources enhanced the understanding of the implementation process and strengthened the validity of the study's findings.

Message Frame-Tailoring in Digital Health Communication: Intervention Redesign and Usability Testing.

BACKGROUND: Message frame-tailoring based on the need for autonomy is a promising strategy to improve the effectiveness of digital health communication interventions. An example of a digital health communication intervention is Personal Advice in Stopping smoking (PAS), a web-based content-tailored smoking cessation program. PAS was effective in improving cessation success rates, but its effect sizes were small and disappeared after 6 months. Therefore, investigating whether message frame-tailoring based on the individual's need for autonomy might improve effect rates is worthwhile. However, to our knowledge, this has not been studied previously. OBJECTIVE: To investigate whether adding message frame-tailoring based on the need for autonomy increases the effectiveness of content-tailored interventions, the PAS program was redesigned to incorporate message frame-tailoring also. This paper described the process of redesigning the PAS program to include message frame-tailoring, providing smokers with autonomy-supportive or controlling message frames-depending on their individual need for autonomy. Therefore, we aimed to extend framing theory, tailoring theory, and self-determination theory. METHODS: Extension of the framing theory, tailoring theory, and self-determination theory by redesigning the PAS program to include message frame-tailoring was conducted in close collaboration with scientific and nonscientific smoking cessation experts (n=10), smokers (n=816), and communication science students (n=19). Various methods were used to redesign the PAS program to include message frame-tailoring with optimal usability: usability testing, think-aloud methodology, heuristic evaluations, and a web-based experiment. RESULTS: The most autonomy-supportive and controlling message frames were identified, the cutoff point for the need for autonomy to distinguish between people with high and those with low need for autonomy was determined, and the usability was optimized. CONCLUSIONS: This resulted in a redesigned digital health communication intervention that included message frame-tailoring and had optimal usability. A detailed description of the redesigning process of the PAS program is provided. TRIAL REGISTRATION: Netherlands Trial Register NL6512 (NRT6700); https://www.trialregister.nl/trial/6512.

Dentists' perceptions and usability testing toward the implementation of the ISAC, a comprehensive oral cancer intervention in dental practices: a qualitative study in Jazan region, Saudi Arabia.

OBJECTIVE: We aimed to explore dentists' perceptions toward the implementation of a comprehensive intervention (ISAC) for the early detection and prevention of oral cancer in a dental clinic. METHODS: The ISAC intervention was presented to ten purposefully sampled dentists in Jazan Dental School (JDS). Participating dental interns were asked to practice the ISAC intervention whilst thinking aloud. A semi-structured interview technique was used to allow free expression of participants' perceptions related to the ISAC intervention and to control the flow of topics. Fleuren's framework theory informed the analysis. The interviews were transcribed verbatim and analyzed using the deductive-inductive framework analysis. RESULTS: Practicing the ISAC intervention was perceived to enhance the early detection and prevention of oral cancer. Serving community needs and engaging community groups were perceived to be related to a high relevance and compatibility of the ISAC intervention. Being a comprehensive intervention with well-defined objectives and being built on relevant data from the participants' community and having dentists as a target group were the perceived relative advantages of the ISAC intervention compared to other programs. A supportive environment, gender-concordance, use of regional trainers, standard examination form and collaboration with other sectors were perceived to be the facilitators. Competition with clinical time, use of different examination forms and low organizational leader interests were perceived as impeding factors against effective implementation in a real-world context. Reward, easy to practice, feeling confidence and satisfaction, advertisement as well as use of a role model approach were perceived to be motivating factors. CONCLUSIONS: Integrating data from representers of different participant groups during intervention conceptualization and development are critical for the intervention compatibility and acceptability. The study findings showed the opportunities of intertwining the intrinsic motivators of satisfaction and altruism existing in the target group and the extrinsic motivator of official diagnostic skill, certification that may boost and sustain the behavior change. Intervention features that influence perceived relevance, compatibility, relative advantage and motivation may be of great importance for intervention practice.

An economic evaluation of an online computer-tailored smoking cessation intervention that includes message frame-tailoring: A randomized controlled trial.

Evidence of economic evaluations of behaviour change interventions is scarce, but needed to guide policy makers' decision-making. This study economically evaluated 4 versions of an innovative online computer-tailored smoking cessation intervention. The economic evaluation from a societal perspective was embedded in a randomized controlled trial among 532 smokers using a 2 (message frame-tailoring, i.e. how messages are presented: autonomy-supportive vs controlling) x 2 (content-tailoring, i.e. what content is presented: tailored vs. generic) design. Both kinds of tailoring, content-tailoring and message frame-tailoring, were based on a set of questions asked at baseline. Self-reported costs, prolonged smoking abstinence (cost-effectiveness) and quality of life (cost-utility) were assessed during a 6-month-follow-up. For cost-effectiveness analysis, costs per abstinent smoker were calculated. For cost-utility analysis, costs per QALY (i.e. quality-adjusted life year) gained were calculated. A willingness-to-pay (WTP) threshold of €20.000 was used. Bootstrapping and sensitivity analysis were conducted. Cost-effectiveness analysis showed that up to a WTP of €2.000, the combination of message frame- and content-tailoring dominated all study groups. From a WTP of €2.005, the content-tailored group dominated all study groups. Cost-utility analysis revealed that the combination of message frame-tailoring and content-tailoring had the highest probability of being the most efficient study group at all levels of the WTP. The combination of message frame-tailoring and content-tailoring in online smoking cessation programmes seemed to have high potential for cost-effectiveness (smoking abstinence) and cost-utility (quality of life), thus providing good value for money. Yet, when the WTP for each abstinent smoker is high (i.e., €2.005 or higher), the addition of message frame-tailoring might not be worth the effort and content-tailoring only is preferred.

Identifying Active Ingredients, Working Mechanisms, and Fidelity Characteristics Reported in Smoking Cessation Interventions in Dutch Primary Care: A Systematic Review.

BACKGROUND: Evidence-based smoking cessation interventions provided by healthcare professionals can be successful in helping citizens to quit smoking. Yet, evidence is needed about the active ingredients of these interventions, how these ingredients work and how they are implemented in practice. Such knowledge is required to effectively support healthcare professionals to optimally put evidence-based smoking cessation interventions to (inter)national practice. OBJECTIVE: To identify active ingredients (including behavior change techniques), mechanisms of action and implementation fidelity reported in smoking cessation interventions in Dutch primary care settings and to relate these to intervention effectiveness. METHODS: A systematic review was conducted by searching nine national intervention or funding databases, five international scientific databases and consulting 17 national smoking cessation experts. Out of 1066 identified manuscripts, 40 interventions were eligible for this review. Based on published protocols, information regarding behavior change techniques and mechanisms of action was systematically abstracted. Additionally, information regarding study characteristics and other active ingredients, effects on smoking behavior and implementation fidelity was abstracted. Comparative effectiveness concerning abstracted intervention characteristics was qualitatively explored. RESULTS: Active ingredients, mechanisms of action and implementation fidelity were moderately to poorly reported. Interventions applying behavior change techniques and interventions with a single behavioral target (i.e. smoking-only versus multiple behaviors) seemed to provide stronger evidence for successfully changing smoking behavior. CONCLUSION: Attention to and reporting on interventions' active ingredients (e.g. behavior change techniques), mechanisms of action and implementation fidelity are prerequisites for developing more effective evidence-based smoking cessation interventions to be successfully implemented in primary healthcare. IMPLICATIONS: This systematic review provides an overview of smoking cessation interventions in Dutch primary care settings, identified since the year 2000. Smoking cessation support is offered in various forms, but our qualitative findings show that interventions including more behavior change techniques and interventions targeting only smoking cessation (compared to multiple behaviors) might be more effective. Results also show that-based on available intervention reports-it is difficult to distinguish patterns of active ingredients (such as behavior change techniques), mechanisms of action and fidelity of implementation in relation to interventions' effectiveness. This means (quality of) reporting on these intervention characteristics should improve.

Do professional perspectives on evidence-based smoking cessation methods align? A Delphi study among researchers and healthcare professionals.

The use of evidence-based smoking cessation interventions (SCIs) can significantly increase the number of successful smoking cessation attempts. To obtain an overview of the knowledge and viewpoints on the effectiveness and use of SCIs, a three-round online Delphi study was conducted among researchers and primary care professionals (PCPs). The four objectives of this study are to gain an overview of (i) the criteria important for recommending SCIs, (ii) the perceptions of both groups on the effectiveness of SCIs, (iii) the factors to consider when counseling different (high-risk) groups of smokers and (iv) the perceptions of both groups on the use of e-cigarettes as an SCI. We found a high level of agreement within groups on which smoker characteristics should be considered when recommending an SCI to smokers. We also found that PCPs display a lower degree of consensus on the effectiveness of SCIs. Both groups see a value in the use of special protocols for different (high-risk) groups of patients, but the two groups did not reach consensus on the use of e-cigarettes as a means to quit. Making an inventory of PCPs' needs regarding SCIs and their usage may provide insight into how to facilitate a better uptake in the primary care setting.

Assessing sexual practices and beliefs among university students in Khartoum, Sudan; a qualitative study.

University students in Sudan are more at risk of contracting HIV than the general population, due to a high rate of sexual activity and low uptake of preventive measures such as condoms. Hence, they are considered an important target for HIV prevention programmes. This study explored students` beliefs about abstinence and pre-marital sex. Thirty semi-structured individual interviews were conducted, based on constructs from the Integrated Change (I-Change) Model. The study sample included 16 (53%) male and 14 (47%) female university students. Their average age was 21.2 years (Range 18-27 and SD 2.5). Both sexual abstainers (N = 19) and sexually active students (N = 11) perceived HIV severity and susceptibility. Most of the participants had a positive attitude towards abstinence. However, sexually active students also perceived some advantages of engaging in sexual practices, such as sexual pleasure and proving adulthood. Sexually active students more often mentioned being influenced in their sexual practices by their peers than by their families. Sexually active students reported lower self-efficacy to refrain from sex than abstainers. Interventions that seek to promote abstinence among those willing to achieve this should stress the advantages of abstinence from sex until marriage, offer tools to resist peer pressure and enhance self-efficacy to abstain. These findings can be used to develop comprehensive HIV prevention programmes that primarily promote abstinence among university students who are not yet sexually active but also consider promoting condom use and other safer-sex practices among those who are sexually active. These interventions should also be gender-sensitive to address the needs of both male and female students.

Identifying Behavior Change Techniques Used in Tobacco Cessation Interventions by Oral Health Professionals and Their Relation to Intervention Effects-A Review of the Scientific Literature.

This review aimed to identify the behavioral change techniques (BCTs) used in behavioral interventions for tobacco cessation at dental practices in relation to their effect on tobacco use. Six scientific databases were searched for behavior change interventions for tobacco cessation and were coded using the BCT taxonomy of behavioral support for smoking cessation (BCTTsm). Fifteen interventions were identified, and data related to intervention characteristics were abstracted. Sixteen BCTs were identified, mainly related to increased motivation and teaching regulatory skills. Goal setting was the most commonly used BCT. Ten out of fifteen interventions effectively impacted tobacco cessation outcomes (OR = 2 to 5.25). Effective interventions more frequently included goal setting, written materials, readiness to quit and ability assessment, tobacco-use assessment, self-efficacy boost, listing reasons for quitting, action planning and environment restructuring. Other BCTs were not clearly associated with an increased effect. Among the behavioral interventions, certain techniques were associated with successful tobacco quitting. Tobacco cessation interventions in a dental setting appear to benefit from using BCTs that increase motivation and teach regulatory skills. The identified BCTs in this review could provide a source to better inform researchers and dentists about the active ingredients in behavior change interventions for tobacco cessation in a dental setting.

Integrating behaviour change interventions and patient decision aids: How to accomplish synergistic effects?

People make numerous health-related choices each day: For example, deciding to brush one's teeth or to eat well and healthy - or not to do these activities. To support complex decisions and subsequent behaviour change, both Behaviour Change Interventions (BCIs) and Patient Decision Aids (PtDAs) have been developed and evolved independently to support people in health-related decision making. In this paper, we critically review BCIs and PtDAs, examine their similarities and differences, and identify potential for integration of expertise to increase the benefits for people engaging with healthcare and health behaviours. The two approaches appear to mainly differ in terms of their (1) goals and foci, (2) theoretical basis, (3) development frameworks, (4) active ingredients and (5) effect evaluation. To facilitate the integration of scientific insights from these two fields, we recommend to (1) bring both fields together and promote interprofessional discussions, (2) train (health) professionals to recognise strengths of both approaches, (3) investigate the synergy of the two fields, (4) be prepared for and try to mitigate a culture shock when the fields start to interact. Knowledge generated by researching PtDAs could be used to facilitate decisional processes that enable patients to choose goals that are in line with their values and preferences, while insights from researching BCIs could be used to facilitate engagement with, and implementation of those goals. This integration could allow researchers and intervention providers to increase the benefits for people engaging with healthcare and health behaviours.

A Web-Based Computer-Tailored Program to Improve Treatment Adherence in Patients With Type 2 Diabetes: Randomized Controlled Trial.

BACKGROUND: Adherence to core type 2 diabetes mellitus (T2DM) treatment behaviors is suboptimal, and nonadherence is generally not limited to one treatment behavior. The internet holds promise for programs that aim to improve adherence. We developed a computer-tailored eHealth program for patients with T2DM to improve their treatment adherence, that is, adherence to both a healthy lifestyle and medical behaviors. OBJECTIVE: The objective of this study is to examine the effectiveness of the eHealth program in a randomized controlled trial. METHODS: Patients with T2DM were recruited by their health professionals and randomized into either the intervention group, that is, access to the eHealth program for 6 months, or a waiting-list control group. In total, 478 participants completed the baseline questionnaire, of which 234 gained access to the eHealth program. Of the 478 participants, 323 were male and 155 were female, the mean age was 60 years, and the participants had unfavorable BMI and HbA1c levels on average. Outcome data were collected through web-based assessments on physical activity (PA) levels, caloric intake from unhealthy snacks, and adherence to oral hypoglycemic agents (OHAs) and insulin therapy. Changes to separate behaviors were standardized and summed into a composite change score representing changes in the overall treatment adherence. Further standardization of this composite change score yielded the primary outcome, which can be interpreted as Cohen d (effect size). Standardized change scores observed in separate behaviors acted as secondary outcomes. Mixed linear regression analyses were conducted to examine the effectiveness of the intervention on overall and separate treatment behavior adherence, accommodating relevant covariates and patient nesting. RESULTS: After the 6-month follow-up assessment, 47.4% (111/234) of participants in the intervention group and 72.5% (177/244) of participants in the control group were retained. The overall treatment adherence improved significantly in the intervention group compared with the control group, reflected by a small effect size (d=0.27; 95% CI 0.032 to 0.509; P=.03). When considering changes in separate treatment behaviors, a significant decrease was observed only in caloric intake from unhealthy snacks in comparison with the control group (d=0.36; 95% CI 0.136 to 0.584; P=.002). For adherence to PA (d=-0.14; 95% CI -0.388 to 0.109; P=.27), OHAs (d=0.27; 95% CI -0.027 to 0.457; P=.08), and insulin therapy (d=0.35; 95% CI -0.066 to 0.773; P=.10), no significant changes were observed. These results from the unadjusted analyses were comparable with the results of the adjusted analyses, the per-protocol analyses, and the sensitivity analyses. CONCLUSIONS: Our multibehavior program significantly improved the overall treatment adherence compared with the control group. To further enhance the impact of the intervention in the personal, societal, and economic areas, a wide-scale implementation of our eHealth intervention is suggested. TRIAL REGISTRATION: Netherlands Trial Register NL664; https://www.trialregister.nl/trial/6664.

Decision aids to facilitate decision making around behavior change in the field of health promotion: A scoping review.

OBJECTIVE: To broadly synthesize literature regarding decision aids (DAs) supporting decision making about diet, physical activity, sleeping and substance use a scoping review was performed. METHODS: Multiple sources were used: (1) Scientific literature searches, (2) excluded references from a Cochrane review regarding DAs for treatments and screenings, and (3) results from additional searches. Interventions had to (1) support informed decision making and (2) provide information and help to choose between at least two options. Two researchers screened titles and abstracts. Relevant information was extracted descriptively. RESULTS: Thirty-five scientific articles and four DAs (grey literature) were included. Results were heterogeneous. Twenty-nine (94%) studies described substance use DAs. All DAs offered information and value and/or preference clarification. Many other elements were included (e.g., goal-setting). DA's effects were mixed. Few studies used standardized measures, e.g., decisional conflict (n = 4, 13%). Some positive behavioral effects were reported: e.g., smoking abstinence (n = 1). CONCLUSIONS: This research shows only some positive behavioral effects of DAs. However, studies reported heterogeneous results/outcomes, impeding knowledge synthesis. Areas of improvement were identified, e.g., establishing which intervention elements are effective regarding health behavior decision making. PRACTICE IMPLICATIONS: DAs can potentially be beneficial in supporting people to change health behaviors - especially regarding smoking.

A smoker's choice? Identifying the most autonomy-supportive message frame in an online computer-tailored smoking cessation intervention.

OBJECTIVE: To test the effect of autonomy-supportive message framing on people's perceived autonomy-support while considering the individual need for autonomy as a moderator. Also, to test whether autonomy-supportive message frames - through increased perceived autonomy-support - lead to more self-determined motivation, and increased intention to quit smoking. DESIGN: An online 2(autonomy-supportive; controlling language) × 2(choice; no choice) between-subjects design with control condition (generic advice) with adult smokers intending to quit (N = 626). MAIN OUTCOME: Intention to quit smoking (Theory of Planned Behaviour). MEASURES: Perceived autonomy-support (Virtual Climate Care Questionnaire), need for autonomy (Health Causality Orientations Scale), self-determined motivation (Treatment Self-Regulation Questionnaire), attitudes, social influence, self-efficacy (I-Change Model). RESULTS: Structural equation modelling revealed no significant effect of autonomy-supportive-message frames on perceived autonomy-support or self-determined motivation, neither did the need for autonomy moderate these effects. Self-determined motivation had a positive, significant effect on intention to quit, mediated by attitudes, social influence, and self-efficacy. CONCLUSION: Although message frames did not affect perceived autonomy-support or self-determined motivation, higher self-determined motivation increased intention to quit via attitudes, social influence, and self-efficacy. Before drawing the conclusion that message framing has no effect, we recommend to replicate this study in a real-life setting with smokers more likely to read and process the message frames more attentively.

An Autonomy-Supportive Online Decision Aid to Assist Smokers in Choosing Evidence-Based Cessation Assistance: Development Process and Protocol of a Randomized Controlled Trial.

BACKGROUND: Decision aids (DAs) may be used to facilitate an autonomous, informed decision to cease smoking and promote the uptake of evidence-based cessation assistance (ie, behavioral support, nicotine replacement therapy, or prescription medication). However, knowledge is lacking regarding their effective elements and (cost-)effectiveness. OBJECTIVE: We describe the development process of an online DA (called "VISOR") that helps smokers to choose evidence-based cessation assistance. Additionally, we provide a description of the protocol of an ongoing randomized controlled trial in which the DA containing an explicit value clarification method (VCM) and tailored advice is compared with a DA without an explicit VCM and tailored advice. METHODS: The development of "VISOR" was based on the International Patient Decision Aid Standards guidelines. Viewpoints of end users (collected through 20 interviews with smokers) and clinical and scientific experts (assessed using 2 Delphi studies with 24 scientists and 38 clinicians) were assessed regarding cessation tool decision making and preferred DA content. These findings, together with principles from the Self-Determination Theory, served as input for the development of the online DA. A first DA prototype was alpha-tested in September 2019 and beta-tested for usability in December 2019; feedback was incorporated and resulted in a final version. The final DA contains (1) an information section, (2) an optional knowledge quiz, (3) a brief smoking assessment, (4) intuitive decision, (5) intermediate advice, (6) an explicit VCM, (7) tailored advice, and (8) access information. A randomized controlled trial is currently being conducted to assess the DA's (cost-)effectiveness compared to a DA that does not include the explicit VCM and the tailored advice; specifically, the DA's effect on smoking abstinence, uptake of evidence-based cessation assistance, smoking abstinence mediated through uptake of evidence-based cessation assistance, and decisional conflict are investigated. Participants are randomly allocated to receive access to 1 of the 2 DAs and are asked to complete 5 questionnaires (including the baseline questionnaire) over a period of 12 months. To evaluate the effects of the DA on the outcome measures, logistic and linear regression analyses as well as mediation analyses will be carried out. An economic evaluation will be performed to assess the cost-effectiveness. RESULTS: Data regarding the effect of the VISOR DA are currently being collected, and data collection is expected to be concluded in 2021. CONCLUSIONS: By making use of an iterative process that integrated different stakeholders' perspectives (including end users), we were able to systematically design an evidence-based DA. The study will contribute to the current knowledge regarding smoking cessation DA application, the added value of explicit VCMs, and the effect of behavioral and informed decision-making outcomes. TRIAL REGISTRATION: Netherlands Trial Register NL8270; https://www.trialregister.nl/trial/8270. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/21772.