Mental health of healthcare workers during the first year of the COVID-19 pandemic in the Netherlands: a longitudinal study.

Purpose: In March 2020, the WHO declared COVID-19 a pandemic. Previous virus outbreaks, such as the SARS outbreak in 2003, appeared to have a great impact on the mental health of healthcare workers. The aim of this study is to examine to what extent mental health of healthcare workers differed from non-healthcare workers during the first year of the COVID-19 pandemic. Methods: We used data from a large-scale longitudinal online survey conducted by the Corona Behavioral Unit in the Netherlands. Eleven measurement rounds were analyzed, from April 2020 to March 2021 (N = 16,615; number of observations = 64,206). Mental health, as measured by the 5-item Mental Health Inventory, was compared between healthcare workers and non-healthcare workers over time, by performing linear GEE-analyses. Results: Mental health scores were higher among healthcare workers compared to non-healthcare workers during the first year of the pandemic (1.29 on a 0-100 scale, 95%-CI = 0.75-1.84). During peak periods of the pandemic, with over 100 hospital admissions or over 25 ICU admissions per day and subsequently more restrictive measures, mental health scores were observed to be lower in both healthcare workers and non-healthcare workers. Conclusion: During the first year of the COVID-19 pandemic, we observed no relevant difference in mental health between healthcare workers and non-healthcare workers in the Netherlands. To be better prepared for another pandemic, future research should investigate which factors hinder and which factors support healthcare workers to maintain a good mental health.

Mental models of the protein shift: Exploring consumers' perceptions of the transition.

The protein transition is one of today's major societal challenges to mitigate climate change. To support lasting consumer engagement, it has been suggested to look into consumers' understanding of the protein transition to identify barriers that go beyond the practical issues of changing one's diet. The current study explored consumers' mental models of how the transition unfolds to examine which factors consumers perceive as important drivers of the transition. With a fixed set of factors and actors identified with a questionnaire, Dutch consumers (N = 214) mapped their mental models. The content and structure of the mental models were analyzed with a focus on how consumers perceive their own role. Animal well-being and environmental concerns were most often included as important drivers. The findings showed a lack of consensus about which actor(s) drive the transition (i.e., none of the actors were included by a majority of the participants). This diffusion of responsibility may be a barrier for consumers to act. Moreover, the relative simplicity of the observed mental models suggests that consumers do not yet employ systems thinking. A systems thinking mindset may help consumers understand how the system behind the transition works and how their individual contributions matter. Two avenues to encourage consumer engagement were identified: 1) emphasizing the responsibility of different actors and what consumers can contribute, and 2) encouraging a systems thinking mindset.

Understanding public support for COVID-19 pandemic mitigation measures over time: Does it wear out?

Background: COVID-19 mitigation measures intend to protect public health, but their adverse psychological, social, and economic effects weaken public support. Less favorable trade-offs may especially weaken support for more restrictive measures. Support for mitigation measures may also differ between population subgroups who experience different benefits and costs, and decrease over time, a phenomenon termed "pandemic fatigue." Methods: We examined self-reported support for COVID-19 mitigation measures in the Netherlands over 12 consecutives waves of data collection between April 2020 and May 2021 in an open population cohort study. Participants were recruited through community panels of the 25 regional public health services, and through links to the online surveys advertised on social media. The 54,010 unique participants in the cohort study on average participated in 4 waves of data collection. Most participants were female (65%), middle-aged [57% (40-69 years)], highly educated (57%), not living alone (84%), residing in an urban area (60%), and born in the Netherlands (95%). Results: COVID-19 mitigation measures implemented in the Netherlands remained generally well-supported over time [all scores >3 on 5-point scale ranging 1 (low)-5 (high)]. During the whole period studied, support was highest for personal hygiene measures, quarantine and wearing face masks, high but somewhat lower for not shaking hands, testing and self-isolation, and restricting social contacts, and lowest for limiting visitors at home, and not traveling abroad. Women and higher educated people were more supportive of some mitigation measures than men and lower educated people. Older people were more supportive of more restrictive measures than younger people, and support for more socially restrictive measures decreased most over time in higher educated people or in younger people. Conclusions: This study found no support for pandemic fatigue in terms of a gradual decline in support for all mitigation measures in the first year of the pandemic. Rather, findings suggest that support for mitigation measures reflects a balancing of benefits and cost, which may change over time, and differ between measures and population subgroups.

How do people understand the spread of COVID-19 infections? Mapping mental models of factors contributing to the pandemic.

OBJECTIVE: To describe the mental models people hold about the COVID-19 pandemic, with a focus on how they understand the factors that drive the spread of COVID-19 and what kind of beliefs are associated with these models. DESIGN: In a series of three studies (total N = 461), we asked participants to identify factors that are relevant for COVID-19 proliferation (Study 1a), rate the importance of factors (Study 1 b), and create a mental model of how these factors relate to virus spread by employing a validated tool for mental model elicitation (Study 2). Main outcome measures: inclusion and centrality of factors in mental models of COVID-19 infection spread. RESULTS: Mitigation measures issued by government, adherence to measures, and virus characteristics were most strongly represented in participants' mental models. Participants who perceived measures as appropriate or who experienced more control and more worry over the spread of the virus created more complex models compared to participants who were less satisfied with measures or who felt lower control and less worry. CONCLUSION: These findings suggest that people are able to create sensible mental models of virus transmission but may appreciate transparent communication to comprehend the bigger picture behind the governmental mitigation strategy.

Understanding COVID-19 vaccination willingness among youth: A survey study in the Netherlands.

Vaccination of youth could be key to preventing future outbreaks of SARS-CoV-2. Given the limited direct health benefit for young people, it is important to understand how youth themselves perceive obtaining a vaccination. This survey study in a representative sample of Dutch youth aged 12-18 showed that 73% were willing to get vaccinated against COVID-19. In regression analyses, vaccination willingness was strongly related to age, perceived personal (protect own health) and societal benefits (to get rid of restrictive policies), and their peers' and parents' vaccination uptake. Negative associations with vaccination willingness were perceived side-effects and potential unknown long term consequences. On-going and transparent communication with up-to-date information about safety and risks, delivered by independent and trusted experts (as perceived by the recipients) seems important for addressing questions and concerns. Local information sessions for youth and parents where a vaccination can be obtained without appointment could have merit in addition to mass media communication.

Understanding a national increase in COVID-19 vaccination intention, the Netherlands, November 2020-March 2021.

The intention to get the COVID-19 vaccine increased from 48% (November 2020) to 75% (March 2021) as national campaigning in the Netherlands commenced. Using a mixed method approach we identified six vaccination beliefs and two contextual factors informing this increase. Analysis of a national survey confirmed that shifting intentions were a function of shifting beliefs: people with stronger intention to vaccinate were most motivated by protecting others and reopening society; those reluctant were most concerned about side effects.

Discussing overweight in dogs during a regular consultation in general practice in the Netherlands.

In previous studies, it has been demonstrated that, similar to general practitioners, veterinarians find it difficult to discuss overweight in dogs. This study aimed to provide insight in the barriers and motivators for veterinarians to discuss overweight in dogs and to compare the results with findings from human medicine. Sub-hypotheses were postulated based on existing literature to investigate if lack of time, fear of offending clients, or lack of skills were potential barriers, and if feeling responsible and feeling compassion were potential motivators for veterinarians to discuss overweight in dogs. To this end, an online survey (n = 59) was conducted. Furthermore, 15 small animal clinicians working in general practice were interviewed by semi-structured face-to-face interviews. Results from the online survey indicated that veterinarians find it sometimes difficult to discuss overweight in dogs. Veterinarians who responded to the online survey did not experience strong barriers but did make use of motivators (e.g. feeling responsible and feeling compassion) when discussing overweight in dogs. Interestingly, results from the semi-structured face-to-face interviews showed that the responding veterinarians did experience strong barriers, as well as motivators, when discussing overweight in dogs with their clients. The most prominent barrier was customer dissatisfaction, whereas lack of time and lack of skills were also experienced. The most prominent motivator was feeling responsible for animal health and preventive veterinary medicine. These findings were strikingly similar to previous research on discussing childhood overweight by general practitioners. To improve treatment and prevention of overweight in dogs, veterinarians need more communication skills and should be more aware of the motivators that drive their self-motivation. Improving awareness on overweight and its comorbidities should be a One Health issue.

Evaluating the Potential Benefit of a Combined Weight Loss Program in Dogs and Their Owners.

Introduction: Little has been published on the psychological bond between the owner and the pet, and how this might influence shared habits that could lead to overweight and obesity. Another factor that could improve the effectiveness of a weight loss plan, is that the owner would see the dog as a weight loss partner and therefore this could increase the motivation to follow the assigned diet and exercise guidelines. Objective: The aim of this research was to evaluate the potential mutual effects of weight loss programs for both dogs and dog owners. Methods: Two studies were conducted: In the human-centered trial, 60 dog owners were enrolled, who signed up to receive dietary and exercise recommendations to lose weight themselves during an 8 week period, from which 29 were randomly assigned to also get recommendations for their dog. For the dog-centered trial, we selected 13 dog owners that wanted their dog to lose weight during a 6 week period, from which 7 were randomly assigned to also get recommendations for themselves. The average weight loss over the time period was recorded. A questionnaire was used to evaluate diet and exercise habits, as well as information about the relationship between the dog and owner. Results: The average human weight loss was 2.6% in the owner+dog group (n = 29) and 2.3% in the owner only group (n = 31; p > 0.05). Forty percent (24/60) of the dogs in the human-centered trial were overweight. The overweight dogs in the owner+dog group (n = 12/29) lost 3.7% of their body weight, compared to 1.2% in the overweight dogs from the owner only group (n = 12/31; p > 0.05). In the dog-centered trial, the 7 dogs in the dog+owner group lost 8.0% of their body weight, vs. 8.3% in the six dogs in the dog only group (p > 0.05). The owners in the dog+owner group lost 2.5% of their body weight, compared to 0.5% in the dog only group (p > 0.05). In both trials owners' perceived responsibility for both their own and their dogs' weight significantly increased. In addition, habit strength regarding unhealthy feeding and exercise behaviors in relation to the dogs decreased, and self-efficacy in relation to providing the dog with healthy food and exercise increased. Conclusion: Active weight loss in either dog owner or dog, seemed to lead to passive weight loss in the other, especially when some tools or guidelines were provided. These findings support mutual benefits of weight loss programs for dogs and dog owners, and support future weight loss programs to be a One Health approach.

When in Doubt, Follow the Crowd? Responsiveness to Social Proof Nudges in the Absence of Clear Preferences.

Nudges have gained popularity as a behavioral change tool that aims to facilitate the selection of the sensible choice option by altering the way choice options are presented. Although nudges are designed to facilitate these choices without interfering with people's prior preferences, both the relation between individuals' prior preferences and nudge effectiveness, as well as the notion that nudges 'facilitate' decision-making have received little empirical scrutiny. Two studies examine the hypothesis that a social proof nudge is particularly effective when people have no clear prior preference, either because people are indifferent (in a color-categorization task; Study 1, N = 255) or because people experience a choice conflict (making shopping decisions about meat products; Study 2, N = 97). Both studies employed a social proof nudge to steer participants' choices. The potential facilitating effect of the nudge was tested using a mouse-tracker paradigm that implicitly assessed experienced uncertainty during decision-making. Results showed that the nudge was effective in steering participants' decisions; the facilitation effect (i.e., reduced uncertainty regarding the decision) was only observed for conflicting preferences, but not under indifference. A better understanding of when and how nudges can influence individuals' behavior may help in deciding whether nudges are an appropriate policy tool for changing particular undesirable behavior.

"Don't Mind If I Do": The Role of Behavioral Resistance in Self-Control's Effects on Behavior.

High self-control is known to be related to the performance of behaviors that have long-term benefits, such as healthy eating. Recently, studies have suggested that people with high self-control may perform goal-directed behaviors not by exerting effortful control but rather by employing smart, effortless strategies. The current paper investigates the crucial role of behavioral resistance in the relation between self-control and goal-directed behaviors: we propose that people with high self-control feel less resistance toward goal-directed behaviors compared to people with low self-control, and that this is associated with the increased frequency of performing these behaviors. Three cross-sectional studies were conducted in which participants reported on their level of self-control, behavioral resistance toward behaviors in the sustainability, healthy eating, exercise, and study/work domains, and their behavior in those domains. Findings consistently show that the relation between self-control and various behaviors is indeed partially mediated by behavioral resistance, although the study designs preclude establishing causal relations. It is implied that lower resistance makes it easier for people with higher self-control to perform the goal-directed behaviors, without requiring much effort. This notion yields an interesting, novel perspective on how people with high self-control manage to function so well.

The (bitter) sweet taste of nudge effectiveness: The role of habits in a portion size nudge, a proof of concept study.

Seemingly insignificant daily practices, such as sugar usage in tea, can have a great accumulated impact on societal issues, such as obesity. That is why these behaviours are often the target of nudge interventions. However, when these behaviours are performed frequently they may turn into habits that are difficult to change. The aim of the current study was to investigate whether a portion size nudge has the potential to work in accordance with (instead of against) existing habits. Specifically, it was tested whether a portion size nudge would be more effective in reducing the amount of sugar added to tea, when people have a strong habit of adding a fixed amount of teaspoons of sugar to a cup of tea. The study (N = 123) had a mixed factorial design with teaspoon size (reduced size vs. control) as a within-subject factor, and habit disruption context condition (hot tea vs. cold tea) as a between-subjects factor. A paired t-test indicated that this nudge reduced sugar intake on average by 27% within subjects. When the context allowed for automatic enactment of the habit, the effectiveness of this nudge was moderated by habit strength. Surprisingly, the nudge effect was actually less pronounced when people had a strong habit. Implications for effective nudge interventions are discussed.

Discussing overweight in children during a regular consultation in general practice: a qualitative study.

BACKGROUND: Overweight in children is a rising problem leading to serious consequences later in life. The Dutch guideline 'Obesity' for general practitioners recommends discussing obesity in children regardless of the reason of consultation and provides diagnostic and therapeutic tools. However, limited literature indicates that general practitioners experience barriers to discuss this topic. The aim of this study was to determine current perceived barriers of general practitioners in discussing overweight during a regular consultation in children aged 4 to 12 years and to what extent they discuss the topic. Furthermore, we attempt to get more insight in the specific needs and ideas for improvement among GPs. METHODS: A semi-structured in-depth interview study was conducted. Dutch general practitioners with a broad range of demographic characteristics were invited to participate. The transcripts were analysed using a modified version of the constant comparative method. Using this method, we identified perceived barriers of general practitioners. RESULTS: Ten general practitioners were included in the study. Four major themes were identified in the interviews: absence of physical or mental complaints related to overweight, internal barriers of the general practitioners, the child's family background and logistics. Major barriers appeared to be a low consultation rate of these children, the sensitivity of the topic (e.g. fear for children's or parents' reactions and/or disturbance of the relation, influence on the self-esteem of the child, resistance in the parents), the absence of a long-standing relation between general practitioner and child or parent, the background of the child and lack of time or prioritizing. CONCLUSION: Dutch general practitioners indicate to experience barriers and need tools for how to discuss children's overweight during regular consultations within the limited time available. The low consultation rate among children aged 4 to 12 years due to lack of physical complaints is mentioned as a new and important barrier. Therefore, the prior focus might be raising awareness among parents concerning overweight in children aged 4 to 12 years and, thereby, stressing the potential supporting role of primary care professionals in tackling the overweight of their child.

Cueing healthier alternatives for take-away: a field experiment on the effects of (disclosing) three nudges on food choices.

BACKGROUND: The current field experiment demonstrates the effectiveness of nudging to promote healthy food choices. METHODS: Three types of nudges were implemented at a take-away food vendor: 1) an accessibility nudge that placed fruits at the front counter; 2) a salience nudge that presented healthy bread rolls to be more visually attractive; and 3) a social proof nudge that conveyed yoghurt as a popular choice. We additionally assessed whether nudging effects would remain robust when a disclosure message was included. The field experiment was conducted over a seven-week period. The measured outcome was the sales of the targeted healthy food products. RESULTS: The accessibility nudge significantly increased the sales of the fresh fruits. The impact of the salience nudge was limited presumably due to existing preferences or habits that typically facilitate bread purchases. As the sales of the yoghurt shakes remained consistently low over the seven-week period the impact of the social proof nudge remained unexamined. Critically, disclosing the purpose of the nudges did not interfere with effects. CONCLUSIONS: Current findings suggest nudging as an effective strategy for healthy food promotion, and offer implications for topical debate regarding the ethics of nudges.

I'm still standing: A longitudinal study on the effect of a default nudge.

OBJECTIVE: This study assessed the effect of a default nudge to reduce sedentary behaviour at work over time. DESIGN AND MAIN OUTCOME MEASURES: A field study was conducted at a governmental organisation. In the present study, the default setting of sit-stand desks (SSDs) was changed from sitting to standing height during a two-week intervention. Stand-up working rates were calculated based on observations that were done prior to, during, two weeks after and two months after the intervention. Additionally, a pre-measure survey (n = 606) and post-measure survey (n = 354) were completed. Intention and social norms concerning stand-up working were compared for the 183 employees who completed both pre- and post-assessments (45.4% female, Mage = 44.21). RESULTS: Stand-up working rates raised from 1.82% in the baseline to 13.13% during the intervention. After the nudge was removed the percentage was 10.01% after two weeks and 7.78% after two months. A multilevel analysis indicated a significant increase in both intention and social norms after the nudge intervention. CONCLUSIONS: This study shows that a default nudge can increase stand-up working rates in offices with SSDs at least until two months after the nudge intervention.

The Hunger Games: Using hunger to promote healthy choices in self-control conflicts.

The majority of existing research and conventional wisdom would advise against shopping on an empty stomach as hunger is assumed to encourage impulsive choices that typically lead to self-control failure (i.e., favouring short-term gratifications at the expense of long-term goals). Nonetheless, through two studies the current research aims to demonstrate that hungry consumers would not always be disadvantaged when encountering a self-control conflict involving a trade-off choice between a healthy vs. a more palatable but unhealthy choice. Particularly we posit that the choice outcome of the self-control conflict is dependent on contextual cues, such that hungry consumers with the tendency to make fast decisions could benefit from following a social proof heuristic promoting the healthy options. In Study 1, we indeed observed participants' self-reported hunger to be negatively associated with state self-control, but as most participants generally experienced low levels of hunger we did not observe apparent effects of hunger on food choice (DV), and correspondingly the potential influence of the social proof heuristic in moderating the choice outcome. However, in Study 2 where hunger was manipulated, we found hungry participants making significantly less healthy choices than satiated participants, but a social proof heuristic mitigated this effect (i.e., in the presence of social proof heuristic hungry participants made just as many healthy food choices as satiated participants; and hungry participants made more healthy choices in the social proof condition than in the no heuristic condition). These findings support our approach of providing contextual cues in the environment in order to work with, rather than against, the impulsivity triggered by hunger to promote successful self-control behaviours.

Supersize my brain: A cross-sectional voxel-based morphometry study on the association between self-reported dietary restraint and regional grey matter volumes.

Restrained eaters do not eat less than their unrestrained counterparts. Proposed underlying mechanisms are that restrained eaters are more reward sensitive and that they have worse inhibitory control. Although fMRI studies assessed these mechanisms, it is unknown how brain anatomy relates to dietary restraint. Voxel-based morphometry was performed on anatomical scans from 155 normal-weight females to investigate how regional grey matter volume correlates with restraint. A positive correlation was found in several areas, including the parahippocampal gyrus, hippocampus, striatum and the amygdala (bilaterally, p<0.05, corrected). A negative correlation was found in several areas, including the inferior frontal gyrus, superior frontal gyrus, supplementary motor area, middle cingulate cortex and precentral gyrus (p<0.05, corrected). That higher restraint relates to higher grey matter volume in reward-related areas and lower grey matter volume in regions involved in inhibition, provides a neuroanatomical underpinning of theories relating restraint to increased reward sensitivity and reduced inhibitory capacity.

Turning Pain Into Cues for Goal-Directed Behavior: Implementation Intentions Reduce Escape-Avoidance Behavior on a Painful Task.

UNLABELLED: Pain automatically elicits escape-avoidance behavior to avert bodily harm. In patients with chronic pain, long-term escape-avoidance behavior may increase the risk of chronic disability. The aim of the presents study was to examine whether implementation intentions reduce escape-avoidance behavior during painful tasks in healthy individuals. Implementation intentions are "if-then" self-statements associating situational cues with goal-directed behaviors. Seventy healthy participants performed a painful finger pressing task, preceded by either implementation intention instructions with pain or a nonpain cue as a cue for goal-directed behavior, or control instructions. Escape-avoidance behavior was operationalized as task duration and response rate. Inhibitory control was measured using the Stop Signal Task. The pain implementation intentions resulted in the longest task duration (P = .02), and thus less escape-avoidance behavior. Low inhibitory control was associated with shorter task duration (P = .03), and thus more escape-avoidance behavior. The nonpain implementation intentions resulted in the highest response rate, but only when inhibitory control was low (P = .04). Implementation intentions referring to pain or nonpain reduce escape-avoidance behavior on a painful task. It is worthwhile to examine whether individuals in pain and with low inhibitory control benefit from interventions that incorporate implementation intentions. PERSPECTIVE: To our knowledge, this study is the first to show that forming implementation intentions reduces escape-avoidance behavior during pain and fosters nonpain goal pursuit. The use of implementation intentions is indicated to be an intervention that could be of use in patients with pain, particularly when inhibitory control is low.

Health behaviour procrastination: a novel reasoned route towards self-regulatory failure.

In this paper, we highlight a novel perspective on health behaviour failure by considering reasoned procrastination as a contributing factor. We argue that the failure to enact intentions does not necessarily occur because people are victims of their strong impulses, but that people may also knowingly and wilfully postpone their intended actions. While procrastination is acknowledged as a factor associated with intention-behaviour gaps in other domains, it has surprisingly received only very little attention in the domain of health behaviour. We argue that it is particularly important to recognise the waxing and waning of intentions: rather than being truly abandoned, intentions may sometimes be temporarily put aside. This paper describes how the procrastination account relates to the intention-behaviour gap as we know it, what is known about procrastination and health behaviour, and what theoretical and practical implications can be derived from the addition of this novel perspective to our understanding of health behaviour change.

Bedtime procrastination: A self-regulation perspective on sleep insufficiency in the general population.

Getting insufficient sleep has serious consequences in terms of mental and physical health. The current study is the first to approach insufficient sleep from a self-regulation perspective by investigating the phenomenon of bedtime procrastination: going to bed later than intended, without having external reasons for doing so. Data from a representative sample of Dutch adults (N = 2431) revealed that a large proportion of the general population experiences getting insufficient sleep and regularly goes to bed later than they would like to. Most importantly, a relationship between self-regulation and experienced insufficient sleep was found, which was mediated by bedtime procrastination.