The modified Manchester Fothergill procedure compared with vaginal hysterectomy with low uterosacral ligament suspension in patients with pelvic organ prolapse: long-term outcome.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to compare the long-term outcome between vaginal hysterectomy with low uterosacral ligament suspension (VH) and the modified Manchester Fothergill procedure (MF) as surgical treatment in patients with pelvic organ prolapse (POP). We hypothesize that MF is non-inferior to VH in the long term. METHODS: In this single-center retrospective cohort study patients who underwent MF or VH for primary apical compartment prolapse between 2003 and 2009 were eligible for inclusion. The primary outcome was subjective recurrence of POP. Secondary outcomes included number and type of reinterventions, time to reintervention and the degree of complaints. RESULTS: One hundred sixty of 398 patients (53 MF, 107 VH) returned the questionnaires (40%). The mean follow-up was 12.97 years for MF and 13.24 years for VH (p = 0.38). There were similar rates of subjective POP recurrence (51% in both groups). The reintervention rate in the MF group was higher but reached no statistical significance [19/53 (36%) versus 29/107 (27%), p = 0.26]. Kaplan-Meier curve showed no statistically significant difference in risk of reintervention after MF at the maximum follow-up of 16.5 years [HR 1.830 (95% CI 0.934-3.586), p = 0.08]. The mean time to reintervention was 3 years shorter in the MF group (p = 0.03). CONCLUSIONS: The subjective recurrence after MF is similar to VH in treatment of POP at the long term. MF appears to be non-inferior to VH when comparing the risk of reintervention. However, the small sample size precludes a definitive conclusion of non-inferiority, and future studies are needed.

The effects of an online decision aid to support the reproductive decision-making process of genetically at risk couples-A pilot study.

Couples at risk of transmitting a genetic disease to their offspring may experience doubts about their reproductive options. This study examines the effects of an online decision aid (DA) on the (joint) reproductive decision-making process of couples (not pregnant at time of inclusion) at risk of transmitting a genetic disease to their offspring. The primary outcome is decisional conflict, and secondary outcomes are knowledge, realistic expectations, deliberation, joint informed decision-making, and decisional self-efficacy. These outcomes were measured with a pretest-posttest design: before use (T0), after use (T1), and 2 weeks after use (T2) of the decision aid (DA). Usability of the DA was assessed at T1. Paired sample t-tests were used to compute differences between baseline and subsequent measurements. The comparisons of T0-T1 and T0-T2 indicate a significant reduction in mean decisional conflict scores with stronger effects for participants with high baseline decisional conflict scores. Furthermore, use of the DA led to increased knowledge, improved realistic expectations, and increased levels of deliberation, with higher increase in participants with low baseline scores. Decision self-efficacy only improved for participants with lower baseline scores. Participants indicated that the information in the DA was comprehensible and clearly organized. These first results indicate that this online DA is an appropriate tool to support couples at risk of transmitting a genetic disease and a desire to have (a) child(ren) in their reproductive decision-making process.

The role of knowledge, risk perceptions, and cues to action among Iranian women concerning cervical cancer and screening: a qualitative exploration.

BACKGROUND: Iran has a low incidence but higher rate of death from cervical cancer (CC). The country is in the process of implementing an organized screening program including HPV testing and cytology. Studies show high dropout in continued testing among eligible women. This qualitative study aimed to explore women's awareness regarding CC and CC testing and the role of knowledge, perceived risk, and cues to action in this process. METHOD: Through a qualitative study based on the Framework Method, we recruited 81 women aged 25-65 who participated in 15 focus group discussions (FGDs) and two in-depth interviews in Tehran. The interviewees were selected purposefully during January to May 2015 from households belonging to different socioeconomic classes until data saturation. The data were acquired through 11 open-ended questions and 32 related probe questions. All interviews were transcribed and independently analyzed by two researchers (Kappa and agreement testing respectively: 0.77, 97.11%). RESULTS: The coded texts were categorized under three themes and 13 subthemes. The three thematic areas referred to knowledge, cues to action, and perceived risks regarding CC and screening. The results showed that women had limited and unspecified knowledge about CC and screening, compounded by misconceptions regarding infection and cancer prevention measures. Social and cultural barriers hindered proper communication between health system/providers and clients and within communities on subjects related to CC and screening. The perceived risk of getting CC was low because of overestimating the role of hereditary factors for CC, difficulty in differentiating between cancer and sexually transmitted infections (STI), and the absence of visible symptoms. CONCLUSION: The results indicate a strong need to invest more efforts to improve health education and communication in the current national health program to promote awareness of the need to screen for CC through, for example, establishing correct knowledge and risk perceptions among women. In addition, this intervention should address women's social environment in order to prevent misconceptions being communicated to women.

Childhood sun safety at different ages: relations between parental sun protection behavior towards their child and children's own sun protection behavior.

BACKGROUND: Sunburns during childhood are strongly associated with development of melanoma in later life. While parents play an important role in children's sun protection, insight in possible shifts in behavioral responsibility from parents towards their children and the possible effect of children's sex is important for targeting sun safety interventions throughout childhood and adolescence. METHODS: This cross-sectional survey study was conducted among a representative sample of Dutch parents (N = 1053) of children aged between 4 and 13 years old. Questionnaires measured both parental and children's own sun safety behavior during planned (e.g. going to the beach) and incidental (e.g. bycicling) sun exposure situations. Analyses of variance were used to test for age group differences and linear regression models were computed to detect behavioral shifts in executive behavior. RESULTS: Parents applied all sun safety behaviors (i.e. sunscreen use, wearing UV-protective clothing and seeking shade) more often on younger children, except for supportive behavior (facilitating children's own sun safety behavior), which remained relatively stable over the years. Older children and girls were more likely to execute sun safety behaviors themselves. A behavioral shift was found in wearing UV-protective clothing during planned situations among 11 year old children. For other behaviors, shifts were predicted after the age of 13. CONCLUSIONS: Older children execute sun safety behaviors more often than younger children, although they still largely depend on their parents' protection. Specific attention for boys in the primary school years, and for both boys and girls in the years adjacent to adolescence is warranted in skin cancer prevention interventions.

Online decision support for persons having a genetic predisposition to cancer and their partners during reproductive decision-making.

A nationwide pretest-posttest study was conducted in all clinical genetic centres in the Netherlands, to evaluate the effects of an online decision aid to support persons who have a genetic predisposition to cancer and their partners in making an informed decision regarding reproductive options. Main outcomes (decisional conflict, knowledge, realistic expectations, level of deliberation, and decision self-efficacy) were measured before use (T0), immediately after use (T1), and at 2 weeks (T2) after use of the decision aid. Paired sample t tests were used to compute differences between the first and subsequent measurements. T0-T1 and T0-T2 comparisons indicate a significant reduction in mean decisional conflict scores with stronger effects for participants with high baseline decisional conflict. Furthermore, use of the decision aid resulted in increased knowledge levels and improved realistic expectations. Level of deliberation only increased for participants with lower baseline levels of deliberation. Decision self-efficacy increased for those with low baseline scores, whereas those with high baseline scores showed a reduction at T2. It can be concluded that use of the decision aid resulted in several positive outcomes indicative of informed decision-making. The decision aid is an appropriate and highly appreciated tool to be used in addition to reproductive counseling.

From action planning and plan enactment to fruit consumption: moderated mediation effects.

OBJECTIVES: Sufficient fruit consumption is beneficial for a healthy live. While many Dutch adults intent to eat the recommended amount of fruit, only 5-10% of the population actually adheres to the recommendation. One mechanism that can help to narrow this gap between intention and actual fruit consumption is action planning. However, action planning is only assumed to be effective if plans are enacted. This study assessed which action plans are made and enacted, and further aimed to investigate two main hypotheses: 1. the effect of action planning (at T1) on fruit consumption (at T2) is mediated by plan enactment (at T3); 2. positive intentions (2a), high self-efficacy (2b) and a strong habit to eat fruit (2c) enhance the mediation of plan enactment, whereas a strong habit to eat snacks (2d) hinders the mediation of plan enactment. METHODS: This study was a self-reported longitudinal online survey study. A total of 428 participants filled in a survey, measuring demographic factors (e.g. gender, age, education level), several socio-cognitive constructs (i.e. attitudes, self-efficacy, habit, action planning, plan enactment), and fruit consumption, at three points in time (baseline, after 1 month, and after 3 months). Mediation and moderated mediation analyses were used to investigate the planning-plan enactment- fruit consumption relationship. RESULTS: Up to 70% of the participants reported to have enacted their T1 action plans at T2. Action planning on fruit consumption was fully mediated by plan enactment (Hypothesis 1). All four proposed moderators (i.e. intention, self-efficacy, habit to consume fruit, and habit to consume snacks) significantly influenced the mediation (Hypotheses 2a-2d). Mediation of plan enactment was only present with high levels of intention, high levels of self-efficacy, strong habits to eat fruit, and weak habits to eat snacks. CONCLUSION: The study suggests the importance of plan enactment for fruit consumption. Furthermore, it emphasizes the necessity of facilitating factors. High levels of intention, self-efficacy and a strong habit to consume fruit clearly aid the enactment of action plans. This suggests that when these factors are moderately low, plan enactment may fail and thus an intervention may require first steps to foster these moderating factors.

Effects of preparatory and action planning instructions on situation-specific and general fruit and snack intake.

Evidence to date suggests heterogeneity in the effects of implementation intentions on health behaviour, including diet. Additional variables and study designs may impact on their effectiveness. Preparatory action, such as making sure fruits are available for consumption, may be an important additional variable. Likewise, most implementation intention research has focused on changes in general intake, yet implementation intention instructions typically require participants to consider behaviour in specific situations. Little is known on how implementation intentions impact situation-specific intake. The present study sought to add to the evidence base by comparing (1) the effects of action planning instructions versus preparatory planning instructions on (2) both situation-specific (as formulated in the implementation intention instruction) and general intake of fruits and in-between meal snack intake frequency. Fruit intake was assessed in average pieces per day, whereas snacking intake was assessed as average frequency in days per week. Using non-probability sampling, 243 undergraduate students who intended to have a healthy diet were randomized to either a standard information control condition, an action planning condition, or a preparatory planning condition. Planning manipulations were based on previous work. Two weeks later, general and situation-specific intake was assessed again in 181 participants. Data were analysed using 2 (time) x 3 (conditions) analyses of variance. Results showed that both planning manipulations were successful in decreasing snack intake frequency in the specified situation, with larger effect sizes for the action planning condition than for the preparatory planning condition. No effects were found on general snack intake frequency or fruit intake. Future planning interventions should more explicitly compare changes in situational and general intake, as well as simultaneously assessed decreases in unhealthy intake and increases in healthy intake.

Sun protection during snow sports: an analysis of behavior and psychosocial determinants.

This study investigated sun protective behavior during snow sports and its psychosocial determinants. A longitudinal study was conducted among 418 Dutch adults who planned to go on a ski holiday. Participants were asked to fill in a questionnaire before and after their ski trip. In the baseline questionnaire several psychosocial factors were measured (i.e. knowledge, risk perception, worry, attitude, social influence, self-efficacy and intention). At follow-up, sunscreen use and frequency of sunburns were measured. The results showed that, despite their generally high intention, a substantial part of the respondents (40%) did not use sunscreen adequately during their ski holiday. Furthermore, one-fourth of the respondents reported at least one sunburn during their ski holiday. Men and younger respondents used sunscreen less frequently and were sunburnt more often. Sunscreen use was predicted by a positive attitude, high self-efficacy levels, high intention, high knowledge and high perceived risk. The background and psychosocial variables explained 32% of the total variance of sunscreen use. Suggestions for future research and interventions are discussed.

Influencing feelings of cancer risk: direct and moderator effects of affectively laden phrases in risk communication.

Evidence is accumulating for the importance of feelings of risk in explaining cancer preventive behaviors, but best practices for influencing these feelings are limited. This study investigated the direct and moderational influence of affectively laden phrases in cancer risk messages. Two experimental studies were conducted in relation to different cancer-related behaviors--sunbed use (n = 112) and red meat consumption (n = 447)--among student and nonstudent samples. Participants were randomly assigned to one of two conditions: (a) a cognitive message using cognitively laden phrases or (b) an affective message using affectively laden phrases. The results revealed that affective phrases did not directly influence feelings of risk in both studies. Evidence for a moderational influence was found in Study 2, suggesting that affective information strengthened the relation between feelings of risk and intention (i.e., participants relied more on their feelings in the decision-making process after exposure to affective information). These findings suggest that solely using affective phrases in risk communication may not be sufficient to directly influence feelings of risk and other methods need to be explored in future research. Moreover, research is needed to replicate our preliminary indications for a moderational influence of affective phrases to advance theory and practice.

Is Action Planning Helpful for Smoking Cessation? Assessing the Effects of Action Planning in a Web-Based Computer-Tailored Intervention.

BACKGROUND AND OBJECTIVES: The aim of this study was to examine the efficacy of a web-assisted computer-tailored smoking cessation intervention, an action planning (AP) intervention in which potential quitters were encouraged to form action plans (e.g., plan a quit date) and execute them (e.g., remove ashtrays). We also investigated whether the AP intervention resulted in more AP and plan execution than a similar, control intervention without the supplementary AP component. METHODS: In a randomized controlled trial, the AP intervention (N = 977) was compared with the control intervention (N = 1,005) in terms of self-reported continued abstinence (CA) and point prevalence abstinence (PPA) six months after baseline. AP, plan execution, and opinion of the intervention were measured one month after baseline. RESULTS: Complete-case logistic regression analysis showed that the AP intervention had a significant effect on CA (OR = 2.01; CI 1.08-3.84, p = .02), whereas intention-to-treat analysis showed a borderline significant effect (OR = 1.68; CI .96-2.92, p = .07). Sixteen percent of the experimental group achieved CA compared to 10% of the control group. The AP intervention had no effect on PPA. The experimental group also showed significantly more AP and plan execution at one month. Execution of plans was associated with smoking cessation. CONCLUSIONS: The effects of the AP intervention on CA, AP, and execution of plans were encouraging. The potential for widespread use of web-based interventions means that even small behavioral effects may have an impact on public health. We recommend that the intervention be intensified and improved.

E-loyalty towards a cancer information website: applying a theoretical framework.

OBJECTIVE: To provide more insight into user perceptions related to e-loyalty towards a cancer information website. This is needed to assure adequate provision of high quality information during the full process of cancer treatment-from diagnosis to after care-and an important first step towards optimizing cancer information websites in order to promote e-loyalty. METHODS: Participants were cancer patients (n = 63) and informal caregivers (n = 202) that visited a website providing regional information about cancer care for all types of cancer. Subsequently, they filled out a questionnaire assessing e-loyalty towards the website and user perceptions (efficiency, effectiveness, active trust and enjoyment) based on a theoretical framework derived from the field of e-commerce. A structural equation model was constructed to test the relationships between user perceptions and e-loyalty. RESULTS: Participants in general could find the information they were looking for (efficiency), thought it was relevant (effectiveness) and that they could act upon it (active trust) and thought the visit itself was pleasant (enjoyment). Effectiveness and enjoyment were both positively related with e-loyalty, but this was mediated by active trust. Efficiency was positively related with e-loyalty. The explained variance of e-loyalty was high (R(2) = 0.70). CONCLUSIONS: This study demonstrates that the importance of user perceptions is not limited to fields such as e-commerce but is also present within the context of cancer information websites. The high information need among participants might explain the positive relationship between efficiency and e-loyalty. Therefore, cancer information websites need to foster easy search and access of information provided.

Predicting fruit consumption: the role of habits, previous behavior and mediation effects.

BACKGROUND: This study assessed the role of habits and previous behavior in predicting fruit consumption as well as their additional predictive contribution besides socio-demographic and motivational factors. In the literature, habits are proposed as a stable construct that needs to be controlled for in longitudinal analyses that predict behavior. The aim of this study is to provide empirical evidence for the inclusion of either previous behavior or habits. METHODS: A random sample of 806 Dutch adults (>18 years) was invited by an online survey panel of a private research company to participate in an online study on fruit consumption. A longitudinal design (N = 574) was used with assessments at baseline and after one (T2) and two months (T3). Multivariate linear regression analysis was used to assess the differential value of habit and previous behavior in the prediction of fruit consumption. RESULTS: Eighty percent of habit strength could be explained by habit strength one month earlier, and 64% of fruit consumption could be explained by fruit consumption one month earlier. Regression analyses revealed that the model with motivational constructs explained 41% of the behavioral variance at T2 and 38% at T3. The addition of previous behavior and habit increased the explained variance up to 66% at T2 and to 59% at T3. Inclusion of these factors resulted in non-significant contributions of the motivational constructs. Furthermore, our findings showed that the effect of habit strength on future behavior was to a large extent mediated by previous behavior. CONCLUSIONS: Both habit and previous behavior are important as predictors of future behavior, and as educational objectives for behavior change programs. Our results revealed less stability for the constructs over time than expected. Habit strength was to a large extent mediated by previous behavior and our results do not strongly suggest a need for the inclusion of both constructs. Future research needs to assess the conditions that determine direct influences of both previous behavior and habit, since these influences may differ per type of health behavior, per context stability in which the behavior is performed, and per time frame used for predicting future behavior.

The importance of affectively-laden beliefs about health risks: the case of tobacco use and sun protection.

Affect is gaining prominence in health behavior research. However, little is known about the relative influence on behavior of specific affectively-laden beliefs about health risks (affective likelihood, worry, anticipated regret), particularly in comparison to cognitive likelihood beliefs. We investigated this issue in relation to two very different cancer-related behaviors. In two prospective studies [tobacco use (N = 1,088); sunscreen use (N = 491)], hierarchical linear and logistic regression analyses revealed that affectively-laden risk beliefs predicted intentions and behaviors more strongly than cognitive likelihood beliefs. Cognitive likelihood contributed independently only for sunscreen use intentions. Smoking-related outcomes were most strongly associated with anticipated regret. Sunscreen-related outcomes were most strongly associated with affective likelihood. Affectively-laden beliefs might be stronger predictors of some cancer-related behaviors than traditional cognitive likelihood measures. Including affective aspects of health risk beliefs in health behavior interventions and theoretical models, including investigating their interrelationships in different behavioral contexts, could advance both theory and practice.

Predicting automaticity in exercise behaviour: the role of perceived behavioural control, affect, intention, action planning, and behaviour.

BACKGROUND: Habit formation has been proposed as a way to maintain behaviour over time. PURPOSE: Recent evidence suggests that constructs additional to repeated performance may predict physical automaticity, but no research has yet explored possible direct impacts of intention, planning, affect, and perceived behavioural control (PBC) on automaticity. METHOD: In a prospective study over a 2-week period amongst 406 undergraduate students (M age = 21.5 years [SD = 2.59], 27.4 % males), we investigated main and interaction effects of past exercise behaviour, PBC, intention, planning, and affect on exercise automaticity. RESULTS: Results showed that - controlling for past behaviour - PBC, affect, and planning were significant and positive predictors of exercise automaticity. Decomposing a significant interaction between PBC and planning when to exercise revealed that planning became less predictive of exercise automaticity at higher levels of PBC. CONCLUSION: Findings show that exercise automaticity is predicted by repeated performance and social-cognitive constructs. Further, interactions between social-cognitive predictors may be different for behavioural automaticity than for behavioural frequency.

Considerations of breast cancer survivors to return for embryo transfer after fertility preservation: A qualitative study.

OBJECTIVE: To gain insight into the considerations of breast cancer survivors to return or not for embryo transfer after the use of fertility preservation. STUDY DESIGN: This is a qualitative study with semi-structured interviews. The interviews were planned until saturation of themes had been achieved. Content analysis was used to analyze the data. Sixteen out of 35 approached women took part in this study. Interviews were conducted with women who had oocytes or embryos cryopreserved prior to breast cancer treatment at the Maastricht University Medical Center between 2008 and 2016. All women who had cryopreservation more than two years ago were invited for the interviews. Women who had recurrence of disease were excluded. In the interviews we hypothesized the situation 'suppose the menses would have been recovered completely' for women who still had chemotherapy-induced menopause or used an GnRH (Gonadotropin-releasing hormone) analogue. RESULTS: Most women had a strong intrinsic motivation to pursue natural conception over the use of earlier cryopreserved oocytes or embryos. Time pressure was the most mentioned consideration to use cryopreserved oocytes or embryos. The wish to use pre-implantation genetic testing (PGT) in the presence of a germline BRCA1/2 mutation was another consideration to opt for embryo transfer. Furthermore, the physician's advice was an important motivation to choose for either natural conception or the use of cryopreserved oocytes or embryos. CONCLUSION: Multiple considerations influence women's decision making on the mode of conception after breast cancer. Although it concerned a single-center study in a highly-selected population, insight into these considerations can help physicians to address these important topics in counseling these women.

Internet guidance in oncology practice: determinants of health professionals' Internet referral behavior.

BACKGROUND: Many cancer patients turn to the Internet to obtain information on their disease. This digital quest is often motivated by a perceived discrepancy between the information received from health professionals and patients' actual informational needs. This discrepancy may be reduced by supplementing standard patient education with reliable online information sources. This study investigates health professionals' opinions, cognitions, and behavior regarding referring cancer patients to Internet-based information. METHODS: Online and written questionnaires were distributed among Dutch oncology nurses and medical specialists, measuring perception of patients' informational needs, prompted and unprompted Internet referral, and socio-cognitive factors regarding referral behavior. RESULTS: Health professionals (N = 130) positively appraised Internet use among cancer patients. Despite recognizing patients' needs for additional information (84%) and need for referral to reliable websites (67%), only 20% frequently referred patients to Internet-based information. Prompted Internet referral was higher (64%). Motives for nonreferral included unfamiliarity with websites and uncertainty about information quality. Intentions towards future referral were moderate to high. To translate intentions into referral, health professionals need reminder tools and information on reliability and content of websites. Cognitive determinants of referral behavior included professionals' attitude, self-efficacy, and intentions regarding referral. CONCLUSIONS: Recognition of patients' information needs does not culminate in Internet referral among health professionals in cancer care. High intentions to change, however, indicate good prospects for future referral. This study yields valuable insights into behavioral determinants of health professionals' Internet referral behavior. Targeting determinants and barriers in future interventions will provide opportunities for optimization of educational practices.

The use of a proactive dissemination strategy to optimize reach of an internet-delivered computer tailored lifestyle intervention.

BACKGROUND: The use of reactive strategies to disseminate effective Internet-delivered lifestyle interventions restricts their level of reach within the target population. This stresses the need to invest in proactive strategies to offer these interventions to the target population. The present study used a proactive strategy to increase reach of an Internet-delivered multi component computer tailored intervention, by embedding the intervention in an existing online health monitoring system of the Regional Public Health Services in the Netherlands. METHODS: The research population consisted of Dutch adults who were invited to participate in the Adult Health Monitor (N = 96,388) offered by the Regional Public Health Services. This Monitor consisted of an online or a written questionnaire. A prospective design was used to determine levels of reach, by focusing on actual participation in the lifestyle intervention. Furthermore, adequacy of reach among the target group was assessed by composing detailed profiles of intervention users. Participants' characteristics, like demographics, behavioral and mental health status and quality of life, were included in the model as predictors. RESULTS: A total of 41,155 (43%) people participated in the Adult Health Monitor, of which 41% (n = 16,940) filled out the online version. More than half of the online participants indicated their interest (n = 9169; 54%) in the computer tailored intervention and 5168 participants (31%) actually participated in the Internet-delivered computer tailored intervention. Males, older respondents and individuals with a higher educational degree were significantly more likely to participate in the intervention. Furthermore, results indicated that especially participants with a relatively healthier lifestyle and a healthy BMI were likely to participate. CONCLUSIONS: With one out of three online Adult Health Monitor participants actually participating in the computer tailored lifestyle intervention, the employed proactive dissemination strategy succeeded in ensuring relatively high levels of reach. Reach among at-risk individuals (e.g. low socioeconomic status and unhealthy lifestyle) was modest. It is therefore essential to further optimize reach by putting additional effort into increasing interest in the lifestyle intervention among at-risk individuals and to encourage them to actually use the intervention. TRIAL REGISTRATION: Dutch Trial Register (NTR1786) and Medical Ethics Committee of Maastricht University and the University Hospital Maastricht (NL2723506809/MEC0903016).

Periodic email prompts to re-use an internet-delivered computer-tailored lifestyle program: influence of prompt content and timing.

BACKGROUND: Adherence to Internet-delivered lifestyle interventions using multiple tailoring is suboptimal. Therefore, it is essential to invest in proactive strategies, such as periodic email prompts, to boost re-use of the intervention. OBJECTIVE: This study investigated the influence of content and timing of a single email prompt on re-use of an Internet-delivered computer-tailored (CT) lifestyle program. METHODS: A sample of municipality employees was invited to participate in the program. All participants who decided to use the program received an email prompting them to revisit the program. A 2×3 (content × timing) design was used to test manipulations of prompt content and timing. Depending on the study group participants were randomly assigned to, they received either a prompt containing standard content (an invitation to revisit the program), or standard content plus a preview of new content placed on the program website. Participants received this prompt after 2, 4, or 6 weeks. In addition to these 6 experimental conditions, a control condition was included consisting of participants who did not receive an additional email prompt. Clicks on the uniform resource locator (URL) provided in the prompt and log-ins to the CT program were objectively monitored. Logistic regression analyses were conducted to determine whether prompt content and/or prompt timing predicted clicking on the URL and logging in to the CT program. RESULTS: Of all program users (N=240), 206 participants received a subsequent email prompting them to revisit the program. A total of 53 participants (25.7%) who received a prompt reacted to this prompt by clicking on the URL, and 25 participants (12.1%) actually logged in to the program. There was a main effect of prompt timing; participants receiving an email prompt 2 weeks after their first visit clicked on the URL significantly more often compared with participants that received the prompt after 4 weeks (odds ratio [OR] 3.069, 95% CI 1.392-6.765, P=.005) and after 6 weeks (OR 4.471, 95% CI 1.909-10.471, P=.001). Furthermore, participants who received an email prompt 2 weeks after their first visit logged in to the program significantly more often compared to participants receiving the prompt after 6 weeks (OR 16.356, 95% CI 2.071-129.196, P=.008). A trend was observed with regard to prompt content. Participants receiving a prompt with additional content were more likely to log in to the program compared to participants who received a standard prompt. However, this result was not statistically significant (OR 2.286, 95% CI 0.892-5.856, P=.09). CONCLUSIONS: The key findings suggest that boosting revisits to a CT program benefits most from relatively short prompt timing. Furthermore, a preview of new website content may be added to a standard prompt to further increase its effectiveness in persuading people to log in to the program.

Does action planning moderate the intention-habit interaction in the exercise domain? A three-way interaction analysis investigation.

Both habit strength and action planning have been found to moderate the intention-exercise behaviour relationship, but no research exists that has investigated how habit strength and action planning simultaneously influence this relationship. The present study was designed to explore this issue in a prospective sample of undergraduate students (N = 415): action planning, habit strength, intention, attitudes, subjective norms and perceived behavioural control were assessed at baseline and exercise behaviour was assessed 2 weeks later. Both habit strength and action planning moderated the intention-exercise relationship, with stronger relationship at higher levels of planning or habit strength. Decomposing a significant action planning × habit strength × intention interaction showed that the strength of the intention-exercise relationship progressed linearly through levels of action planning and habit strength. These novel results show that action planning strengthens the intention-habit strength interaction in the exercise domain: exercise interventions should therefore focus on simultaneously bolstering action planning and habit strength.

Identifying factors for optimal development of health-related websites: a delphi study among experts and potential future users.

BACKGROUND: The Internet has become a popular medium for offering tailored and targeted health promotion programs to the general public. However, suboptimal levels of program use in the target population limit the public health impact of these programs. Optimizing program development is considered as one of the main processes to increase usage rates. OBJECTIVE: To distinguish factors potentially related to optimal development of health-related websites by involving both experts and potential users. By considering and incorporating the opinions of experts and potential users in the development process, involvement in the program is expected to increase, consequently resulting in increased appreciation, lower levels of attrition, and higher levels of sustained use. METHODS: We conducted a systematic three-round Delphi study through the Internet. Both national and international experts (from the fields of health promotion, health psychology, e-communication, and technical Web design) and potential users were invited via email to participate. During this study an extensive list of factors potentially related to optimal development of health-related websites was identified, by focusing on factors related to layout, general and risk information provision, questionnaire use, additional services, and ease of use. Furthermore, we assessed the extent to which experts and potential users agreed on the importance of these factors. Differences as well as similarities among experts and potentials users were deduced. RESULTS: In total, 20 of 62 contacted experts participated in the first round (32% response rate); 60 of 200 contacted experts (30% response rate) and 210 potential users (95% response rate) completed the second-round questionnaire, and 32 of 60 contacted experts completed the third round (53% response rate). Results revealed important factors consented upon by experts and potential users (eg, ease of use, clear structure, and detailed health information provision), as well as differences regarding important factors consented upon by experts (eg, visual aids, self-monitoring tool, and iterative health feedback) or by potential users only (eg, bread crumb navigation and prevention of receiving spam). CONCLUSIONS: This study is an important first step in determining the agreed-upon factors that should be taken into account when developing online health promotion programs. The public health impact of these programs will be improved by optimizing the development process in line with these factors.