Free-living physical activity and executive function: A multi-study analysis of age groups and times of day / Actividad física de vida libre y función ejecutiva: un análisis de múltiples estudios de grupos de edad y horas del día

Background: Executive Function (EF) is a potential mechanism linking physical activity (PA) and mental health. However, evidence regarding the association between free-living PA and EF is limited with mixed results. Across two studies, we examined associations between accelerometer-assessed moderate-to-vigorous PA (MVPA) and facets of EF in different age groups (Study 1) and at different times of day (Study 2). Method: In Study 1, we tested the association between MVPA and verbal fluency across seven days in 285 participants (children, adults, older adults). In Study 2, we tested between- and within-person associations between MVPA and working memory (afternoon, evening, next morning) across three 18-day bursts in 64 preadolescents. Results: Study 1 showed no association between MVPA and verbal fluency overall, but there was an interaction by age group: a positive association was evident in older adults only. In Study 2, we observed a positive between-person association between MVPA and subsequent afternoon and next morning working memory, but not within-person. In the evening, MVPA was not related to working memory. Conclusions: The association between free-living PA and EF differs between age groups and times of day. Future research should consider these factors when examining the association and its role for mental health.(AU)

Free-living physical activity and executive function: A multi-study analysis of age groups and times of day.

Background: Executive Function (EF) is a potential mechanism linking physical activity (PA) and mental health. However, evidence regarding the association between free-living PA and EF is limited with mixed results. Across two studies, we examined associations between accelerometer-assessed moderate-to-vigorous PA (MVPA) and facets of EF in different age groups (Study 1) and at different times of day (Study 2). Method: In Study 1, we tested the association between MVPA and verbal fluency across seven days in 285 participants (children, adults, older adults). In Study 2, we tested between- and within-person associations between MVPA and working memory (afternoon, evening, next morning) across three 18-day bursts in 64 preadolescents. Results: Study 1 showed no association between MVPA and verbal fluency overall, but there was an interaction by age group: a positive association was evident in older adults only. In Study 2, we observed a positive between-person association between MVPA and subsequent afternoon and next morning working memory, but not within-person. In the evening, MVPA was not related to working memory. Conclusions: The association between free-living PA and EF differs between age groups and times of day. Future research should consider these factors when examining the association and its role for mental health.

Stress in performance-related pay: the effect of payment contracts and social-evaluative threat.

There is some evidence that performance-related pay (PRP) leads to higher levels of stress as it incentivizes employees to work harder for longer. However, PRP in the workplace also typically involves performance monitoring, which may introduce an additional source of stress via social-evaluative threat (SET). The current study examined the effect of PRP on stress while varying the level of performance monitoring/SET. Using an incentivized mixed design experiment, 206 participants completed a simulated work task after being randomly allocated to either a PRP contract (£0.20 per correct response, n = 110) or minimum-performance fixed payment contract (£5 for ≥10 correct responses; £0 for <10, n = 96) condition. All participants completed the task during a high SET (explicit performance monitoring) and low SET (no monitoring) condition. Subjective and objective stress were measured through self-report and salivary cortisol. High SET led to higher levels of self-reported stress but not cortisol, whereas there was no effect of the payment condition on either self-reported stress or cortisol. A statistically significant interaction revealed that high SET-fixed payment participants were significantly more stressed than those in the high SET-PRP group. Estimating the regressions separately for high- and low-performing individuals found that the effect was driven by low-performing individuals. These results suggest that fixed payment contracts that have a minimum performance threshold and which include performance monitoring and SET can be more stressful than traditional piece-rate PRP contracts. The current study suggests that incorporating performance monitoring and SET into payment contracts may affect the well-being of employees.

The stability of physicians' risk attitudes across time and domains.

Risk attitude is known to influence physicians' decision-making under uncertainty. Research on the risk attitudes of physicians is therefore important in facilitating a better understanding of physicians' decisions. However, little is known about the stability of physicians' risk attitudes across domains. Using five waves of data from a prospective panel study of Australian physicians from 2013 to 2017, we explored the stability of risk attitudes over a four-year period and examined the association between negative life events and risk attitudes among 4417 physicians. Further, we tested the stability of risk attitude across three domains most relevant to a physician's career and clinical decision-making (financial, career and clinical). The results showed that risk attitude was stable over time at both the mean and individual levels but the correlation between domains was modest. There were no significant associations between negative life events and risk attitude changes in all three domains. These findings suggest that risk attitude can be assumed to be constant but domain-specificity needs to be considered in analyses of physician decision-making.

Classifying the non-metabolic demands of different physical activity types: The Physical Activity Demand (PAD) typology.

Different physical activity types vary in metabolic demand (intensity), but also in non-metabolic physical demand (balance, co-ordination, speed and flexibility), cognitive demand (attention, memory and decision making), and social demand (social interaction). Activity types with different combinations of demands may have different effects on health outcomes but this cannot be formally tested until such demands can be reliably quantified. The present Delphi expert consensus study aimed to objectively quantify the cognitive, physical and social demands of different core physical activity types and use these scores to create a formal Physical Activity Demand (PAD) typology. International experts (n = 40; experts in cognitive science, psychology, sports science and physiology; 7 different nationalities; 18 male/22 female; M = 13.75 years of disciplinary experience) systematically rated the intrinsic cognitive, physical and social demands of 61 common activity types over 2-rounds of a modified Delphi (expert consensus) study. Consensus (>70% agreement) was reached after 2 rounds on the demands of 59/61 activity types. Cognitive, physical and social demand scores were combined to create an overall non-metabolic demand rating for each activity type, and two-step cluster-analysis was used to identify groups of activities with comparable demand profiles. Three distinct clusters of activities were identified representing activity types with low (n = 12 activities; e.g. domestic cleaning), moderate (n = 23 activities; e.g. tai-chi) and high (n = 24 activities; e.g. football) total non-metabolic demands. These activity types were then organised into a formal typology. This typology can now be used to test hypotheses about if and why physical activity types with different combinations of cognitive, physical and social demands affect health outcomes in different ways.

User Experiences in a Digital Intervention to Support Total Skin Self-examination by Melanoma Survivors: Nested Qualitative Evaluation Embedded in a Randomized Controlled Trial.

BACKGROUND: Melanoma is a relatively common cancer type with a high survival rate, but survivors risk recurrences or second primaries. Consequently, patients receive regular hospital follow-up, but this can be burdensome to attend and not optimally timed to detect arising problems. Total skin self-examination (TSSE) supports improved clinical outcomes from melanoma via earlier detection of recurrences and second primaries, and digital technology has the potential to support TSSE. Recent research with app-based interventions aimed at improving the well-being of older adults has found that they can use the technology and benefit from it, supporting the use of digital health care in diverse demographic groups. Thus, the Achieving Self-directed Integrated Cancer Aftercare (ASICA) digital health care intervention was developed. The intervention provided melanoma survivors with a monthly prompt to perform a TSSE as well as access to a dermatology nurse who provided them with feedback on photographs and descriptions of their skin. OBJECTIVE: We aimed to explore participants' attitudes, beliefs, and experiences regarding TSSE practices. Furthermore, we explored how participants experienced technology and how it influenced their practice of TSSE. Finally, we explored the practical and technical experiences of ASICA users. METHODS: This was a nested qualitative evaluation within a dual-center randomized controlled trial of the ASICA intervention. We conducted semistructured telephone interviews with the participants during a randomized controlled trial. The participants were purposively sampled to achieve a representative sample with representative proportions by age, sex, and residential geography. Interviews were transcribed verbatim and analyzed using a framework analysis approach applied within NVivo 12. RESULTS: A total of 22 interviews were conducted with participants from both groups. In total, 40% (9/22) of the interviewed participants were from rural areas, and 60% (13/22) were from urban areas; 60% (13/22) were from the intervention group, and 40% (9/22) were from the control group. Themes evolved around skin-checking behavior, other people's input into skin checking, contribution of health care professionals outside ASICA and its value, ideas around technology, practical experiences, and potential improvements. ASICA appeared to change participants' perceptions of skin checking. Users were more likely to report routinely performing TSSE thoroughly. There was some variation in beliefs about skin checking and using technology for health care. Overall, ASICA was experienced positively by participants. Several practical suggestions were made for the improvement of ASICA. CONCLUSIONS: The ASICA intervention appeared to have positively influenced the attitudes and TSSE practices of melanoma survivors. This study provides important qualitative information about how a digital health care intervention is an effective means of prompting, recording, and responding to structured TSSE by melanoma survivors. Technical improvements are required, but the app offers promise for technologically enhanced melanoma follow-up in future. TRIAL REGISTRATION: ClinicalTrials.gov NCT03328247; https://clinicaltrials.gov/ct2/show/NCT03328247?term=ASICA&rank=1. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-019-3453-x.

Barriers and facilitators of adherence to the use of ASICA, a digital app designed to support people previously treated for melanoma: concise report of a qualitative study.

We developed the Achieving Self-directed Integrated Cancer Aftercare (ASICA) in melanoma app to support monthly total-skin self-examinations (TSSE) by people previously treated for melanoma. A randomized 12-month trial demonstrated ASICA supported optimal monthly TSSE adherence in a third of participants (ClinicalTrials.gov NCT03328247). However, a further third of participants adhered well initially but subsequently dropped off, and a final third did not adhere at all. This follow-up qualitative study investigated trial participants' perceptions of barriers and facilitators to TSSE adherence using the app. Three former trial participants participated in a single focus group and 11 participated in new semistructured telephone interviews. These were analysed thematically alongside secondary analysis of 13 qualitative interviews conducted during the trial. All transcripts were recorded, transcribed and analysed thematically. Five themes encompassing barriers and facilitators to ASICA adherence emerged. These were: technology, role of others, tailoring, disease journey and competing priorities. These data will inform further development of ASICA to increase user adherence.

Habits and Reflective Processes in COVID-19 Transmission-reducing Behaviors: Examining Theoretical Predictions in a Representative Sample of the Population of Scotland.

BACKGROUND: Based on theory, COVID-19 transmission-reducing behaviors (TRBs) should become habitual because of their frequent performance. Habits have been hypothesized to develop through reflective processes and, to act in conjunction with them. PURPOSE: We investigated the existence, development, and consequences of TRB habits, for physical distancing, handwashing, and wearing face coverings. METHODS: A representative sample of the Scottish population (N = 1,003) was interviewed by a commercial polling company in August-October 2020 and half were re-interviewed later. Measures included adherence, habit, personal routine tendency, reflective processes, and action control for three TRBs. Data were analyzed using general linear modeling, regression, and mediation analyses. RESULTS: Handwashing was most habitual; only face covering became more habitual over time. Routine tendencies predicted TRB habits, and adherence to handwashing and physical distancing. Those reporting greater habits reported better adherence, for physical distancing and handwashing, and this remained true after controlling for previous adherence. Reflective and habit processes independently predicted adherence for physical distancing and handwashing; only reflective processes were independently predictive for face covering. The relationship between planning and forgetting and adherence was partly direct, and partly mediated by habit. CONCLUSIONS: The results confirm hypotheses from habit theory including the role of repetition and of personal routine tendency in developing habits. They are consistent with dual processing theory in finding that both reflective and habit processes predict adherence to TRBs. Action planning partly mediated the relation between reflective processes and adherence. The COVID-19 pandemic has enabled the testing and confirmation of several theoretical hypotheses about habit processes in the enactment of TRBs.

During the COVID-19 pandemic we were all asked to adopt protective behaviors, for example, keeping distance from people, wearing face masks, and handwashing. When people do the same thing repeatedly in the same situation, that behavior is likely to become a habit. As habits are generally easier to perform and maintain than planned behaviors, understanding whether the protective behaviors we adopted during COVID-19 became habitual will help us understand how best to support people to adopt infection protective behaviors in future. In this study we examined whether protective behaviors became habitual over time during the pandemic. We found that handwashing was the most habitual behavior. This is likely because hand washing was a behavior that people already regularly performed pre-pandemic. Wearing face masks was the only behavior to become more habitual over time. People with stronger habits were more likely to perform the recommendations about handwashing and physical distancing. When you want people to perform a new protective behavior this can be accomplished by making a plan to do it. Following through on these plans will eventually form habits. Habitually performed behaviors that prevent COVID-19 might also help prevent other infections and could therefore improve population health.

Postcancer treatment support programme: an evaluation.

OBJECTIVES: As the number of people living beyond cancer treatment has increased, supportive post-treatment interventions have become increasingly important. The present study investigates whether participation in the Maggie's 'Where Now?' post-cancer support programme is associated with improvements in healthy eating, quality of life, self-efficacy (confidence) or cancer worry. METHODS: In a pre-post design, 88 people who had completed cancer treatment and were enrolled in the 7-week 'Where Now?' programme at Maggie's centres across the UK rated their diet, activity, quality of life, self-efficacy and cancer worries before and after programme participation. Programme content was coded to identify the techniques used to create change ('behaviour change techniques'). RESULTS: Programme participation was associated with significant improvements in general self-efficacy (p=0.01), self-efficacy about engaging in physical activity (p<0.01), quality of life (p<0.01) and cancer worry (p=0.04) but not with changes in healthy eating (p=0.23). CONCLUSION: Participation in the 'Where Now?' programme is associated with significant improvements in several key psychological outcomes in people living beyond cancer. The techniques most commonly used in the programme to create change were giving participants instructions about how to perform a particular behaviour, encouraging problemsolving to overcome barriers and setting goals.

The Achieving Self-directed Integrated Cancer Aftercare Intervention for Detection of Recurrent and Second Primary Melanoma in Survivors of Melanoma: Pilot Randomized Controlled Trial.

BACKGROUND: Melanoma is common with increasing incidence. Guidelines recommend monthly total skin self-examinations (TSSEs) by survivors to detect recurrent and new primary melanomas. TSSE is underperformed despite evidence of benefit. OBJECTIVE: This study compares the effect on psychological well-being and TSSE practice of a self-directed digital intervention with treatment as usual in patients treated for a first stage 0 to IIC primary cutaneous melanoma within the preceding 60 months. METHODS: This randomized clinical trial was conducted at 2 UK National Health Service hospitals (Aberdeen Royal Infirmary, Grampian, and Addenbrooke's, Cambridge). Adults (≥18 years) diagnosed with a first 0 to IIC primary cutaneous melanoma were randomized to receive Achieving Self-directed Integrated Cancer Aftercare (ASICA), a tablet-based intervention prompting and supporting TSSE in survivors of melanoma, or to usual care. The hypothesis was that ASICA would increase TSSE practice in users affected by melanoma and compared with controls without affecting psychological well-being. The main primary outcomes were melanoma worry (Melanoma Worry Scale), anxiety and depression (Hospital Anxiety and Depression Scale), and quality of life (EQ-5D-5L) as well as secondary outcomes collected using postal questionnaires 3, 6, and 12 months following randomization. RESULTS: A total of 240 recruits were randomized (1:1) into the ASICA (n=121, 50.4%) or control (n=119, 49.6%) groups. There were no significant differences between groups for melanoma worry at 12 months (mean difference: 0.12, 95% CI -0.6 to 0.84; P=.74), 3 months (0.23, 95% CI -0.31 to 0.78; P=.40), or 6 months (-0.1, 95% CI -0.7 to 0.51; P=.76). The ASICA group had lower anxiety scores at 12 months (-0.54, 95% CI -1.31 to 0.230; P=.17), 3 months (-0.13, 95% CI -0.79 to 0.54; P=.71), and significantly at 6 months (-1.00, 95% CI -1.74 to -0.26; P=.009). Depression scores were similar, being lower at 12 months (-0.44, 95% CI -1.11 to 0.23; P=.20) and 3 months (-0.24, 95% CI -0.84 to 0.35; P=.42) but only significantly lower at 6 months (-0.77, 95% CI -1.41 to -0.12; P=.02). The ASICA group had significantly higher quality of life scores at 12 months (0.044, 95% CI 0.003-0.085; P=.04) and 6 months (0.070, 95% CI 0.032-0.107; P<.001) and nonsignificantly at 3 months (0.024, 95% CI -0.006 to 0.054; P=.11). ASICA users reported significantly more regular (>5) TSSEs during the study year and significantly higher levels of self-efficacy in conducting TSSE. They also reported significantly higher levels of planning and intention to perform TSSE in the future. CONCLUSIONS: Using ASICA for 12 months does not increase melanoma worry, can reduce anxiety and depression, and may improve quality of life. ASICA has the potential to improve the well-being and vigilance of survivors of melanoma and enable the benefits of regular TSSE. TRIAL REGISTRATION: ClinicalTrials.gov NCT03328247; https://clinicaltrials.gov/ct2/show/NCT03328247. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-019-3453-x.

Salivary cortisol in university students after the COVID-19 pandemic.

The COVID-19 pandemic required people to navigate lockdowns and unfamiliar restrictions for the first time. It is known that situations characterised by uncontrollability and novelty heighten the physiological response to stress. The data presented here was collected as part of an experimental stress study and offered an opportunity to compare cortisol levels upon arrival to the lab before and after the first UK lockdown, when students had to navigate novel health and safety restrictions on campus. Participants (n = 152) were students who took part in an experiment designed to measure salivary cortisol levels as a response to a stress task. All provided a baseline cortisol sample after arriving to the lab but before the experimental task. Pre-lockdown participants (n = 72) were familiar with the campus rules whereas post-lockdown participants (n = 80) had to adhere to novel restrictions, including health questionnaires, PPE and social distancing. The post-lockdown sample had significantly higher levels of baseline cortisol, cortisol output (AUCg) and cortisol response (AUCi) than the pre-lockdown group. This effect remained significant even after controlling for sample characteristics. These findings suggest that navigating new restrictions may lead to heightened levels of anticipatory stress even if there is no difference in recent general mental health before and after the lockdown.

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).

Bedtime Routines Intervention for Children (BRIC) project: results from a non-randomised feasibility, proof-of concept study.

BACKGROUND: Bedtime routines are highly recurrent family activities with implications for children's wellbeing, development and health. AIMS: The objective of this study is to co-develop and test in a feasibility, proof-of-concept study a bedtime routines intervention using text messages aimed at first-time parents with young children. METHODS: Fifty first-time parents with children aged 1-3 years were recruited for this study. Parents received a text message-based intervention for 7-consecutive nights which provided support and information on achieving optimal bedtime routines. Parents completed pre- and post-intervention questionnaires focusing on children's sleep, bedtime routines and parental mood disturbance. Feedback was provided at the end of the study. RESULTS: Recruitment target and high retention with 98%, or 49 out of 50 participants completing the study were achieved. Pre- and post-intervention, there were improvements in total children's sleep with children sleeping longer and having less disrupted sleep overall (MD = - 7.77 (SD = 17.91), t(48) = - 3.03, p = .004, CI (- 12.91, - 2.63) and in overall quality of bedtime routines (MD = - 5.00, SD = 7.01, t(48) = - 4.98, p < .001, CI (- 7.01, - 2.98). Parental mood disturbance decreased pre- to post-intervention (MD = 5.87, SD = 15.43, t(48) = 2.66), p = .010, CI (1.44, 10.30). Parents provided positive feedback about the intervention and valued the support that was provided to them. CONCLUSIONS: Bedtime routines were successfully altered with short-term benefits for children's sleep and parental mood. Future research will need to utilize a more robust, longitudinal approach for a definite exploration of sustained changes in bedtime routines and their long-term implications for children and parents.

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.

Bedtime Routine Characteristics and Activities in Families with Young Children in the North of England.

Bedtime routines have been shown to have significant associations with health, wellbeing and development outcomes for children and parents. Despite the importance of bedtime routines, most research has been carried out in the United States, with little information on bedtime routine characteristics and activities for families in other countries such as the United Kingdom and England in particular. Additionally, little is known about the possible effects of weekends vs. weekdays on the quality of bedtime routines. Finally, traditional, retrospective approaches have been most used in capturing data on bedtime routines, limiting our understanding of a dynamic and complex behaviour. The aim of this study was to explore bedtime routine characteristics and activities in families in the North of England with a real-time, dynamic data collection approach and to examine possible effects of weekend nights on the quality of bedtime routines. In total, 185 parents with children ages 3 to 7 years old provided data around their bedtime routine activities using an automated text-survey assessment over a 7-night period. Information on socio-economic and demographic characteristics were also gathered during recruitment. A small majority of parents managed to achieve all crucial elements of an optimal bedtime routine every night, with 53% reporting brushing their children's teeth every night, 25% reading to their children every night and 30% consistently putting their children to bed at the same time each night. Results showed significant differences between weekend (especially Saturday) and weekday routines (F(1, 100) = 97.584, p < 0.001), with an additional effect for parental employment (F(1, 175) = 7.151, p < 0.05). Results highlight variability in bedtime routine activities and characteristics between families. Many families undertook, in a consistent manner, activities that are closely aligned with good practices and recommendations on what constitutes an optimal bedtime routine, while others struggled. Routines remained relatively stable during weekdays but showed signs of change over the weekend. Additional studies on mechanisms and elements affecting the formation, development and maintenance of bedtime routines are needed alongside studies on supporting and assisting families to achieve optimal routines.

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.

Antibiotic prescribing for respiratory tract infection: exploring drivers of cognitive effort and factors associated with inappropriate prescribing.

BACKGROUND: Antibiotics are over-prescribed for upper respiratory tract infection (URTI). It is unclear how factors known to influence prescribing decisions operate 'in the moment': dual process theories, which propose two systems of thought ('automatic' and 'analytical'), may inform this. OBJECTIVE(S): Investigate cognitive processes underlying antibiotic prescribing for URTI and the factors associated with inappropriate prescribing. METHODS: We conducted a mixed methods study. Primary care physicians in Scotland (n = 158) made prescribing decisions for patient scenarios describing sore throat or otitis media delivered online. Decision difficulty and decision time were recorded. Decisions were categorized as appropriate or inappropriate based on clinical guidelines. Regression analyses explored relationships between scenario and physician characteristics and decision difficulty, time and appropriateness. A subgroup (n = 5) verbalized their thoughts (think aloud) whilst making decisions for a subset of scenarios. Interviews were analysed inductively. RESULTS: Illness duration of 4+ days was associated with greater difficulty. Inappropriate prescribing was associated with clinical factors suggesting viral cause and with patient preference against antibiotics. In interviews, physicians made appropriate decisions quickly for easier cases, with little deliberation, reflecting automatic-type processes. For more difficult cases, physicians deliberated over information in some instances, but not in others, with inappropriate prescribing occurring in both instances. Some interpretations of illness duration and unilateral ear examination findings (for otitis media) were associated with inappropriate prescribing. CONCLUSION: Both automatic and analytical processes may lead to inappropriate prescribing. Interventions to support appropriate prescribing may benefit from targeting interpretation of illness duration and otitis media ear exam findings and facilitating appropriate use of both modes of thinking.

Antibiotics are often used to treat the common cold and ear/nose/throat infections but typically do not work for these issues. We explored the reasons why this prescribing may happen and some of the difficulties doctors might experience when making these treatment decisions. Doctors reviewed written descriptions of patients and decided whether or not to prescribe antibiotics. Some of these doctors also took part in an interview where they 'thought aloud' (said what they were thinking as they were thinking it) while considering the patient descriptions. When the patient had been ill for four or more days, this made decisions more difficult. Sometimes decisions to prescribe due to this illness duration and due to findings from an ear exam were not in line with guidelines for prescribing. Some decisions to prescribe seemed to be more related to automatic habits, while others occurred after careful deliberation over the information. Doctors need more support to make decisions involving these factors and may benefit from strategies to help them use their automatic/habitual thinking and their deliberative thinking in the best ways.

Healthy snacks in hospitals: Testing the potential effects of changes in availability.

BACKGROUND: Hospitals offer snacks for sale to patients, staff and visitors. AIM: As food choice is heavily influenced by the options available, the present study (a) audited snack availability and purchase in NHS hospital sites across a large UK city; and (b) tested the potential effects of changes to this availability in an online choice experiment. METHODS: In Study 1 (audit), single-serve snacks (n=376) available in 76 hospital food retail units were audited. Purchasing data were obtained from six food retail units over four weeks (27,989 sales). In Study 2 (online experiment), participants (n=159) chose snacks from pictured ranges containing 25% (minority), 50% (equivalent) or 75% (majority) healthy options. RESULTS: Available single-serve snacks varied markedly in calorie (18-641 kcals), fat (0-39 g), sugar (0.1-76 g) and salt (0-2.9 g). Only 30% of available snacks were healthy options and only 25% of the most commonly purchased snacks were healthy options. In Study 2, snack choice was significantly associated with the availability of healthy options in the choice array (X2 (2)= 59.71, p<.01). More participants made healthy choices when product ranges contained 75% healthy options compared to 50% (p<.01) and 50% healthy options compared with 25% (p<.01). CONCLUSIONS: Healthy snacks are readily available in NHS sites but there is a greater relative variety of unhealthy snack products. Many consumers continue to purchase unhealthy items. Further increasing the availability and variety of healthy options may support consumers to make healthier choices.

Defining and measuring bedtime routines in families with young children-A DELPHI process for reaching wider consensus.

INTRODUCTION: Bedtime routines are one of the most common family activities. They affect children' wellbeing, development and health. Despite their importance, there is limited evidence and agreement on what constitutes an optimal bedtime routine. This study aims to reach expert consensus on a definition of optimal bedtime routines and to propose a measurement for bedtime routines. METHOD: Four-step DELPHI process completed between February and March 2020 with 59 experts from different scientific, health and social care backgrounds. The DELPHI process started with an expert discussion group and then continued with 3 formal DELPHI rounds during which different elements of the definition and measurement of bedtime routines were iteratively refined. The proposed measurement of bedtime routines was then validated against existing data following the end of the DELPHI process. RESULTS: At the end of the four round DELPHI process and with a consistent 70% agreement level, a holistic definition of bedtime routines for families with young children between the ages of 2 and 8 years was achieved. Additionally, two approaches for measuring bedtime routines, one static (one-off) and one dynamic (over a 7-night period) are proposed following the end of the DELPHI process. A Bland-Altman difference plot was also calculated and visually examined showing agreement between the measurements that could allow them to be used interchangeably. DISCUSSION: Both the definition and the proposed measurements of bedtime routines are an important, initial step towards capturing a behavioural determinant of important health and developmental outcomes in children.

Development of a behaviour change workplace-based intervention to improve nurses' eating and physical activity.

BACKGROUND: There is a critical need for an intervention to improve nurses' eating and physical activity behaviours. As nurses spend a substantial proportion of their waking hours at work, concerted efforts to deliver such interventions in the workplace is growing. This study formed part of a multiphase programme of research that aimed to systematically develop an evidence-based and theory-informed workplace intervention to promote changes in eating and physical activity among nurses. METHODS: The intervention was developed iteratively, in line with Medical Research Council complex intervention guidelines. It involved four activities: (1) identifying the evidence base, (2) understanding the determinants of nurses' eating and physical activity behaviour change through theory-based qualitative interviews and survey, (3) identifying intervention options using the Behaviour Change Wheel, and (4) specifying intervention content and implementation options using a taxonomy of behaviour change techniques. RESULTS: Data from 13 randomised controlled trials indicated that workplace-based behaviour change interventions targeted to this population are effective in changing behaviour. The evidence base was, however, limited in quantity and quality. Nurses' beliefs about important factors determining their eating and physical activity behaviour were identified across 16 qualitative interviews and 245 survey responses, and key determinants included environmental context and resources, behavioural regulation, emotion, beliefs about consequences, knowledge and optimism. Based on these findings, 22 behaviour change techniques suitable for targeting the identified determinants were identified and combined into a potential workplace intervention. CONCLUSIONS: An evidence-based and theory-informed intervention tailored to the target population and setting has been explicitly conceptualised using a systematic approach. The proposed intervention addresses previous evidence gaps for the user population of nurses. Further to this, such an intervention, if implemented, has the potential to impact nurses' eating and physical activity behaviours and in turn, the health of nurses and the quality of healthcare delivery.