Dose-Response Relationship of a Web-Based Tailored Intervention Promoting Human Papillomavirus Vaccination: Process Evaluation of a Randomized Controlled Trial.

BACKGROUND: In the Netherlands, human papillomavirus (HPV) vaccination uptake remains low. To improve informed decision making (IDM) and HPV vaccination acceptability, we systematically developed an interactive, web-based tailored intervention to which mothers of Dutch girls were invited to participate. OBJECTIVE: The aim of this study was to provide insight into the intervention's working mechanisms by evaluating (1) program use, (2) program acceptability, and (3) the relationship of program use with program acceptability and intervention effects (ie, dose-response relationship). METHODS: Only mothers from the intervention arm of a randomized controlled trial that assessed the effectiveness of the web-based, tailored intervention were included in this study. They were invited to visit the website of the web-based intervention between baseline (January 2015, just before access to the intervention) and follow up (March 2015, prior to the first HPV vaccination). Indicators for program use were time of website use (ie, duration of intervention exposure) and completeness (ie, proportion of all available web pages visited). HPV vaccination uptake registered by Praeventis was used as the primary outcome. Secondary outcomes were IDM, decisional conflict, and social-psychological determinants of HPV vaccination uptake. RESULTS: Among the 3995 invited mothers, 2509 (62.80%) logged on to the website, 2239 of whom (89.24%) visited at least one page of the intervention components. On average, mothers spent 21.39 minutes (SD 12.41) on the website and completed 50.04% (SD 26.18%) of the website components. Participants rated the website 7.64 (SD 1.39) on a 10-point scale. Program acceptability was significantly associated with completeness (ß=4.36, P<.001), but not with time of website use (ß=-.07, P=.77). Intention-to-treat analysis (N=3995) showed a significant positive effect of completeness on all outcome measures (all P<.003; Bonferroni-corrected α=.05/15 factors), including on HPV vaccination uptake. Time of website use had a significant positive effect on all outcomes (all P<.003), except for uptake (P=.20), risk perception when not vaccinated (P=.14), subjective norms (P=.03), and habit (P=.01). CONCLUSIONS: Program use and acceptability of the intervention were adequate. Completeness was positively associated with acceptability. Furthermore, positive effects (ie, dose-response effects) were found for completeness and time of website use on the mothers' IDM, decisional conflict, and almost all of the social-psychological determinants of HPV vaccination acceptability. In addition, the extent to which mothers completed the intervention had a positive impact on their daughters' vaccination uptake. This indicates that the web-based, tailored intervention fits well with the mothers' needs, and that completeness of use is essential for improving HPV vaccination uptake, acceptability, and IDM. Program use should therefore be promoted. TRIAL REGISTRATION: Netherlands Trial Register NTR4795; https://www.trialregister.nl/trial/4795.

Correction: Effectiveness of a Web-Based Tailored Intervention With Virtual Assistants Promoting the Acceptability of HPV Vaccination Among Mothers of Invited Girls: Randomized Controlled Trial.

[This corrects the article DOI: .].

Effect Evaluation of a Web-Based Coaching Intervention to Support Implementation of Sex Education Among Secondary School Teachers: Randomized Controlled Trial.

BACKGROUND: The quality of implementation is important to ensure the effectiveness of behavioral change interventions in practice. Implementing such programs with completeness and adherence is not an automatic process and may require additional support. In school settings, the support teachers receive during implementation is often limited and appears to fall short when attempting to preserve completeness and adherence in program delivery. With the aim to improve completeness and adherence of teachers' delivery of a sexual health promoting intervention ("Long Live Love" [LLL]) in secondary education, a Web-based e-coach was developed ("lesgevenindeliefde.nl"or"teachinglove.nl"). The effectiveness of the e-coach, as part of a broader implementation strategy, in influencing teachers' implementation was evaluated. OBJECTIVE: This study aimed to report on the effect evaluation to determine the effect of the Web-based e-coach on teacher implementation of a school-based sex education program called LLL and on its determinants. METHODS: A cluster randomized controlled trial (e-coaching vs waiting list control) was conducted with a baseline assessment (T0) and follow-up (T1) 2 weeks after completing the LLL program. A total of 43 schools with 83 teachers participated in the study. In the follow-up, 38 schools participated, 23 in the e-coaching condition with 41 teachers and 15 in the control condition with 26 teachers. Multilevel regression analysis was used to evaluate the effect of the e-coaching website on implementation behavior, namely, completeness and adherence to LLL implementation, and on its determinants. RESULTS: The e-coaching intervention was not found to have an effect on teachers' implementation behavior; teachers assigned to the experimental e-coaching website did not score higher on completeness (P=.60) or adherence (P=.67) as compared with teachers in the control condition. When comparing the 30 teachers who made actual use of the e-coaching website with the 37 teachers who did not, no significant differences were found either (P≥.54). In addition, there was no effect of e-coaching on the determinants of teacher implementation behavior (t67-75≤0.69; P≥.22). CONCLUSIONS: E-coaching was not found to be effective in enhancing completeness of and adherence to LLL by teachers. The lack of effect may be attributed to the intervention content, the limited use, or the study design itself. The e-coaching intervention may not have adequately addressed adherence and completeness of LLL to bring about behavioral change. Furthermore, the e-coaching intervention was not or insufficiently used by teachers. A possible biased sample of motivated, able teachers may have agreed to participate in the study, and a possible "ceiling effect" may have been present because of the high implementation grade. This, however, does not imply that Web-based coaching in itself is an ineffective strategy to promote adherence and completeness of program implementation. A process evaluation is required as follow-up. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number ISRCTN11754581; http://www.isrctn.com/ISRCTN11754581 (Archived by WebCite at http://www.webcitation.org/70C5TUOOh).

Towards local implementation of Dutch health policy guidelines: a concept-mapping approach.

To develop a targeted implementation strategy for a municipal health policy guideline, implementation targets of two guideline users [Regional Health Services (RHSs)] and guideline developers of leading national health institutes were made explicit. Therefore, characteristics of successful implementation of the guideline were identified. Differences and similarities in perceptions of these characteristics between RHSs and developers were explored. Separate concept mapping procedures were executed in two RHSs, one with representatives from partner local health organizations and municipalities, the second with RHS members only. A third map was conducted with the developers of the guideline. All mapping procedures followed the same design of generating statements up to interpretation of results with participants. Concept mapping, as a practical implementation tool, will be discussed in the context of international research literature on guideline implementation in public health. Guideline developers consider implementation successful when substantive components (health issues) of the guidelines, content are visible in local policy practice. RHSs, local organizations and municipalities view the implementation process itself within and between organizations as more relevant, and state that usability of the guideline for municipal policy and commitment by officials and municipal managers are critical targets for successful implementation. Between the RHSs, differences in implementation targets were smaller than between RHSs and guideline developers. For successful implementation, RHSs tend to focus on process targets while developers focus more on the thematic contents of the guideline. Implications of these different orientations for implementation strategies are dealt with in the discussion.

Determinants of Human Papillomavirus Vaccination Intention Among Female Sex Workers in Amsterdam, the Netherlands.

INTRODUCTION: Female sex workers (FSWs) are at risk for human papillomavirus (HPV)-induced diseases but are currently not targeted by the HPV vaccination program in the Netherlands. We explored determinants of their intention to get vaccinated against HPV in case vaccination would be offered to them. METHODS: In 2016, FSWs 18 years and older having a sexually transmitted infection consultation with the Prostitution & Health Center (P&G292) in Amsterdam, either at the clinic or at their working location, were invited to complete a questionnaire assessing sociopsychological determinants of HPV vaccination intention (scale ranging from -3 to +3). Determinants of HPV vaccination intention were assessed with univariable and multivariable linear regression. In addition, we explored the effect of out-of-pocket payment on intention. RESULTS: Between May and September 2016, 294 FSWs participated. The median age was 29 years (interquartile range, 25-37 years). Human papillomavirus vaccination intention was high (mean, 2.0; 95% confidence interval [CI], 1.8-2.2). In multivariable analysis, attitude (ß = 0.6; 95% CI, 0.5-0.7), descriptive norm (ß = 0.2; 95% CI, 0.1-0.3), self-efficacy (ß = 0.2; 95% CI, 0.1-0.3), beliefs (ß = 0.1; 95% CI, 0.0-0.2), and subjective norm (ß = 0.1; 95% CI, 0.0-0.2) seemed to be the strongest predictors of HPV vaccination intention (R = 0.54). Human papillomavirus vaccination intention decreased significantly to a mean of 0.2 when vaccination would require out-of-pocket payment of &OV0556;350. CONCLUSIONS: The HPV vaccination intention among FSWs seems relatively high and is most strongly constituted in attitudinal, normative, and self-efficacy beliefs. Out-of-pocket payment will probably have a negative impact on their HPV vaccination acceptability.

Motivational and contextual determinants of HPV-vaccination uptake: A longitudinal study among mothers of girls invited for the HPV-vaccination.

BACKGROUND: In the Netherlands, HPV-vaccination uptake among 12-year-old girls remains to be lower (61% in 2016) than expected. The present study is about 1) replicating the extent to which social-psychological determinants found in earlier cross-sectional studies explain HPV-vaccination intention, and 2) testing whether HPV-vaccination intention, as well as other social-psychological determinants, are good predictors of future HPV-vaccination uptake in a longitudinal design. METHODS: A random sample of mothers of girls invited for the vaccination in 2015 was drawn from the Dutch vaccination register (Praeventis) (N=36,000) and from three online panels (N=2483). Two months prior to the vaccination of girls, their mothers were requested to complete a web-based questionnaire by letter (Praeventis sample) or by e-mail (panel samples). HPV-vaccination uptake was derived from Praeventis. Backward linear and logistic regression analyses were conducted to examine most dominant predictors of HPV-vaccination intention and uptake, respectively. The total sample used for data analyses consisted of 8062 mothers. Response rates were 18% for the Praeventis sample and 47% for the panel samples. RESULTS: HPV-vaccination intention was best explained by attitude, beliefs, subjective norms, habit, and perceived relative effectiveness of the vaccination; they explained 83% of the variance in HPV-vaccination intention. Intention appeared to be the only stable predictor of HPV-vaccination uptake and explained 43% of the variance in HPV-vaccination uptake. CONCLUSIONS: These results confirm what was found by earlier cross-sectional studies, and provide strong leads for selecting relevant targets in the planning of future communication strategies aiming to improve HPV-vaccination uptake.

A longitudinal study on determinants of HPV vaccination uptake in parents/guardians from different ethnic backgrounds in Amsterdam, the Netherlands.

BACKGROUND: Human papillomavirus (HPV) vaccination coverage in the Netherlands is low (~60%) compared to other childhood vaccinations (>90%), and even lower among ethnic minorities. The aim of this study was to explore the possible impact of ethnicity on the determinants of both HPV vaccination intention and HPV vaccination uptake among parents/guardians having a daughter that is invited for the HPV vaccination. METHODS: In February 2014, parents/guardians living in Amsterdam were invited to complete a questionnaire about social-psychological determinants of their decision making process regarding the HPV vaccination of their daughter and socio-demographic characteristics. This questionnaire was sent approximately one month before the daughter was scheduled to receive her first HPV vaccine dose. Their daughters' HPV vaccination status was retrieved from the national vaccination database. We distinguished four ethnic groups: Dutch (NL), Surinamese, Netherlands Antillean, and Aruban (SNA), Middle-Eastern and North-African (MENA), and Other. To assess the impact of determinants on both intention and uptake, linear and logistic regression analyses were used respectively. Missing data were imputed using multiple imputation by chained equation. RESULTS: In total 1,309 parents/guardians participated (33% participation rate). In all groups we found the mothers' intention to be the strongest predictor of their daughters' HPV vaccination uptake. Explained variance of uptake was highest in the NL-group (pseudo-R2:0.56) and lower in the other ethnic groups (pseudo-R2 varied between 0.23 and 0.29). The lower explained variance can be attributed to the relative large proportion of participants with a positive intention that finally did not go for vaccination in the SNA-group (11%) and MENA-group (30%). Explained variance (R2) of intention varied between 0.66 and 0.77 across ethnic groups, and was best explained by the proximal social-psychological determinants. The strength of association of these determinants with both intention and uptake were largely similar across ethnic groups. CONCLUSION: We conclude that the same determinants should be targeted in the different ethnic groups, although the mode of delivery of the intervention needs to be tailored to the different cultural backgrounds. Further research is needed to explain the observed discrepancy between intention and uptake, especially among parents/guardians in the non-Dutch groups.

Implementation of a guideline for local health policy making by regional health services: exploring determinants of use by a web survey.

BACKGROUND: Previous evaluation showed insufficient use of a national guideline for integrated local health policy by Regional Health Services (RHS) in the Netherlands. The guideline focuses on five health topics and includes five checklists to support integrated municipal health policies. This study explores the determinants of guideline use by regional Dutch health professionals. METHODS: A web survey was send to 304 RHS health professionals. The questionnaire was based on a theory- and research-based framework of determinants of public health innovations. Main outcomes were guideline use and completeness of use, defined as the number of health topics and checklists used. Associations between determinants and (completeness of) guideline use were explored by multivariate regression models. RESULTS: The survey was started by 120 professionals (39%). Finally, results from 73 respondents (24%) were eligible for analyses. All 28 Dutch RHS organizations were represented in the final dataset. About half of the respondents (48%) used the guideline. The average score for completeness of use (potential range 1-10) was 2.37 (sd = 1.78; range 1-7). Knowledge, perceived task responsibility and usability were significantly related to guideline use in univariate analyses. Only usability remained significant in the multivariate model on guideline use. Only self-efficacy accounted for significant proportions of variance in completeness of use. CONCLUSIONS: The results imply that strategies to improve guideline use by RHSs should primarily target perceived usability. Self-efficacy appeared the primary target for improving completeness of guideline use. Methods for targeting these determinants in RHSs are discussed.

Effectiveness of a Web-Based Tailored Intervention With Virtual Assistants Promoting the Acceptability of HPV Vaccination Among Mothers of Invited Girls: Randomized Controlled Trial.

BACKGROUND: In 2010, the human papillomavirus (HPV) vaccination was introduced in the Dutch National Immunization Program for 12-year-old girls, aiming to reduce the incidence of cervical cancer in women. HPV vaccination uptake turned out to be lower than expected: 61% versus 70%, respectively. Mothers were shown to play the most important role in the immunization decision about this vaccination. They had also expressed their need for interactive personal information about the HPV vaccination over and above the existing universal general information. To improve the effectiveness of the existing education about the HPV vaccination, we systematically developed a Web-based tailored intervention with virtual assistants providing mothers of girls to be invited with tailored feedback on their decision making about the HPV vaccination. OBJECTIVE: The aim of this study was to evaluate the effectiveness of the Web-based tailored intervention for promoting HPV vaccination acceptance by means of a randomized controlled trial (RCT). METHODS: Mothers were recruited via the Dutch vaccination register (Praeventis) (n=36,000) and three Web-based panels (n=2483). Those who gave informed consent (N=8062) were randomly assigned to the control (n=4067) or intervention condition (n=3995). HPV vaccination uptake, as registered by Praeventis once the HPV vaccination round was completed, was used as the primary outcome. Secondary outcomes were differential scores across conditions between baseline (before the provided access to the new tailored intervention) and follow-up (just before the first vaccination) regarding the mothers' degree of informed decision making (IDM), decisional conflict, and critical determinants of HPV vaccination uptake among which are intention, attitude, risk perception, and outcome beliefs. RESULTS: Intention-to-treat analysis (N=8062) showed a significant positive effect of the intervention on IDM, decisional conflict, and nearly all determinants of HPV vaccination uptake (P<.001). No effect was found on uptake (P=.60). This may be attributed to the overall high uptake rates in both conditions. Mothers evaluated the intervention as highly positive, including the website as well as the virtual assistants that were used to deliver the tailored feedback. CONCLUSIONS: This computer-tailored intervention has the potential to improve HPV vaccination acceptability and IDM and to decrease decisional conflict among mothers of invited girls. Implications for future research are discussed. TRIAL REGISTRATION: Trialregister.nl NTR4935; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4935 (Archived by WebCite at http://www.webcitation.org/6srT7l9EM).

Unravelling the factors decisive to the implementation of EPODE-derived community approaches targeting childhood obesity: a longitudinal, multiple case study.

BACKGROUND: Implementation of intersectoral community approaches often fails due to a translational gap between the approach as intended and the approach as implemented in practice. Knowledge about the implementation determinants of such approaches is needed to facilitate future implementation processes. METHODS: The implementation of five EPODE-derived intersectoral community approaches was studied longitudinally. Semi-structured interviews were held with 189 community stakeholders from four sectors to elucidate which determinants influenced implementation, and if an to which extent determinants differed across communities, sectors and over time. A framework approach was used to analyze our data. RESULTS: Twenty-two key determinants of implementation were identified. Facilitators named were mostly proximal (stakeholder level), and barriers were mostly distal (context level). Key determinants varied greatly across sectors and over time, especially between the educational & health care sector and the private, welfare & sports sector. Only 'perceived importance of IACO goals' was identified as an universal implementation facilitator. CONCLUSIONS: Striking differences in determinants were found across sectors and over time. Also, stakeholders expressed that possibilities to adapt the approach to the local context were needed to improve implementation. We therefore propose to develop sector- and time specific leads for implementation, which should be approved and amended (over time) by stakeholders. This so-called 'mutual adaptation' allows for the use of both scientific insights and practice-based knowledge, enabling program management and community stakeholders to collaboratively improve their implementation efforts.

Evaluation of a Serious Self-Regulation Game Intervention for Overweight-Related Behaviors ("Balance It"): A Pilot Study.

BACKGROUND: Serious games have the potential to promote health behavior. Because overweight is still a major issue among secondary vocational education students in the Netherlands, this study piloted the effects of "Balance It," a serious self-regulation game intervention targeting students' overweight-related behaviors: dietary intake and physical activity (PA). OBJECTIVE: We aimed to pilot the effects of Balance It on secondary vocational education students' dietary intake and PA. METHODS: In total, 501 secondary vocational education students participated at baseline (intervention: n=250; control: n=251) in this pre-post cluster randomized trial. After 4 weeks, at immediate posttest, 231 students filled in the posttest questionnaire (intervention: n=105; control: n=126). The sample had a mean age of 17.28 (SD 1.26, range 15-21) years, 62.8% (145/231) were female, and 26.8% (62/231) had a non-Dutch background. Body mass index (BMI kg/m2) ranged from 14.4 to 31.1 (mean 21.1, SD 3.3). The intervention and control groups were compared on the primary (behavioral) outcomes of dietary intake (fruit and vegetable consumption, snack consumption, and soft drink consumption) and PA (moderate and vigorous). Additionally, we explored (1) differences between the intervention and control groups in determinants of dietary intake and PA, including attitude, self-efficacy, intention, barrier identification, action planning, and action control, and (2) differences between active (intervention) users and the control group in dietary intake, PA, and associated determinants. RESULTS: After corrections for multiple testing, we did not find significant differences between the intervention group and control group in terms of dietary intake, PA, and determinants of dietary intake and PA. Exploratory research indicated that only 27.6% (29/105) of the intervention group reported actual intervention use (ie, active users). For exploratory reasons, we compared the active users (n=29) with the control group (n=124) and corrected for multiple testing. Results showed that active users' snack consumption decreased more strongly (active users: mean change=-0.20; control group: mean change=-0.08; beta=-0.36, P=.01, R2 change=.05), and their use of active transport had a stronger increase (active users: mean change=0.92; control group=-0.12; beta=1.58, P=.02, R2 change=.03) than the control group. Results also revealed significant differences in action planning (active users: mean change=0.42; control group: mean change=0.07; beta=0.91, P=.01, R2 change=.04) and action control (active users: mean change=0.63; control group: mean change=-0.05; beta=1.25, P=.001, R2 change=.08) in terms of unhealthy eating. CONCLUSIONS: The Balance It intervention did not show favorable effects on dietary intake and PA compared to the control condition. However, only a small number of people in the intervention condition actually used Balance It (27.6%). Exploratory analyses did suggest that, if used as planned, Balance It could contribute to changing dietary intake and PA behaviors, albeit it remains debatable whether this would be sufficient to prevent overweight.

A stitch in time saves nine? A repeated cross-sectional case study on the implementation of the intersectoral community approach Youth At a Healthy Weight.

BACKGROUND: The implementation of programs complex in design, such as the intersectoral community approach Youth At a Healthy Weight (JOGG), often deviates from their application as intended. There is limited knowledge of their implementation processes, making it difficult to formulate sound implementation strategies. METHODS: For two years, we performed a repeated cross-sectional case study on the implementation of a JOGG fruit and water campaign targeting children age 0-12. Semi-structured observations, interviews, field notes and professionals' logs entries were used to evaluate implementation process. Data was analyzed via a framework approach; within-case and cross-case displays were formulated and key determinants identified. Principles from Qualitative Comparative Analysis (QCA) were used to identify causal configurations of determinants per sector and implementation phase. RESULTS: Implementation completeness differed, but was highest in the educational and health care sector, and higher for key than additional activities. Determinants and causal configurations of determinants were mostly sector- and implementation phase specific. High campaign ownership and possibilities for campaign adaptation were most frequently mentioned as facilitators. A lack of reinforcement strategies, low priority for campaign use and incompatibility of own goals with campaign goals were most often indicated as barriers. DISCUSSION: We advise multiple 'stitches in time'; tailoring implementation strategies to specific implementation phases and sectors using both the results from this study and a mutual adaptation strategy in which professionals are involved in the development of implementation strategies. CONCLUSION: The results of this study show that the implementation process of IACOs is complex and sustainable implementation is difficult to achieve. Moreover, this study reveals that the implementation process is influenced by predominantly sector and implementation phase specific (causal configurations of) determinants.

Vaccination decision-making of immigrant parents in the Netherlands; a focus group study.

BACKGROUND: Although the vaccination coverage in most high income countries is high, variations in coverage rates on the national level among different ethnic backgrounds are reported. A qualitative study was performed to explore factors that influence decision-making among parents with different ethnic backgrounds in the Netherlands. METHODS: Six focus groups were conducted with 33 mothers of Moroccan, Turkish and other ethnic backgrounds with at least one child aged 0-4 years. Data were analysed using thematic analysis. RESULTS: Parents had a positive attitude towards childhood vaccination and a high confidence in the advices of Child Vaccine Providers (CVPs). Vaccinating their children was perceived as self-evident and important. Parents do perceive a language barrier in understanding the provided NIP-information, and they had a need for more NIP- information, particularly about the targeted diseases. Another barrier parents perceived was the distance to the Child Welfare Center (CWC), especially when the weather was bad and when they had no access to a car. CONCLUSION: More information about targeted diseases and complete information regarding benefits and drawbacks of the NIP should be provided to the parents. To fulfill parents' information needs, NIP information meetings can be organized at CWCs in different languages. Providing NIP information material in Turkish, Arabic and Berber language with easy access is also recommended. Providing information tailored to these parents' needs is important to sustain high vaccination participation, and to ensure acceptance of future vaccinations.

Cultural, social and intrapersonal factors associated with clusters of co-occurring health-related behaviours among adolescents.

BACKGROUND: Adverse health-related behaviours (HRBs) have been shown to co-occur in adolescents. Evidence lacks on factors associated with these co-occurring HRBs. The Theory of Triadic Influence (TTI) offers a route to categorize these determinants according to type (social, cultural and intrapersonal) and distance in the causal pathway (ultimate or distal). Our aims were to identify cultural, social and intrapersonal factors associated with co-occurring HRBs and to assess the relative importance of ultimate and distal factors for each cluster of co-occurring HRBs. METHODS: Respondents concerned a random sample of 898 adolescents aged 12-18 years, stratified by age, sex and educational level of head of household. Data were collected via face-to-face computer-assisted interviewing and internet questionnaires. Analyses were performed for young (12-15 years) and late (16-18 years) adolescents regarding two and three clusters of HRB, respectively. RESULTS: For each cluster of HRBs (e.g. smoking, delinquency), associated factors were found. These accounted for 27 to 57% of the total variance per cluster. Factors came in particular from the intrapersonal stream of the TTI at the ultimate level and the social stream at the distal level. Associations were strongest for parenting practices, risk behaviours of friends and parents and self-control. CONCLUSION: Results of this study confirm that it is possible to identify a selection of cultural, social and intrapersonal factors associated with co-occurring HRBs among adolescents.

Disease detection or public opinion reflection? Content analysis of tweets, other social media, and online newspapers during the measles outbreak in The Netherlands in 2013.

BACKGROUND: In May 2013, a measles outbreak began in the Netherlands among Orthodox Protestants who often refuse vaccination for religious reasons. OBJECTIVE: Our aim was to compare the number of messages expressed on Twitter and other social media during the measles outbreak with the number of online news articles and the number of reported measles cases to answer the question if and when social media reflect public opinion patterns versus disease patterns. METHODS: We analyzed measles-related tweets, other social media messages, and online newspaper articles over a 7-month period (April 15 to November 11, 2013) with regard to topic and sentiment. Thematic analysis was used to structure and analyze the topics. RESULTS: There was a stronger correlation between the weekly number of social media messages and the weekly number of online news articles (P<.001 for both tweets and other social media messages) than between the weekly number of social media messages and the weekly number of reported measles cases (P=.003 and P=.048 for tweets and other social media messages, respectively), especially after the summer break. All data sources showed 3 large peaks, possibly triggered by announcements about the measles outbreak by the Dutch National Institute for Public Health and the Environment and statements made by well-known politicians. Most messages informed the public about the measles outbreak (ie, about the number of measles cases) (93/165, 56.4%) followed by messages about preventive measures taken to control the measles spread (47/132, 35.6%). The leading opinion expressed was frustration regarding people who do not vaccinate because of religious reasons (42/88, 48%). CONCLUSIONS: The monitoring of online (social) media might be useful for improving communication policies aiming to preserve vaccination acceptability among the general public. Data extracted from online (social) media provide insight into the opinions that are at a certain moment salient among the public, which enables public health institutes to respond immediately and appropriately to those public concerns. More research is required to develop an automatic coding system that captures content and user's characteristics that are most relevant to the diseases within the National Immunization Program and related public health events and can inform official responses.

Effects of transfer-oriented curriculum on multiple behaviors in the Netherlands.

Many school health promotion curricula address a single health behavior, without paying attention to potential learning effects in associated behavioral domains. We developed an innovative curriculum about smoking and safe sex that also focused on promoting students' transfer of knowledge, skills and attitudes to other domains. In a quasi-experimental study involving 1107 students (Grades 7 and 8) in the Netherlands, the curriculum was compared with regular lessons about smoking and safe sex. The central research questions were to what extent the transfer-oriented curriculum: (i) had effects on psychosocial determinants and behaviors in the domains of smoking and safe sex, (ii) had effects on determinants and behaviors in three domains about which no lessons were taught (consumption of alcohol, fruit and breakfast). Multi-level analyses showed that the answer to both questions is positive. The results indicate that a transfer approach may have surplus value over the classic domain-specific approach and warrant further elaboration in the future.

A primer on the use of cluster analysis or factor analysis to assess co-occurrence of risk behaviors.

OBJECTIVE: The aim of this paper is to provide a guideline to a universal understanding of the analysis of co-occurrence of risk behaviors. The use of cluster analysis and factor analysis was clarified. METHOD: A theoretical introduction to cluster analysis and factor analysis and examples from literature were provided. A representative sample (N=4395) of the Dutch population, aged 16-40 and participating from fall 2005 to spring 2006, was used to illustrate the use of both techniques in assessing the co-occurrence of risk behaviors. RESULTS: Whereas cluster analysis techniques serve to focus on particular clusters of individuals showing the same behavioral pattern, factor analysis techniques are used to assess possible groups of interrelated health-risk behaviors that can be explained by an unknown common source. Choice between the techniques partly depends on the research question and the aim of the research, and has different implications for inferences and policy. CONCLUSION: By integrating theory and results from an illustrative example, a guideline has been provided that contributes towards a systematic approach in the assessment of co-occurrence of risk behaviors. Following this guideline, a better comparison between outcomes from various studies is expected, leading to improved effectiveness of multiple behavior change interventions.

Towards a measurement instrument for determinants of innovations.

OBJECTIVE: To develop a short instrument to measure determinants of innovations that may affect its implementation. DESIGN: We pooled the original data from eight empirical studies of the implementation of evidence-based innovations. The studies used a list of 60 potentially relevant determinants based on a systematic review of empirical studies and a Delphi study among implementation experts. Each study used similar methods to measure both the implementation of the innovation and determinants. Missing values in the final data set were replaced by plausible values using multiple imputation. We assessed which determinants predicted completeness of use of the innovation (% of recommendations applied). In addition, 22 implementation experts were consulted about the results and about implications for designing a short instrument. SETTING: Eight innovations introduced in Preventive Child Health Care or schools in the Netherlands. PARTICIPANTS: Doctors, nurses, doctor's assistants and teachers; 1977 respondents in total. RESULTS: The initial list of 60 determinants could be reduced to 29. Twenty-one determinants were based on the pooled analysis of the eight studies, seven on the theoretical expectations of the experts consulted and one new determinant was added on the basis of the experts' practical experience. CONCLUSIONS: The instrument is promising and should be further validated. We invite researchers to use and explore the instrument in multiple settings. The instrument describes how each determinant should preferably be measured (questions and response scales). It can be used both before and after the introduction of an innovation to gain an understanding of the critical change objectives.

Examining the relationship between completeness of teachers' implementation of the Krachtvoer healthy diet programme and changes in students' dietary intakes.

OBJECTIVE: The goal of the current study was to examine if the completeness of programme implementation and the completeness of implementation of specific programme elements of the Dutch school-based healthy diet promotion programme Krachtvoer are related to short- and longer-term changes in students' fruit, sweets and breakfast intakes. DESIGN: Data on students' dietary intakes were collected 1­4 weeks and 6 months after programme implementation. Teachers filled in a logbook on programme implementation after each lesson. The relationships between changes in students' dietary intakes and completeness of implementation of the programme and of specific programme elements were tested using mixed linear regression analyses. SETTING: Thirteen Dutch prevocational schools. SUBJECTS: Eight hundred and seventy-six of the 1117 participating students and eighteen of the twenty-two participating teachers. RESULTS: Completeness of programme implementation was positively related to an increase in fruit consumption in the short term. Completeness of implementation of food exposure activities and a practical lesson on advertisements were related to an increase in fruit consumption in the short as well as the longer term. No such relationships were found for sweets and breakfast consumption. CONCLUSIONS: Our results indicate that efforts should be made to help teachers implement the programme as fully as possible.

Exploring facilitating factors and barriers to the nationwide dissemination of a Dutch school-based obesity prevention program "DOiT": a study protocol.

BACKGROUND: The evidence-based Dutch Obesity Intervention in Teenagers (DOiT) program is a school-based obesity prevention program for 12 to 14-year olds attending the first two years of prevocational education. This paper describes the study protocol applied to evaluate (a) the nationwide dissemination process of DOiT in the Netherlands, and (b) the relationship between quality of implementation and effectiveness during nationwide dissemination of the program in the Netherlands. METHODS: In order to explore facilitating factors and barriers for dissemination of DOiT, we monitored the process of adoption, implementation and continuation of the DOiT program among 20 prevocational schools in the Netherlands. The study was an observational study using qualitative (i.e. semi-structured interviews) and quantitative methods (i.e. questionnaires and logbooks). Eight process indicators were assessed: recruitment, context, reach, dosage, fidelity, satisfaction, effectiveness and continuation. All teachers, students and parents involved in the implementation of the program were invited to participate in the study. As part of the process evaluation, a cluster-controlled trial with ten control schools was conducted to evaluate the effectiveness of the program on students' anthropometry and energy balance-related behaviours and its association with quality of implementation. DISCUSSION: The identified impeding and facilitating factors will contribute to an adjusted strategy promoting adoption, implementation and continuation of the DOiT program to ensure optimal use and, thereby, prevention of obesity in Dutch adolescents. TRIAL REGISTRATION: Current Controlled Trials ISRCTN92755979.