Describing, predicting and explaining adherence to total skin self-examination (TSSE) in people with melanoma: a 12-month longitudinal study.

OBJECTIVES: To describe trajectories in melanoma survivors' adherence to monthly total skin self-examination (TSSE) over 12 months, and to investigate whether adherence trajectories can be predicted from demographic, cognitive or emotional factors at baseline. DESIGN: A longitudinal observational study nested within the intervention arm of the ASICA (Achieving Self-Directed Integrated Cancer Aftercare) randomised controlled trial. SETTING: Follow-up secondary care in Aberdeen and Cambridge UK. PARTICIPANTS: n=104 adults (48 men/56 women; mean age 58.83 years, SD 13.47, range 28-85 years; mean Scottish Index of Multiple Deprivation score 8.03, SD 1.73, range 2-10) who had been treated for stage 0-IIC primary cutaneous melanoma in the preceding 60 months and were actively participating in the intervention arm of the ASICA trial. INTERVENTIONS: All participants were using the ASICA intervention-a tablet-based intervention designed to support monthly TSSE. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was adherence to guideline recommended (monthly) TSSE over 12 months. This was determined from time-stamped TSSE data recorded by the ASICA intervention app. RESULTS: Latent growth mixture models identified three TSSE adherence trajectories (adherent -41%; drop-off -35%; non-adherent -24%). People who were non-adherent were less likely to intend to perform TSSE as recommended, intending to do it more frequently (OR=0.21, 95% CI 0.06 to 0.81, p=0.023) and were more depressed (OR=1.31, 95% CI 1.06 to 1.61, p=0.011) than people who were adherent. People whose adherence dropped off over time had less well-developed action plans (OR=0.78, 95% CI 0.63 to 0.96, p=0.016) and lower self-efficacy about TSSE (OR=0.92, 95% CI 0.86 to 0.99, p=0.028) than people who were adherent. CONCLUSIONS: Adherence to monthly TSSE in people treated for melanoma can be differentiated into adherent, drop-off and non-adherent trajectories. Collecting information about intentions to engage in TSSE, depression, self-efficacy and/or action planning at outset may help to identify those who would benefit from additional intervention. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT03328247).

Changing healthcare professionals' non-reflective processes to improve the quality of care.

RATIONALE: Translating research evidence into clinical practice to improve care involves healthcare professionals adopting new behaviours and changing or stopping their existing behaviours. However, changing healthcare professional behaviour can be difficult, particularly when it involves changing repetitive, ingrained ways of providing care. There is an increasing focus on understanding healthcare professional behaviour in terms of non-reflective processes, such as habits and routines, in addition to the more often studied deliberative processes. Theories of habit and routine provide two complementary lenses for understanding healthcare professional behaviour, although to date, each perspective has only been applied in isolation. OBJECTIVES: To combine theories of habit and routine to generate a broader understanding of healthcare professional behaviour and how it might be changed. METHODS: Sixteen experts met for a two-day multidisciplinary workshop on how to advance implementation science by developing greater understanding of non-reflective processes. RESULTS: From a psychological perspective 'habit' is understood as a process that maintains ingrained behaviour through a learned link between contextual cues and behaviours that have become associated with those cues. Theories of habit are useful for understanding the individual's role in developing and maintaining specific ways of working. Theories of routine add to this perspective by describing how clinical practices are formed, adapted, reinforced and discontinued in and through interactions with colleagues, systems and organisational procedures. We suggest a selection of theory-based strategies to advance understanding of healthcare professionals' habits and routines and how to change them. CONCLUSION: Combining theories of habit and routines has the potential to advance implementation science by providing a fuller understanding of the range of factors, operating at multiple levels of analysis, which can impact on the behaviours of healthcare professionals, and so quality of care provision.

Achieving integrated self-directed Cancer aftercare (ASICA) for melanoma: how a digital intervention to support total skin self-examination was used by people treated for cutaneous melanoma.

BACKGROUND: Melanoma incidence has quadrupled since 1970 and melanoma is now the second most common cancer in individuals under 50. Targeted immunotherapies for melanoma now potentially enable long-term remission even in advanced melanoma, but these melanoma survivors require ongoing surveillance, with implications for NHS resources and significant social and psychological consequences for patients. Total skin self-examination (TSSE) can detect recurrence earlier and improve clinical outcomes but is underperformed in the UK. To support survivors, the Achieving Self-directed Integrated Cancer Aftercare (ASICA) intervention was developed to prompt and improve TSSE performance, with subsequent reporting of concerns and submission of skin photos to a Dermatology Nurse Practitioner (DNP). ASICA was delivered as a randomized pilot trial. METHODS: This paper reports on process evaluation. Data on participants' demographics and the concerns they reported during the trial were tabulated and displayed using Microsoft Excel and SPSS. We explored which participants used ASICA, and how frequently, to report any skin concerns. We also determined how the interactions had worked in terms of quality of skin photographs submitted, clinical assessments made by the DNP, and the assessments and decisions made for each concern. Finally, we explored significant events occurring during the trial. Data on participants' demographics and the concerns they reported during the trial were tabulated and displayed using SPSS. A semi-structured interview was undertaken with the DNP to gain perspective on the range of concerns presented and how they were resolved. RESULTS: Of 121 recruited melanoma patients receiving ASICA for 12 months, 69 participants submitted a total of 123 reports detailing 189 separate skin-related concerns and including 188 skin photographs. Where participants fully complied with follow-up by the DNP, concerns were usually resolved remotely, but 19 (10.1%) were seen at a secondary care clinic and 14 (7.4%) referred to their GP. 49 (25.9%) of concerns were not completely resolved due to partial non-compliance with DNP follow-up. CONCLUSION: Melanoma patients randomized to the ASICA intervention were able to report skin-related concerns that could be resolved remotely through interaction with a DNP. Feasibility issues highlighted by ASICA will support further development and optimization of this digital tool. TRIAL REGISTRATION: Clinical Trials.gov , NCT03328247 . Registered on 1 November 2017.

How can we better prepare new doctors for the tasks and challenges of ward rounds?: An observational study of junior doctors' experiences.

PURPOSE: Ward rounds play a crucial role in the delivery of patient care in inpatient settings, but involve a complex mix of tasks, skills and challenges for junior doctors to negotiate. This study informs the development of high-quality training by identifying the activities that junior doctors perform, and those associated with stress during real-life ward rounds. MATERIALS AND METHODS: All activities performed by FY1 doctors (n = 60) over 2 ward rounds were coded in real-time by a trained observer using the work observation method by activity timing (WOMBAT). Doctors' heart rate was continuously recorded and non-metabolic peaks in heart rate used as a physiological indicator of stress. RESULTS: During ward rounds, FY1 doctors commonly engaged in indirect patient care, professional communication, documentation and observation. Very little time was spent on direct patient care (6%) or explicit supervision/education (0.01%). Heart rate data indicated that stress was highest during administrative tasks while interacting directly with patients while stepping out of rounds to complete personal tasks, when answering bleeps and while multi-tasking. CONCLUSIONS: Training that specifically covers the activities involved, skills required, and challenges inherent in real-life ward rounds may better prepare FY doctors for this complex area of practice.

Development of an online tool for linking behavior change techniques and mechanisms of action based on triangulation of findings from literature synthesis and expert consensus.

Researchers, practitioners, and policymakers develop interventions to change behavior based on their understanding of how behavior change techniques (BCTs) impact the determinants of behavior. A transparent, systematic, and accessible method of linking BCTs with the processes through which they change behavior (i.e., their mechanisms of action [MoAs]) would advance the understanding of intervention effects and improve theory and intervention development. The purpose of this study is to triangulate evidence for hypothesized BCT-MoA links obtained in two previous studies and present the results in an interactive, online tool. Two previous studies generated evidence on links between 56 BCTs and 26 MoAs based on their frequency in literature synthesis and on expert consensus. Concordance between the findings of the two studies was examined using multilevel modeling. Uncertainties and differences between the two studies were reconciled by 16 behavior change experts using consensus development methods. The resulting evidence was used to generate an online tool. The two studies showed concordance for 25 of the 26 MoAs and agreement for 37 links and for 460 "nonlinks." A further 55 links were resolved by consensus (total of 92 [37 + 55] hypothesized BCT-MoA links). Full data on 1,456 possible links was incorporated into the online interactive Theory and Technique Tool (https://theoryandtechniquetool.humanbehaviourchange.org/). This triangulation of two distinct sources of evidence provides guidance on how BCTs may affect the mechanisms that change behavior and is available as a resource for behavior change intervention designers, researchers and theorists, supporting intervention design, research synthesis, and collaborative research.

Analysing N-of-1 observational data in health psychology and behavioural medicine: a 10-step SPSS tutorial for beginners.

Background: N-of-1 observational studies can be used to describe natural intra-individual changes in health-related behaviours or symptoms over time, to test behavioural theories and to develop highly personalised health interventions. To date, N-of-1 observational methods have been under-used in health psychology and behavioural medicine. One reason for this may be the perceived complexity of statistical analysis of N-of-1 data. Objective: This tutorial paper describes a 10-step procedure for the analysis of N-of-1 observational data using dynamic regression modelling in SPSS for researchers, students and clinicians who are new to this area. The 10-step procedure is illustrated using real data from an N-of-1 observational study exploring the relationship between pain and physical activity. Conclusion: The availability of a user-friendly and robust statistical technique for the analysis of N-of-1 data using SPSS may foster increased awareness, knowledge and skills and establish N-of-1 designs as a useful methodological tool in health psychology and behavioural medicine.

Clinical decisions and time since rest break: An analysis of decision fatigue in nurses.

OBJECTIVE: The present study investigates whether nurses working for a national medical telephone helpline show evidence of "decision fatigue," as measured by a shift from effortful to easier and more conservative decisions as the time since their last rest break increases. METHOD: In an observational, repeated-measures study, data from approximately 4,000 calls to 150 nurses working for the Scottish NHS 24 medical helpline (37% of the national workforce) were modeled to determine whether the likelihood of a nurse's decision to refer a patient to another health professional the same day (the clinically safest but most conservative and resource inefficient decision) varied according to the number of calls taken/time elapsed since a nurse's last rest break and/or since the start of shift. Analyses used mixed-effect logistic regression. RESULTS: For every consecutive call taken since last rest break, the odds of nurses making a conservative management decision (i.e., arranging for callers to see another health professional the same day) increased by 5.5% (p = .001, 95% confidence interval [CI: 2.2, 8.8]), an increase in odds of 20.5% per work hour (p < .001, 95% CI [9.1, 33.2]) or 49.0% (on average) from immediately after 1 break to immediately before the next. Decision-making was not significantly related to general or cumulative workload (calls or time elapsed since start of shift). CONCLUSIONS: Every consecutive decision that nurses make since their last break produces a predictable shift toward more conservative, and less resource-efficient, decisions. Theoretical models of cognitive fatigue can elucidate how and why this shift occurs, helping to identify potentially modifiable determinants of patient care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

How many calories do nurses burn at work? A real-time study of nurses' energy expenditure.

BACKGROUND: Nurses have high rates of overweight and obesity, and physical inactivity is one key determinant of weight gain. AIMS: The present study aims to quantify nurses' energy expenditure over a standard 12-hour shift to establish whether activity levels at work are too low to maintain a healthy body weight. METHODS: Ward-based nurses (n = 96, 90 female, mean age = 36 years, mean experience = 10 years, mean body mass index = 26.6) wore heart rate and physical activity monitors for the duration of one full working shift. Heart rate and activity data were used in combination with demographic information to estimate each nurse's energy expenditure over 12 hours. RESULTS: On average, nurses burned 2.12 kcals per minute while at work, equating to 1521 kcals/6364 kJ (SD = 403 kcals/1686 kJ) per 12-hour shift. Energy expenditure over 12 hours varied markedly between nurses (from 812 kcals/3397 kJ to 3005 kcals/12,573 kJ) but was sufficient in 72% of participants (assuming minimal resting levels of energy expenditure for the 12 hours not at work) to burn off a daily calorie intake of 2000 kcals. CONCLUSIONS: Three-quarters of nurses expend more energy on working days than is required to maintain a healthy body weight if dietary intake does not exceed recommended levels.

Are Processes in Acceptance & Commitment Therapy (ACT) Related to Chronic Pain Outcomes Within Individuals Over Time? An Exploratory Study Using n-of-1 Designs.

INTRODUCTION: Acceptance & Commitment Therapy (ACT) explicitly postulates experiential avoidance (EA) and values-based living (VBL) as essential treatment processes. As outcomes from between-subject studies cannot readily be generalized to within-subject processes in individuals, we explored the unfolding of, and relationship between, EA and VBL and levels of pain interference in daily life and emotional well-being within individuals experiencing chronic pain. METHODS: Using n-of-1 designs, three participants following a multidisciplinary treatment program filled out a 12-item daily questionnaire (87-110 days). After multiple imputation of missing data, McKnight Time-series analysis procedures were performed for each participant separately. The interrelationships of EA, VBL and pain intensity, and the relationship of EA and VBL beyond pain intensity with both chronic pain outcomes were assessed both concurrently (same day) and prospectively (consecutive days). RESULTS: Both EA and VBL were associated with at least one of five outcome variables (four domains of pain interference and emotional well-being) beyond pain intensity in two participants, but not in the third participant. These associations primarily existed for concurrent, but not consecutive, days. In contrast to VBL, EA was not associated with emotional well-being for any of the three participants. CONCLUSIONS: Although the finding that ACT-processes were associated with pain outcomes on concurrent days is consistent with ACT theory, the absence of such associations on consecutive days means that alternative explanations cannot be rule out. One possibility is that pain interference fluctuates within days at a higher variability rate than was currently assessed. Future research should consider using a higher measurement frequency to be able to grasp time-lagged effects.

Why does work cause fatigue? A real-time investigation of fatigue, and determinants of fatigue in nurses working 12-hour shifts.

BACKGROUND: One of the striking regularities of human behavior is that a prolonged physical, cognitive, or emotional activity leads to feelings of fatigue. Fatigue could be due to (1) depletion of a finite resource of physical and/or psychological energy or (2) changes in motivation, attention, and goal-directed effort (e.g. motivational control theory). PURPOSE: To contrast predictions from these two views in a real-time study of subjective fatigue in nurses while working. METHODS: One hundred nurses provided 1,453 assessments over two 12-hr shifts. Nurses rated fatigue, demand, control, and reward every 90 min. Physical energy expenditure was measured objectively using Actiheart. Hypotheses were tested using multilevel models to predict fatigue from (a) the accumulated values of physical energy expended, demand, control, and reward over the shift and (b) from distributed lag models of the same variables over the previous 90 min. RESULTS: Virtually all participants showed increasing fatigue over the work period. This increase was slightly greater when working overnight. Fatigue was not dependent on physical energy expended nor perceived work demands. However, it was related to perceived control over work and perceived reward associated with work. CONCLUSIONS: Findings provide little support for a resource depletion model; however, the finding that control and reward both predicted fatigue is consistent with a motivational account of fatigue.

Intention, beliefs and mood assessed using electronic diaries predicts attendance at cardiac rehabilitation: An observational study.

BACKGROUND: Cardiac rehabilitationis effective in promoting physical/psychological recovery following acute coronary syndrome. Yet, rates of attendance at outpatient cardiac rehabilitation by eligible patients are low. OBJECTIVES: This study examined the determinants of attendance at outpatient cardiac rehabilitation in acute coronary syndrome patients following discharge until cardiac rehabilitation commencement. DESIGN: A weekly electronic diary measured cardiac-related cognitions and mood and examined their relation to attendance at outpatient cardiac rehabilitation. SETTINGS: Three United Kingdom National Health Service secondary care settings in two Health Board areas in Scotland. PARTICIPANTS: Acute coronary syndrome patients were recruited from March 2012 to June 2013 prior to hospital discharge. Of 488 eligible patients referred for cardiac rehabilitation, 214 consented. METHODS: Consecutive patients completed a pre-hospital discharge questionnaire targeting age, diagnosis, social class and smoking history. Acute coronary syndrome patients then completed a weekly electronic diary from the first week of discharge until the start of cardiac rehabilitation. Multilevel structural equation models estimated the effects of initial, i.e. baseline and rate of change in cardiac-related cognition and mood on attendance. Intention to attend cardiac rehabilitation was reflected, log transformed, reported thereafter as "do not intend". The role of "do not intend" was explored as a mediator of the relationship between cardiac-related cognition and mood on attendance. RESULTS: 166 participants provided, on average, 5 weeks of diary entries before cardiac rehabilitation commenced. High intention (i.e. low "do not intend") to attend CR and its rate of increase over time predicted attendance. Low negative emotional representation, high perceived necessity, high confidence in maintaining function, low negative affect, and high positive affect following discharge predicted attendance at cardiac rehabilitation. The rate of change in cardiac-related mood and these cognitions was not predictive. Baseline and rate of change in "do not intend" entirely mediated relationships between a) perceived necessity, b) negative affect and attendance at cardiac rehabilitation. CONCLUSIONS: Negative affect in the first weeks following discharge represents the key challenge to a patient maintaining their intention to attend cardiac rehabilitation. Intervention to improve attendance should focus on improving intention to attend following discharge and during recovery by improving patient understanding of cardiac rehabilitation and reducing negative affect.

Communication of behaviour change interventions: Can they be recognised from written descriptions?

OBJECTIVE: Communication of the content of a behaviour change intervention (BCI) involves clear description followed by appropriate recognition and interpretation. We investigated accuracy of recognition of BCI descriptions and the effects of training in the behaviour change taxonomy BCTTv1. METHODS: Materials were 166 written descriptions of two BCIs previously written by 166 separate writers after viewing a video of the BCI. Each of the current participants (12 naïve and 12 trained in BCTTv1) was presented with a random sample of the written descriptions and asked to form groups of descriptions they judged to be describing the same intervention. For each participant, we assessed the number of groupings of BCI descriptions, their purity (containing only one BCI) and their differentiation (having a dominant BCI). RESULTS: All except one participant classified the descriptions into more than two groupings. Naïve participants created significantly more groupings, fewer 'pure' groupings and less differentiated groupings (all Mann-Whitney p < .05). CONCLUSIONS: Written communications of BCI contents may not be recognised and interpreted adequately to support implementation. BCT taxonomy training may lead to some progress in interpreting the active content of interventions but, based on this limited study, further progress is needed if BCIs for accurate implementation.

The state of the art and future opportunities for using longitudinal n-of-1 methods in health behaviour research: a systematic literature overview.

n-of-1 studies test hypotheses within individuals based on repeated measurement of variables within the individual over time. Intra-individual effects may differ from those found in between-participant studies. Using examples from a systematic review of n-of-1 studies in health behaviour research, this article provides a state of the art overview of the use of n-of-1 methods, organised according to key methodological considerations related to n-of-1 design and analysis, and describes future challenges and opportunities. A comprehensive search strategy (PROSPERO:CRD42014007258) was used to identify articles published between 2000 and 2016, reporting observational or interventional n-of-1 studies with health behaviour outcomes. Thirty-nine articles were identified which reported on n-of-1 observational designs and a range of n-of-1 interventional designs, including AB, ABA, ABABA, alternating treatments, n-of-1 randomised controlled trial, multiple baseline and changing criterion designs. Behaviours measured included treatment adherence, physical activity, drug/alcohol use, sleep, smoking and eating behaviour. Descriptive, visual or statistical analyses were used. We identify scope and opportunities for using n-of-1 methods to answer key questions in health behaviour research. n-of-1 methods provide the tools needed to help advance theoretical knowledge and personalise/tailor health behaviour interventions to individuals.

What do Demand-Control and Effort-Reward work stress questionnaires really measure? A discriminant content validity study of relevance and representativeness of measures.

OBJECTIVES: The Demand-Control (DC) and Effort-Reward Imbalance (ERI) models predict health in a work context. Self-report measures of the four key constructs (demand, control, effort, and reward) have been developed and it is important that these measures have good content validity uncontaminated by content from other constructs. We assessed relevance (whether items reflect the constructs) and representativeness (whether all aspects of the construct are assessed, and all items contribute to that assessment) across the instruments and items. METHODS: Two studies examined fourteen demand/control items from the Job Content Questionnaire and seventeen effort/reward items from the Effort-Reward Imbalance measure using discriminant content validation and a third study developed new methods to assess instrument representativeness. Both methods use judges' ratings and construct definitions to get transparent quantitative estimates of construct validity. Study 1 used dictionary definitions while studies 2 and 3 used published phrases to define constructs. RESULTS: Overall, 3/5 demand items, 4/9 control items, 1/6 effort items, and 7/11 reward items were uniquely classified to the appropriate theoretical construct and were therefore 'pure' items with discriminant content validity (DCV). All pure items measured a defining phrase. However, both the DC and ERI assessment instruments failed to assess all defining aspects. CONCLUSIONS: Finding good discriminant content validity for demand and reward measures means these measures are usable and our quantitative results can guide item selection. By contrast, effort and control measures had limitations (in relevance and representativeness) presenting a challenge to the implementation of the theories. Statement of contribution What is already known on this subject? While the reliability and construct validity of Demand-Control and Effort-Reward-Imbalance (DC and ERI) work stress measures are routinely reported, there has not been adequate investigation of their content validity. This paper investigates their content validity in terms of both relevance and representativeness and provides a model for the investigation of content validity of measures in health psychology more generally. What does this study add? A new application of an existing method, discriminant content validity, and a new method of assessing instrument representativeness. 'Pure' DC and ERI items are identified, as are constructs that are not fully represented by their assessment instruments. The findings are important for studies attempting to distinguish between the main DC and ERI work stress constructs. The quantitative results can be used to guide item selection for future studies.

What Is Behavioural Medicine? Commentary on Definition Proposed by Dekker, Stauder and Penedo.

PURPOSE: Dekker et al. (2016) propose an updated definition of behavioural medicine. METHOD: In this commentary, we discuss how the field and the disciplines involved have changed over time before suggesting small amendments to the proposed definition. RESULTS: We suggest that the range of medicine which might be considered 'behavioural' is increasing to encompass virtually all medical practice. In addition, the role of behaviour and the potential for behaviour change as a means of improving health have become increasingly important. A defining characteristic of behavioural medicine is the involvement of multiple disciplines, working together or in parallel and, as the extent of the field expands, more disciplines are likely to be involved. CONCLUSION: We therefore propose that the definition should represent the full width of the research, practice and disciplines involved in behavioural medicine.

Stressors, Appraisal of Stressors, Experienced Stress and Cardiac Response: A Real-Time, Real-Life Investigation of Work Stress in Nurses.

BACKGROUND: Stress in health care professionals may reflect both the work and appraisal of work and impacts on the individuals, their patients, colleagues and managers. PURPOSE: The purpose of the present study is to examine physiological and psychological effects of stressors (tasks) and theory-based perceptions of work stressors within and between nurses in real time. METHODS: During two work shifts, 100 nurses rated experienced stress, affect, fatigue, theory-based measures of work stress and nursing tasks on electronic diaries every 90 min, whereas heart rate and activity were measured continuously. RESULTS: Heart rate was associated with both demand and effort. Experienced stress was related to demand, control, effort and reward. Effort and reward interacted as predicted (but only within people). Results were unchanged when allowance was made for work tasks. CONCLUSIONS: Real-time appraisals were more important than actual tasks in predicting both psychological and physiological correlates of stress. At times when effort was high, perceived reward reduced stress.

Understanding usage of a hybrid website and smartphone app for weight management: a mixed-methods study.

BACKGROUND: Advancements in mobile phone technology offer huge potential for enhancing the timely delivery of health behavior change interventions. The development of smartphone-based health interventions (apps) is a rapidly growing field of research, yet there have been few longitudinal examinations of how people experience and use these apps within their day-to-day routines, particularly within the context of a hybrid Web- and app-based intervention. OBJECTIVE: This study used an in-depth mixed-methods design to examine individual variation in (1) impact on self-reported goal engagement (ie, motivation, self-efficacy, awareness, effort, achievement) of access to a weight management app (POWeR Tracker) when provided alongside a Web-based weight management intervention (POWeR) and (2) usage and views of POWeR Tracker. METHODS: Thirteen adults were provided access to POWeR and were monitored over a 4-week period. Access to POWeR Tracker was provided in 2 alternate weeks (ie, weeks 1 and 3 or weeks 2 and 4). Participants' goal engagement was measured daily via self-report. Mixed effects models were used to examine change in goal engagement between the weeks when POWeR Tracker was and was not available and whether the extent of change in goal engagement varied between individual participants. Usage of POWeR and POWeR Tracker was automatically recorded for each participant. Telephone interviews were conducted and analyzed using inductive thematic analysis to further explore participants' experiences using POWeR and POWeR Tracker. RESULTS: Access to POWeR Tracker was associated with a significant increase in participants' awareness of their eating (ß1=0.31, P=.04) and physical activity goals (ß1=0.28, P=.03). The level of increase varied between individual participants. Usage data showed that participants used the POWeR website for similar amounts of time during the weeks when POWeR Tracker was (mean 29 minutes, SD 31 minutes) and was not available (mean 27 minutes, SD 33 minutes). POWeR Tracker was mostly accessed in short bursts (mean 3 minutes, SD 2 minutes) during convenient moments or moments when participants deemed the intervention content most relevant. The qualitative data indicated that nearly all participants agreed that it was more convenient to access information on-the-go via their mobiles compared to a computer. However, participants varied in their views and usage of the Web- versus app-based components and the informational versus tracking tools provided by POWeR Tracker. CONCLUSIONS: This study provides evidence that smartphones have the potential to improve individuals' engagement with their health-related goals when used as a supplement to an existing online intervention. The perceived convenience of mobile access to information does not appear to deter use of Web-based interventions or strengthen the impact of app access on goal engagement. A mixed-methods design enabled exploration of individual variation in daily usage of the app-based tools.

The physical environment and health-enhancing activity during the school commute: global positioning system, geographical information systems and accelerometry.

Active school travel is in decline. An understanding of the potential determinants of health-enhancing physical activity during the school commute may help to inform interventions aimed at reversing these trends. The purpose of this study was to identify the physical environmental factors associated with health-enhancing physical activity during the school commute. Data were collected in 2009 on 166 children commuting home from school in Scotland. Data on location and physical activity were measured using global positioning systems (GPS) and accelerometers, and mapped using geographical information systems (GIS). Multi-level logistic regression models accounting for repeated observations within participants were used to test for associations between each land-use category (road/track/path, other man-made, greenspace, other natural) and moderate-to-vigorous physical activity (MVPA). Thirty-nine children provided 2,782 matched data points. Over one third (37.1%) of children's school commute time was spent in MVPA. Children commuted approximately equal amounts of time via natural and man-made land-uses (50.2% and 49.8% respectively). Commuting via road/track/path was associated with increased likelihood of MVPA (Exp(B)=1.23, P <0.05), but this association was not seen for commuting via other manmade land-uses. No association was noted between greenspace use and MVPA, but travelling via other natural land-uses was associated with lower odds of MVPA (Exp(B)=0.32, P <0.05). Children spend equal amounts of time commuting to school via man-made and natural land-uses, yet man-made transportation route infrastructure appears to provide greater opportunities for achieving health-enhancing physical activity levels.

Stress in telephone helpline nurses is associated with failures of concentration, attention and memory, and with more conservative referral decisions.

Nurses working for telephone-based medical helplines must maintain attentional focus while quickly and accurately processing information given by callers to make safe and appropriate treatment decisions. In this study, both higher levels of general occupational stress and elevated stress levels on particular shifts were associated with more frequent failures of attention, memory, and concentration in telephone nurses. Exposure to a stressful shift was also associated with a measurable increase in objectively assessed information-processing errors. Nurses who experienced more frequent cognitive failures at work made more conservative decisions, tending to refer patients on to other health professionals more often than other nurses. As stress is associated with cognitive performance decrements in telephone nursing, stress-reduction interventions could improve the quality and safety of care that callers to medical helplines receive.