Barriers and facilitators to the HPV vaccine among mothers of adolescent girls: a qualitative study conducted in Trinidad and Tobago.

Cervical cancer is a major public health problem in Latin America and the Caribbean and the human papillomavirus (HPV) vaccine may prevent thousands of cases of cervical cancer. The current study explored barriers and facilitators that affected the acceptance of the HPV vaccine by mothers of adolescents. This paper explores the qualitative findings from a larger mixed-methods study. Six focus groups were conducted (N = 33) throughout Trinidad and Tobago with mothers of adolescent girls. Three major themes emerged: a) cervical cancer and vaccine knowledge, b) barriers to uptake, and c) rephrasing the vaccine strategy. Data indicated that no widespread strategies to educate the population about the vaccine had occurred. Barriers to uptake of the vaccine were related to a lack of information on the efficacy and safety of HPV vaccines. Parents were unaware that the HPV caused cervical cancer. It is recommended that physicians and other health professionals be used to deliver targeted messages to parents and adolescents to improve uptake of the vaccine.

Burden of Hearing Loss on Communication Partners and Its Influence on Pursuit of Hearing Evaluation.

OBJECTIVE: Describe how the burden on the communication partner (CP) from the patient's hearing loss, as perceived by both the patient and their CP, influences a patient's pursuit of hearing evaluation. DESIGN: Cross-sectional design. Demographics, perception of patient's hearing loss, and associated burden on the CP were collected from both patient and CP via online questionnaires. Patients and their CPs from Duke University Medical Center Otolaryngology Clinic, 55 to 75 years of age, being seen for any reason, who indicated a CP has expressed concern about their hearing. Final sample was 245 matched pairs. RESULTS: Based on completed questionnaires, on average, patients perceived their own hearing loss as more burdensome to the CP than the CP did. However, CPs of patients who believed themselves to have no hearing handicap scored the patient's hearing loss 54.3% higher than the patient. The patient's perspective about the amount of burden their hearing loss placed on the CP predicted patients seeking a hearing evaluation. CONCLUSIONS: Recognition of early stage hearing loss and associated burden on CPs may be delayed in patients; CPs may help elucidate unrecognized concerns. Educational approaches that raise awareness of burden of hearing loss on CPs along with hearing loss indications could be a feasible, multidimensional strategy to promote help seeking behaviors.

Factors influencing pursuit of hearing evaluation: Enhancing the health belief model with perceived burden from hearing loss on communication partners.

OBJECTIVE: There is limited application of health behavior-based theoretical models in hearing healthcare, yet other fields utilizing these models have shown their value in affecting behavior change. The health belief model (HBM) has demonstrated appropriateness for hearing research. This study assessed factors that influence an individual with suspected hearing loss to pursue clinical evaluation, with a focus on perceived burden of hearing loss on communication partners, using the HBM as a framework. DESIGN: Cross-sectional design collecting demographics along with three validated hearing-loss related questionnaires. STUDY SAMPLE: Patients from Duke University Medical Center Otolaryngology Clinic aged 55-75 years who indicated a communication partner had expressed concern about their hearing. A final sample of 413 completed questionnaire sets was achieved. RESULTS: The HBM model construct 'cues to action' was a significant (p <0.001) predictor of pursuing hearing evaluation. Perceived burden of hearing loss on communication partners was a significant (p <0.001) predictor of pursuing hearing evaluation and improves the model fit when added to the HBM: 72.0% correct prediction when burden is added versus 66.6% when not (p <0.0001). CONCLUSIONS: Hearing healthcare initiatives that incorporate these factors may improve hearing help-seeking behavior. More research using sound theoretical models in hearing healthcare is warranted.

Religious involvement and health-related behaviors among Black Seventh-Day Adventists in Canada.

BACKGROUND: Most studies that involve Black Seventh-Day Adventists (SDAs) have been conducted in the United States. We sought to examine the association between religious involvement and lifestyle practices among Black SDAs in Canada. METHOD: A convenience sample of 509 Black SDA church members 18 years and older completed a self-administered questionnaire, assessing religious involvement and seven lifestyle practices promoted by the SDA church: diet, physical activity, water intake, exposure to sunlight, alcohol use, caffeine and tobacco use, and rest. RESULTS: Compliance with lifestyle practices ranged from a low of 10% meeting fitness guidelines to a high of 99% abstaining from tobacco products. Religious involvement and lifestyle were positively related (rs = .11, p < .05). Multivariate analyses indicated that private religious practice (ß = .16, p =.003), importance of the health principles (ß = .17, p = .003), and acceptance of health principles (ß = .65, p = .00001) significantly predicted the number of behaviors practiced. CONCLUSION: Greater religious involvement is associated with positive lifestyle practices but is not an independent predictor of lifestyle practices for Black Canadian SDAs.

Socio-demographics and asthma prevalence, management, and outcomes among children 1-11 years of age in California.

BACKGROUND: Asthma disproportionately affects minority and low-income children. We examined asthma prevalence, management and outcomes, focusing on race/ethnicity and acculturation of parents (particularly English language proficiency). METHODS: This cross-sectional, correlational analysis used a de-identified population-based survey, the California Health Interview Survey, for years 2001-2015. Survey-weighted analysis with SAS 9.4 was used to determine asthma prevalence among children 1 to 11 years of age. Descriptive analysis was conducted, adjusting for survey design and combination of multiple years of data. The Pearson test, using design-based F values was used to determine statistically significant differences between those having/not having a doctor diagnosis of asthma. Multivariable logistic regression, with jackknife approach to obtain confidence intervals, was used to examine associations of child and parental characteristics with asthma prevalence, management, and outcomes. RESULTS: The 61,625 completed surveys represented an estimated annual population of 5.7 million children, of which 12.9 % had asthma. There were significant (p < 0.001) differences by age, gender, race, and language proficiency, with higher asthma prevalence for children 6 to 11 years of age (15.5 %), males (15.3 %), African Americans (19.5 %), and parents speaking English very well (14.1 %). Compared to children whose parents spoke English very well, those whose parents spoke English not well or not at all were less likely to achieve optimal asthma management, i.e. to have received a management plan from doctor (OR 0.30; 95 % Confidence Interval 0.20-0.46)), to be currently taking medication to control asthma (OR 0.52; 95 % CI 0.36-0.74)), or to be not confident in ability to control asthma (OR 3.10; 95 % CI 1.49-6.42). Children whose parents spoke English fairly well rather than very well had worse outcomes, i.e. were more likely to have an emergency room visit in past 12 months (OR 1.92; 95 % CI 1.03-3.61) and were more likely to miss school due to asthma in past 12 months (OR 0.71; 1.01-2.94). CONCLUSIONS: Socio-demographics had a limited role in explaining differences across a handful of asthma management and outcome measures in California. Parental English language proficiency had the most consistent influence, underscoring the need for culturally and linguistically competent care.

Factors influencing implementation of personalized prevention plans among annual wellness visit patients using the theory of planned behavior: A quantitative study.

BACKGROUND: The Affordable Care Act provides Medicare Part B beneficiaries access to cost-free Annual Wellness Visits (AWVs). Patients receive health behavior recommendations from a Personalized Prevention Plan (PPP) during AWV encounters. AIMS: To identify factors clinical pharmacists can use to influence adoption of PPPs in primary care practices. METHOD: Utilizing a cross-sectional design, 77 Medicare patients (mean age 74.05 ±â€¯8.04 years) presenting for subsequent AWV completed a theory of planned behavior (TPB) based questionnaire at two primary care practices. RESULTS: 66.2% reported they were in the process of implementing PPPs and 51.9% reported implementing recommendations in the previous 12 months. TPB constructs accounted for 35.8% (p < .001) of the variation in intention, with subjective norm (SN) (ß = 0.359, p = 0.004) as the strongest determinant, followed by attitude (ß = 0.195, p = 0.093), and perceived behavioral control (PBC) (ß = 0.103, p = 0.384). Intention accounted for 27.1% of the variance for implementing PPPs and was not a significant determinant (ß = 0.047, p = 0.917). Addition of past behavior with TPB constructs significantly improved the predictability of the TPB model, accounted for 55% of the variation in intention (p < .001), and demonstrated a significant positive influence (ß = 0.636, p < 0.001) on future PPP implementations. DISCUSSION: This study demonstrates utility of the TPB in predicting implementation of PPPs. CONCLUSIONS: Clinical pharmacists positioned as providers of AWVs can strengthen intention to adopt PPPs by integrating referents into AWV processes, and evaluating past behavior trends to improve future PPP implementation.

Perceived church-based needs and assets for HIV/AIDS prevention in an urban Nigerian community.

Health intervention programs have the potential to use church-based assets to address a wide range of health issues. This study examined the assets Nigerian church members believed their churches needed, including the assets they thought they had to engage in HIV/AIDS prevention activities. Eight hundred and thirty members from 83 churches completed a questionnaire designed from forum focus group data. Respondents were males and females aged 18 years old and above, with primary, secondary, university, or vocational education, and were more likely to be married than single (never married), separated, divorced, widowed or remarried. The data revealed that church members needed access to health promotion assets, including the expertise of members who are health professionals to engage in HIV/AIDS prevention activities. We recommend an intensive HIV/AIDS prevention reorientation-training workshop for church leaders to ensure a sustainable plan to address HIV/AIDS prevention needs.

Assessing Medicare Patients' Salient Beliefs to Improve Annual Wellness Visit Health Outcomes.

OBJECTIVE: To identify key beliefs that influence behavior, regarding Medicare's Annual Wellness Visit (AWV) and older patients' willingness to implement personalized prevention plans.
DESIGN: Cross-sectional. In-depth semi-structured focus group sessions with Medicare patients in July 2018.
SETTING: Two primary care physician-based practices.
INTERVENTION: A trained moderator facilitated two focus group sessions, and used open-ended questions based on the theory of planned behavior to elicit behavioral, normative, and control beliefs associated with implementing personalized prevention plans.
MAIN OUTCOME MEASURE: Content analysis of the focus groups' transcribed data was used to identify modal salient beliefs. Transcribed focus group sessions were analyzed utilizing grounded-theory methods for emergent themes.
RESULTS: A total of 13 older patients participated in the focus group sessions. Prevalent behavioral beliefs among participants influenced by patient-centered care outcomes included improvement in physical activity, adopting a healthy balanced diet, and weight loss.
Interpersonal and environmental disparities influenced commonly reported control factors such as lack of support at home and affordable fitness facilities. Macro-level influences such as physicians and social marketing by insurance providers, and health partners and spousal support were identified as important normative factors.
CONCLUSION: Identified salient beliefs were congruent to social determinants of health in Medicare patients. Results of the study demonstrate perceived enablers and barriers of elderly patients regarding implementing health-promoting advice. AWV pharmacists should address perceived barriers to improve attitudes and self-efficacy; and incorporate enabling beliefs into adherence strategies to improve adoption of health recommendations.

Heart Rate Variability and Cardiovascular Adaptations Among Cancer-Survivors Following a 26-Week Exercise Intervention.

Cardiotoxicity as a result of cancer treatment contributes to autonomic dysfunction and decreased cardiorespiratory fitness among cancer survivors. These deleterious cardiovascular outcomes reduce the survival prognosis for cancer patients and contribute to poor quality of life among survivors. Exercise interventions have been shown as effective in mitigating treatment-related side effects. However, previously published interventions have not explored the potential for improvement in autonomic dysfunction (heart rate variability, HRV). This study examined cardiovascular adaptations in cancer survivors (n = 76) who participated in a 26-week intervention consisting of combined aerobic and resistance training (CART). The most noteworthy improvements occurred during the first 13 weeks of training and were maintained throughout the end of the 26-week period. HRrest improved from baseline (PRE) to the midpoint (MID) (P = .036) and from PRE to POST timepoints (P = .029). HRV and VO2max did not initially appear to change in response to CART. However, after stratification on time since treatment, participants who were 5 or more years from their last treatment experienced improvements (ie increase) in the HRV characteristic of HF power (P = .050) and also in VO2max (P =.043), when compared to those experiencing less than 5 years of time since their last treatment. These findings highlight a need for more attention to address the cardiorespiratory deficits experienced by those who have recently completed cancer treatment. In conclusion, the CART intervention is effective in improving cardiorespiratory fitness and autonomic dysfunction. The structure of the intervention is feasible for cancer survivors to continue with at home, using minimal resources, and without supervision. This at-home model may be even more acceptable to recent survivors that may be homebound immediately following treatment.

Health beliefs and the prevention of hypertension in a black population living in London.

In the United Kingdom, the morbidity and mortality associated with hypertension is much higher in Blacks than in Whites. We studied a convenience sample of 312 persons aged 25-79 years from 17 predominantly Black Seventh-Day Adventist churches across London by using the health belief model to examine their beliefs about the prevention of hypertension. A questionnaire was used to collect demographic and anthropometric data, lifestyle practices, and perceptions toward hypertension by using the health belief model constructs of susceptibility, severity, benefits, barriers, and self-efficacy. A relative risk estimate score was developed to assess the presence of several risk factors of hypertension for each participant. Based on multiple regression analyses, the demographic variables were independent predictors of systolic blood pressure (R2 = .195), the combined behavioral variable (risk score) was an independent predictor of diastolic blood pressure (beta = .18, P = .02), and self-efficacy was the only independent variable significantly associated with risk scores (beta = -.21, P = .008). The perception of self-efficacy to perform behaviors that will decrease hypertension risk needs to be effectively harnessed by health educators to decrease the prevalence of hypertension in this population.

Peer support and breastfeeding intentions among black WIC participants.

The purpose of this study was to identify what factors impact low-income women's infant feeding decisions. A cross-sectional convenience sample of 109 black pregnant women, ages 18 to 45, regularly attending Women, Infant, and Children (WIC) clinics and associated programs in the Inland Empire Region of California were recruited to complete a structured questionnaire about their breastfeeding beliefs and intentions. Multivariable logistic regression was used to explore participant's intentions to breastfeed. After adjusting for confounding factors, results indicate that women who attended support groups were more than twice as likely to intend to breastfeed compared with women who did not. These results highlight the importance of social influences on the decision to breastfeed, and indicate the need for broadened community-based education for the promotion of breastfeeding.

Fall-related Comorbidity and Health Beliefs among Cancer Survivors Participating in a Community-based Exercise Intervention.

OBJECTIVES: Health beliefs (HB) and fall and balance-related outcomes were examined following a 26-week community-based exercise intervention among cancer survivors (CS). METHODS: Fall and balance-related measures and HB were quantitatively and qualitatively examined during a 26-week intervention among CS (N = 33). Of the 33 participants, 28 consented to an interview about their physical activity (PA) behavior. RESULTS: Participants scored high on balance efficacy (median ± range = 8.68 ± 1.53) and reported high perception of having barriers to PA (mean ± SD = 4.66 ± 0.59). Fall-related measures improved after the 26-week intervention (p = .002). Most cues to action to engage in PA were delivered by a healthcare professional (N = 18). Once enrolled in the intervention, social benefits and access to a program tailored toward CS emerged as motivating factors to engage in PA (N = 12, N = 11, respectively). CONCLUSIONS: There is a need to design fall risk reduction programs tailored to CS and to offer these programs in an environment that fits the unique physical and social needs of CS.

An examination of ecological predictors of health literacy in black college students.

OBJECTIVE: Health literacy is a determinant of health, but disparities in health literacy persist. This study examined the influence of ecological factors on college students' health literacy. PARTICIPANTS: During January 2016 a nonrandom sample of black undergraduate students (n = 298) aged 18-24 were recruited from enrollment lists at two urban universities in the Southeastern United States. METHODS: Information on health literacy as well as numerous intrapersonal, social, and cultural-environment factors was obtained using an electronic questionnaire and then statistically modeled. RESULTS: Ecological factors accounted for 28.7% of the variance in health literacy. In particular, reappraisal (B = 0.323, p < .001), suppression (B = -0.289, p < .001), campus health education (B = 0.192, p < .05), campus tobacco culture (B = -0.174, p < .05), and perceived norms (B = -0.153, p < .05) directly predicted health literacy. CONCLUSIONS: Although intrapersonal factors influence health literacy, the sociocultural environment of college can also foster or hinder college students' health literacy.

Predicting Malawian Women's Intention to Adhere to Antiretroviral Therapy.

BACKGROUND: With the increase in scaling up of antiretroviral therapy (ART), knowledge of the need for adherence to ART is pivotal for successful treatment outcomes. DESIGN AND METHODS: A cross-sectional study was carried out between October and December 2013. We administered theory of planned behaviour (TPB) and adherence questionnaires to 358 women aged 18-49 years, from a rural and urban ART-clinics in southern Malawi. Hierarchical linear regression models were used to predict intentions to adhere to ART. RESULTS: Regression models show that attitude (ß=0.47), subjective norm (ß=0.31) and perceived behavioural control (ß=0.12) explain 55% of the variance in intentions to adhere to ART. The relationship between both food insecurity and perceived side effects with intentions to adhere to ART is mediated by attitude, subjective norm, and perceived behavioural control. Household (r=0.20) and individual (r=0.21) food insecurity were positively and significantly correlated with perceived behavioural control. Household food insecurity had a negative correlation with perceived side effects (r=-0.11). Perceived side effects were positively correlated with attitude (r=0.25). There was no statistically significant relationship between intentions to adhere to ART in the future and one month self-report of past month adherence. These interactions suggest that attitude predicted adherence only when food insecurity is high or perception of side effects is strong. CONCLUSIONS: This study shows that modification might be needed when using TPB constructs in resource constraint environments. Significance for public healthThe knowledge of the rates of adherence to antiretroviral therapy (ART) could be used to evaluate planning and project, which could lead to better outcomes predicted by treatment efficacy data. In addition, knowledge of adherence behaviour could help the development of interventions focusing on collaboration between healthcare providers and Malawian government to provide food support for patients on ART. The interventions could also focus on providing better counselling support to improve beliefs regarding control over taking the medication and perceived versus real side effects. It is relevant for public health professors to understand factors influencing women's ART adherence, in order to create interventions that are appropriate for increasing ART adherence, which may lead to improved outcomes among women with HIV living in endemic regions with limited treatment access.

Saudi women's beliefs on the use of car infant restraints: a qualitative study.

OBJECTIVE: The focus of this study was to identify the salient beliefs of pregnant women in Saudi Arabia that may influence their intentions to use infant restraints for their children. These beliefs were later used to inform a subsequent quantitative study. METHODS: This qualitative study employed Ajzen's theory of planned behavior to elicit the salient behavioral, normative, and control beliefs of Saudi pregnant women regarding the use of infant restraints for their future children. Twenty-five pregnant women participated in 2 focus groups conducted in June 2013 at Dallah Hospital in Riyadh. RESULTS: Lack of health education and law enforcement; cultural pressure and traditions; counsel from family, specifically from husbands and mothers; desire to stay close to the child; family size; and car size were key factors in deciding whether or not to use car seats; the high cost of car seats was not. CONCLUSIONS: Aside from providing awareness to future mothers and the general public, health interventions should target the specific beliefs identified in this study. Because participants identified husbands as significant referents, further studies are needed to examine the husbands' attitudes and beliefs.

Contextual factors influencing health-related quality of life in African American and Latina breast cancer survivors.

PURPOSE: This study explored the relationships between systemic- and individual-level contextual factors and health-related quality of life (HRQOL) in a cohort of African American and Latina breast cancer survivors (BCS). METHODS: Baseline questionnaire data of 320 BCS who participated in a HRQOL psycho-educational intervention were abstracted from the parent study. Hierarchical regression analysis tested the independent effects of contextual factors on HRQOL. RESULTS: HRQOL was higher in BCS who: were diagnosed at < stage 2 (b = -1.38, p < 0.05), expressed satisfaction with their health care (b = 0.20, p < 0.001), had fewer comorbidities (b = - 0.60, p < 0.001) and depressive symptoms (b = -0.30, p < 0.001), and practiced healthy diet and exercise habits (b = 0.02, p < 0.05). Demographic and cancer-related factors accounted for 14 % of the variance in HRQOL (F[6, 274] = 7.25, p < 0.001). The socio-cultural context (i.e., ethnicity, life stress, perceived social support) explained 20 % of the variance in HRQOL (FΔ[3, 271] = 27.32, p < 0.001). The health care system context contributed an additional 8 % to explaining HRQOL (FΔ[1, 270] = 34.88, p < 0.001). Health status and behavioral factors accounted for 18 % of the variance (FΔ[4, 266] = 29.55, p < 0.001). The full model explained 59 % of the variance in HRQOL (F[14, 266] = 27.76, p < 0.001). CONCLUSIONS: HRQOL in ethnic minority BCS is multifaceted and is significantly influenced by cancer-related, socio-cultural, health care system, health status, and behavioral contextual factors. Therefore, survivorship research and practice must address broad multi-level domains to achieve equitable and optimal breast cancer outcomes. IMPLICATIONS FOR CANCER SURVIVORS: To enhance HRQOL, survivors must be provided the know-how and support to maintain healthy lifestyle and self-management practices. Advocates must engage the care team to consider systemic factors, including life stress and community resources, to be more patient-centered.

Health Beliefs About Tobacco With Betel Nut Use Among Adults in Yap, Micronesia.

Tobacco use is high among Pacific Islanders in general and little tobacco research has been done in Yap, Micronesia. This study aimed to explore perceptions of tobacco use coupled with chewing of betel (areca) nut among adults in Yap using self-administered questionnaires based on the health belief model. A Likert scale (ranging from strongly disagree to strongly agree or very unlikely to very likely) was used to measure susceptibility, severity, benefits, barriers, cues to action, and self-efficacy among individuals aged 18 and older. Older adults felt quitting tobacco or betel nut use would be significantly more difficult because of social reasons and withdrawal problems. Most participants felt susceptible to tobacco-related diseases. These findings possibly indicate a receptive attitude toward any future tobacco use prevention and intervention program. Older Yapese population would need to be especially targeted. Health promotion programs should target smoking behaviors and risk reduction.

Obesity, diabetes, hypertension, and vegetarian status among Seventh-Day Adventists in Barbados: preliminary results.

A population-based sample of Seventh-Day Adventists was studied to determine the relationship between vegetarian status, body mass index (BMI), obesity, diabetes mellitus (DM), and hypertension, in order to gain a better understanding of factors influencing chronic diseases in Barbados. A systematic sampling from a random start technique was used to select participants for the study. A standard questionnaire was used to collect data on demographic and lifestyle characteristics, to record anthropometrics and blood pressure measurements, and to ascertain the hypertension and diabetes status of participants. The sample population consisted of 407 Barbadian Seventh-Day Adventists (SDAs), who ranged in age from 25 to 74 years. One hundred fifty-three (37.6%) participants were male, and 254 (62.4%) were female, and 43.5% were vegetarians. The prevalence rates of diabetes and hypertension were lower among long-term vegetarians, compared to non-vegetarians, and long-term vegetarians were, on average, leaner than non-vegetarians within the same cohort. A significant association was observed between a vegetarian diet and obesity (vegetarian by definition P=.04, self-reported vegetarian P=.009) in this population. Other components of the study population lifestyle should be further analyzed to determine the roles they may plan in lessening the prevalence rates of obesity, diabetes, and hypertension.

Exploring family factors and sexual behaviors in a group of Black and Hispanic adolescent males.

OBJECTIVE: To explore family factors that influence sexual behaviors among a group of Black and Hispanic adolescent males. METHODS: One hundred seventy-eight subjects were selected from a convenience sample of 431 adolescents who participated in a 1996 Youth Survey conducted in San Bernardino County, California. RESULTS: Having a sibling who was a teen parent was significantly associated with engaging in sexual intercourse among Hispanics. Among Blacks, having a father who was a teen dad was significantly associated with sexual intercourse. CONCLUSIONS: Findings showed relationships between family characteristics and sexual attitudes and behaviors among participants.

Using the theory of planned behavior to predict infant restraint use in Saudi Arabia.

OBJECTIVES: To determine whether the theory of planned behavior (TPB) predicted intent of child restraint system (CRS) use among pregnant women in the Kingdom of Saudi Arabia (KSA). METHODS: In this cross-sectional study conducted in Dallah Hospital, Riyadh, KSA during June-July 2013, 196 pregnant women completed surveys assessing their beliefs regarding CRS. Simultaneous observations were conducted among a different sample of 150 women to determine CRS usage at hospital discharge following maternity stay. RESULTS: Logistic regression model with TPB constructs and covariates as predictors of CRS usage intent was significant (χ2=64.986, p<0.0001) and predicted 38% of intent. There was an increase in odds of intent for attitudes (31.5%, p<0.05), subjective norm (55.3%, p<0.001), and perceived behavioral control (76.9%, p<0.001). The 3 logistic regression models testing the association of the relevant set of composite belief scores were also significant for attitudes (χ2=16.803, p<0.05), subjective norm (χ2=29.681, p<0.0001), and perceived behavioral control (χ2=20.516, p<0.05). The behavioral observation showed that none of the 150 women observed used CRS for their newborn at discharge. CONCLUSION: The TPB constructs were significantly and independently associated with higher intent for CRS usage. While TPB appears to be a useful tool to identify beliefs related to CRS usage intentions in KSA, the results of the separate behavioral observation indicate that intentions may not be related to the actual usage of CRS in the Kingdom. Further studies are recommended to examine this association.