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.

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 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.

Identification of Relevant Sociocognitive Determinants Explaining Multiple Parental Sun Protection Behaviors.

BACKGROUND: Adequate sun safety during childhood is crucial for decreasing skin cancer risk in later life. Although parents are an essential target group in applying sun protection measures for their children, insight into the determinants associated with their sun protection behaviors is limited. AIMS: This study aims to identify the most relevant determinants in predicting multiple parental sun protection intentions and behaviors in different sun exposure situations. METHOD: A longitudinal survey study with two measurements was conducted among Dutch parents (N = 670) of children (4-12 years old). Twenty-seven sociocognitive determinants were examined in terms of relevance regarding four parental sun protection behaviors in different sun exposure situations. The Confidence Interval-Based Estimation of Relevance approach was used to visualize room for improvement (sample means) on all determinants and their association strengths (correlations) with sun protection intentions and behaviors. RESULTS: Behavior-specific rather than generic determinants were most relevant in explaining all sun protection behaviors. Of these determinants, attitude, self-efficacy and action planning, and especially parental feelings of difficulty in performing sun protection behaviors, were most relevant. Altogether, the explained variance of all sociocognitive determinants was highest for shade-seeking behavior (R2 = .41 and .43) and lowest for supportive behavior (R2 = .19 and .29) in both planned and incidental sun exposure situations, respectively. DISCUSSION: This study provides detailed insight into relevant sociocognitive determinants of parental sun protection behaviors in various sun exposure situations and directions for composing parental skin cancer prevention interventions. CONCLUSIONS: Future composition of sun safety interventions should emphasize on enhancing parental feelings of self-efficacy, especially for shade-seeking and clothing behaviors.

Children's sunburn exposed: identification of sun exposure and parental sun protection patterns.

Preventing sunburn in childhood is imperative in the light of skin cancer prevention. To provide directions for targeted interventions, a better understanding of children's sunburn and associated parental behaviours is necessary. To explore sun exposure and parent-for-child sun protection patterns and their relationship with sunburn experienced in children. An online survey was conducted among parents (n = 1,299) of children (4 to 12 years). Latent class analysis (LCA) was performed to identify parental subgroups for children's sunburn, sun exposure and several sun protection behaviours (i.e. applying sunscreen, clothing, seeking shade) in two sun exposure settings (i.e. planned versus incidental). LCA results were validated by assessing predictions of class membership through several socio-demographic characteristics. Reported sunburn in the previous year was frequent (>40%). Four latent classes of sunburn-exposure-protection were identified. Overall, the majority of parents reported fair sun protection behaviours. While a low level of protection behaviour was not strongly reflected in lower sunburn rates among the classes, a high level of planned exposure (e.g. going to the beach) seemed to correspond with higher sunburn risk. Parents of younger children and those with more sensitive skin reported sun protection measures more frequently. Older children and those with more sensitive skin experienced more sunburn. This study contributes to current insight into children's sunburn, based on parent-proxy reports. Although a clear differentiation in sunburn risk was not found, several variables, relevant for future interventions, were indicated. By further understanding the complexity of children's sunburn, further research may be directed accordingly.

A Qualitative Exploration of Parental Perceptions Regarding Children's Sun Exposure, Sun Protection, and Sunburn.

Sun protection among children is of utmost importance since sunburn in early life is a major risk factor for skin cancer development. Because parents play a vital role in enhancing sun safety among children, this study explored parental perceptions concerning sun exposure, sun protection behaviors, and sunburn in children. Additionally, the context in which children experience sunburn in order to assist the development, optimization, and targeting of sun safety interventions for parents is revealed. A qualitative study design, using a semi-structured interview guide addressing several themes (e.g., sun exposure, sun protection, and sunburn experiences), was used. Data were collected in the Netherlands in the fall of 2019. Parents were recruited via purposive sampling at schools, youth services centers, and social media. Execution, transcription, and coding of the interviews was done by two researchers, using the qualitative analyzing program Nvivo (interrater reliability of d = 0.84). In total, 26 interviews were performed (n = 17 mothers, n = 17 daughters, aged between 4 and 11 years). Parental perceptions and recall of their child's lifetime sunburn were frequent, even though all parents reported using at least one sun protection measure during sun exposure situations and parents seemed often unaware of their child's sunburn. Moreover, parents reported an overreliance on sunscreen, often failing to adequately protect their children's skin. Water-related activities, a lack of shade, and misconceptions regarding UV-index were often related to sunburn. In addition, unexpected sun exposure or longer exposure duration than initially planned were reported as challenging situations. The majority of parents had positive perceptions regarding tanned skin for both themselves as for children. This study provides directions for skin cancer prevention efforts targeted at both parents and their children. Since a lack of knowledge regarding sufficient sun protection measures and sunburn occurrence in various situations was reported, educational efforts are warranted. Additionally, focusing on clothing, shade-seeking, and adequate sunscreen use is recommended to increase children's sun safety. By intervening in the physical environment as well (e.g., providing shady areas), sun protection barriers can be reduced. Lastly, the general positive attitude toward tanned skin evident in this study is certainly worthy of attention in future interventions.

Reproductive decision-making in the context of hereditary cancer: the effects of an online decision aid on informed decision-making.

Individuals having a genetic predisposition to cancer and their partners face challenging decisions regarding their wish to have children. This study aimed to determine the effects of an online decision aid to support couples in making an informed decision regarding their reproductive options. A nationwide pretest-posttest study was conducted in the Netherlands among 131 participants between November 2016 and May 2018. Couples were eligible for participation if one partner had a pathogenic variant predisposing for an autosomal dominant hereditary cancer syndrome. Participants completed a questionnaire before use (T0), and at 3 months (T3) after use of the decision aid to assess the primary outcome measure informed decision-making, and the secondary outcome measures decisional conflict, knowledge, realistic expectations, level of deliberation, and decision self-efficacy. T0-T3 comparisons show an overall positive effect for all outcome measures (all ps < 0.05; knowledge (ES = - 1.05), decisional conflict (ES = 0.99), participants' decision self-efficacy (ES = -0.55), level of deliberation (ES = - 0.50), and realistic expectations (ES = - 0.44). Informed decision-making increased over time and 58.0% of the participants made an informed reproductive decision at T3. The online decision aid seems to be an appropriate tool to complement standard reproductive counseling to support our target group in making an informed reproductive decision. Use of the decision aid may lessen the negative psychological impact of decision-making on couples' daily life and wellbeing.

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.

A Combination of Factors Related to Smoking Behavior, Attractive Product Characteristics, and Socio-Cognitive Factors are Important to Distinguish a Dual User from an Exclusive E-Cigarette User.

Although total cessation of nicotine and tobacco products would be most beneficial to improve public health, exclusive e-cigarette use has potential health benefits for smokers compared to cigarette smoking. This study investigated differences between dual users and exclusive e-cigarette users provide information to optimize health communication about smoking and vaping. A cross-sectional survey (n = 116) among 80 current, adult dual users and 36 current, adult-exclusive e-cigarette users was conducted in the Netherlands. The questionnaire assessed four clusters of factors: (1) Past and current smoking and vaping behavior, (2) product characteristics used, (3) attractiveness and reasons related to cigarettes and e-cigarettes, and (4) socio-cognitive factors regarding smoking, vaping, and not smoking or vaping. We used random forest-a machine learning algorithm-to identify distinguishing features between dual users and e-cigarette users. We are able to discern a dual user from an exclusive e-cigarette user with 86.2% accuracy based on seven factors: Social ties with other smokers, quantity of tobacco cigarettes smoked in the past (e-cigarette users) or currently (dual users), self-efficacy to not vape and smoke, unattractiveness of cigarettes, attitude towards e-cigarettes, barriers: accessibility of e-cigarettes, and intention to quit vaping (A). This combination of features provides information on how to improve health communication about smoking and vaping.

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.

A deliberate choice? Exploring factors related to informed decision-making about childhood vaccination among acceptors, refusers, and partial acceptors.

OBJECTIVE: In light of the decline in childhood vaccination coverage, the question rises concerning what factors play a role in informed decision-making about childhood vaccination. Insight into factors related to this decision helps us to support parents' informed decision-making about childhood vaccination. METHOD: We conducted 12 semi-structured focus group interviews across the Netherlands based on a definition of informed decision-making: three with acceptors, three with refusers, and six with partial acceptors to ask about knowledge, attitudes, deliberation, and information needs. We performed a thematic analysis of the transcripts. RESULTS: Acceptors viewed the decision to participate in the National Immunization Program (NIP) as self-evident. Refusers and partial acceptors, however, reported to extensively deliberate the pros and cons of accepting or refusing the NIP in much detail. Their answers indicated that their knowledge was not always evidence-based. In addition, refusers and partial acceptors perceived fewer risks of vaccine-preventable diseases (VPDs), more risks of side-effects of vaccines, less social support from their environment, less trust in child welfare centers (CWCs), and information provided than acceptors. CONCLUSION: We observed distinct differences in factors related to decision-making about childhood vaccination between acceptors, refusers, and partial acceptors. Acceptors in the current study perceived accepting childhood vaccinations as self-evident, refusers relied mostly on anecdotal information rather than evidence-based information to weigh up the pros and cons vaccines and the VPDs, and partial acceptors elaborately deliberated the pros and cons of each vaccine and VPD individually, which was time-consuming and difficult. To strengthen and support decision-making among parents, more elaborate dialogues are needed between Child Vaccine Providers (CVPs) and parents. These discussions could build trust between parents and CVPs, be used to discuss the evidence-based advantages of childhood vaccinations, and to decrease parents' susceptibility to anecdotal information and misperceptions about childhood vaccinations shared by other parents.

A Deliberate Choice? Exploring the Decision to Switch from Cigarettes to E-Cigarettes.

E-cigarettes are increasingly popular among both cigarette smokers and non-users. Although smoking cessation yields the most individual and population health benefits, switching to exclusive e-cigarette use offers some individual health benefits for cigarette smokers. However, e-cigarette use is not harmless, and its use among non-cigarette smokers should be prevented. Our study aims to explore the decision-making process about e-cigarettes among an e-cigarette users, cigarette smokers, and non-users. We conducted 12 semi-structured focus group interviews with e-cigarette users, cigarette smokers, and non-users. We performed a thematic analysis of the interview transcripts. First, knowledge reported by e-cigarette users was mainly based on other users' experiences. Second, cigarette smokers and non-users were more negative towards e-cigarettes than e-cigarette users. Third, e-cigarette users considered switching from cigarette smoking to e-cigarette use by deliberating relevant information, and weighing up the benefits and disadvantages of e-cigarette use versus smoking. Additionally, important factors in the decision-making process were a perception of risks and benefits of e-cigarettes compared to cigarettes, a supportive social environment about e-cigarette use, and trust in information offered about the risks and benefits of e-cigarettes. Our findings provide insight into what we can learn from the conscious decision-making process of e-cigarette users who switched from cigarettes to e-cigarettes. This information can be considered to develop targeted communications strategies to stimulate a conscious decision-making process, these may highlight benefits of switching to e-cigarettes for cigarette smokers, discussing the risks of smoking, and correcting misperceptions about the perceived risks and benefits of e-cigarette use.

The influence of pre-motivational factors on behavior via motivational factors: a test of the I-Change model.

BACKGROUND: The I-Change Model for explaining motivational and behavioral change postulates that an awareness phase precedes the motivation phase of a person, and that effects of pre-motivational factors on behavior are partially mediated by motivational factors. This study tests this assumption with regard to physical activity. METHODS: Observational longitudinal survey study (baseline, three months, six months) amongst Dutch adults (N = 2434). Structural equation modelling was used to investigate whether the influence of (1) knowledge, (2) cognizance, (3) cues, and (4) risk perception separately on intention and physical activity were mediated by motivational factors (i.e. attitudes, self-efficacy and social influence). Subsequently, a comprehensive model including all pre-motivational factors was estimated to test the same assumption for all pre-motivational factors simultaneously. RESULTS: The results indicate that the associations of cognizance, risk perception and cues with behavior were fully mediated by motivational factors when tested separately. When tested simultaneously only the effect of cognizance remained. Cognizance was most strongly associated with positive attitudes ß = .13, p < .01, self-efficacy ß = .13, p < .01, and intention ß = .14, p < .01. No direct link with behavior was found. CONCLUSION: The results suggest that pre-motivational factors are important to form a motivation; however, they do not directly influence behavior. The inclusion of factors such as risk perception and cognizance would help to get a better understanding of motivation formation and behavior.

Exploring the preferences of involved health professionals regarding the implementation of an online decision aid to support couples during reproductive decision-making in hereditary cancer: a mixed methods approach.

To support persons having a genetic predisposition to cancer and their partners during reproductive decision-making, an online decision aid was developed and evaluated. To maximize the impact of the support tool, this mixed methods study aims at developing the optimal implementation strategy for the decision aid. A questionnaire to assess the critical determinants that may affect this implementation was completed by health professionals involved in oncogenetic counselling (N = 46). Subsequently, semi-structured focus groups (N = 19) and individual telephonic interviews (N = 15) were performed with a subset of health professionals. All health professionals indicated to be willing to refer couples to the decision aid, preferably at the moment of receiving the genetic test result. They agreed that the primary requirement for implementation in daily practice was ease of referring couples and preferably free online accessibility. Referral to the tool was able to be included in the standard report couples receive after consultation, thereby making the use of additional paper-based materials redundant (e.g. flyers). Furthermore, incorporating the link to the decision aid on patient organization websites was suggested. Health professionals agreed that implementation would benefit more from promoting awareness regarding the decision aid rather than the inclusion of the tool in official clinical guidelines. To foster implementation of the decision aid, the distribution of online newsletters and the designation of a contact person charged with continued implementation in each Clinical Genetic Center were suggested. Based on these preferences and recommendations, the implementation of the online decision aid will be nationally executed to optimize impact.

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.

The development of an online decision aid to support persons having a genetic predisposition to cancer and their partners during reproductive decision-making: a usability and pilot study.

An online decision aid to support persons having a genetic predisposition to cancer and their partners during reproductive decision-making was developed. A two-phase usability test was conducted among 12 couples (N = 22; 2 persons participated without their partner) at risk for hereditary cancer and 15 health care providers. Couples and health care providers expressed similar suggestions for improvements, and evaluated the modified decision aid as acceptable, easy to use, and comprehensible. The final decision aid was pilot tested (N = 16) with paired sample t tests comparing main outcomes (decisional conflict, knowledge, realistic expectations regarding the reproductive options and decision self-efficacy) before (T0), immediately (T1) and 2 weeks after (T2) use of the decision aid. Pilot testing indicated decreased decisional conflict scores, increased knowledge, and improved realistic expectations regarding the reproductive options, at T1 and T2. No effect was found for couples' decision self-efficacy. The positive findings during usability testing were thus reflected in the pilot study. The decision aid will be further evaluated in a nationwide pretest-posttest study to facilitate implementation in the onco-genetic counselling setting. Ultimately, it is expected that the decision aid will enable end-users to make an informed decision.

Factors Associated with Acceptability, Consideration and Intention of Uptake of Direct-To-Consumer Genetic Testing: A Survey Study.

BACKGROUND: With interest in personalised health care growing, so is interest in personal genetic testing. This is now offered direct-to-consumer, thereby referred to as direct-to-consumer genetic testing (DTC-GT). Criticisms have been expressed on whether a truly informed decision to undergo testing is made with regard to these services. In order to provide relevant information to achieve this, knowing the characteristics of the expected user population is helpful. Therefore, the aim of this study is to identify characteristics of individuals who (1) find the concept of DTC-GT acceptable and (2) consider undergoing DTC-GT in the distant or near future. METHODS: This cross-sectional study investigated factors associated with acceptability, consideration and intention in the Dutch general population. Studied variables included awareness, principles and how-to knowledge, attitude, innovativeness, and multiple demographic characteristics. Generalised linear models were applied to identify associated variables. RESULTS: Full data was obtained for 836 respondents. Of those, 18.3% found DTC-GT somewhat or totally acceptable, whereas 12.6% considered and 5.5% intended to undergo DTC-GT in the distant or near future. Acceptability was greater with lower principles knowledge, and consideration and intention with lower how-to knowledge. A more positive attitude and greater innovativeness were associated with an increase in all 3 outcomes. CONCLUSION: Informed decision making may be hampered as individuals with lower how-to knowledge were found to be more interested in pursuing testing. The identified characteristics can be used in development and distribution of public and personalized information, in order to help consumers make a truly informed decision.

Perceptions and Reasons Regarding E-Cigarette Use among Users and Non-Users: A Narrative Literature Review.

This paper aims to provide an in-depth understanding of the attractiveness of e-cigarettes for several different groups. For this purpose, perceptions of and reasons for e-cigarette use were systematically reviewed as reported by e-cigarette users, cigarette smokers, dual users, and non-users, among both adults and youth. MEDLINE® and Scopus were used to search for relevant articles, and references of included studies were also investigated. Two reviewers screened all titles and abstracts independently, blinded to authors and journal titles (Cohen’s Kappa = 0.83), resulting in 72 eligible articles. Risk perceptions, perceived benefits, and reasons for e-cigarette use were categorized in themes and sub-themes. Risk perceptions included harmfulness in general, and specific health risks. Perceived benefits included improved taste and smell, and safety for bystanders. Reasons for use included (health) benefits, curiosity, smoking cessation, and friends using e-cigarettes. The findings highlight that there is a variety of perceptions and reasons mentioned by adult and youth e-cigarette users, cigarette smokers, dual users, and non-users. As such, this overview provides valuable information for scientists, public health professionals, behavior change experts, and regulators to improve future research, risk communication, and possibilities to effectively regulate e-cigarettes.

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.