Promoting informed decision making about maternal pertussis vaccination: the systematic development of an online tailored decision aid and a centering-based group antenatal care intervention.

Introduction: Maintaining and enhancing vaccine confidence continues to be a challenge. Making an informed decision not only helps to avoid potential future regret but also reduces susceptibility to misinformation. There is an urgent need for interventions that facilitate informed decision-making about vaccines. This paper describes the systematic development of two interventions designed to promote informed decision making and indirectly, acceptance of maternal pertussis vaccination (MPV) in the Netherlands. Materials and methods: The 6-step Intervention Mapping (IM) protocol was used for the development of an online tailored decision aid and Centering Pregnancy-based Group Antenatal Care (CP) intervention. A needs assessment was done using empirical literature and conducting a survey and focus groups (1), intervention objectives were formulated at the behavior and determinants levels (2), theoretical methods of behavior change were selected and translated into practical applications (3), which were further developed into the two interventions using user-centered design (4). Finally, plans were developed for implementation (5), and evaluation (6) of the interventions. Results: The needs assessment showed that pregnant women often based their decision about MPV on information sourced online and conversations with their partners, obstetric care providers, and peers. Responding to these findings, we systematically developed two interactive, theory-based interventions. We created an online tailored decision aid, subjecting it to four iterations of testing among pregnant women, including those with low literacy levels. Participants evaluated prototypes of the intervention positively on relevance and usability. In addition, a CP intervention was developed with midwives. Conclusion: Using IM resulted in the creation of an online decision aid and CP intervention to promote informed decision making regarding MPV. This description of the systematic development of the interventions not only serves to illustrate design rationales, it will also aid the interpretation of the evaluation of the interventions, the development of future interventions promoting informed decision and acceptance of vaccines, and comparisons with other interventions.

Behavior Change Techniques That Prevent or Decrease Obesity in Youth With a Low Socioeconomic Status: A Systematic Review and Meta-Analysis.

Background: Interventions, targeting youth, are necessary to prevent obesity later in life. Especially youth with low socioeconomic status (SES) are vulnerable to develop obesity. This meta-analysis examines the effectiveness of behavioral change techniques (BCTs) to prevent or reduce obesity among 0 to 18-year-olds with a low SES in developed countries. Method: Intervention studies were identified from systematic reviews or meta-analyses published between 2010 and 2020 and retrieved from PsycInfo, Cochrane systematic review, and PubMed. The main outcome was body mass index (BMI), and we coded the BCTs. Results: Data from 30 studies were included in the meta-analysis. The pooled postintervention effects of these studies indicated a nonsignificant decrease in BMI for the intervention group. Longer follow-up (≥12 months) showed favorable differences for intervention studies, although that BMI change was small. Subgroup analyses showed larger effects for studies with six or more BCTs. Furthermore, subgroup analyses showed a significant pooled effect in favor of the intervention for the presence of a specific BCT (problem-solving, social support, instruction on how to perform the behavior, identification of self as role model, and demonstration of the behavior), or absence of a specific BCT (information about health consequences). The intervention program duration and age group of the study population did not significantly influence the studies' effect sizes. Conclusions: Generally, the effects of interventions on BMI change among youth with low SES are small to neglectable. Studies with more than six BCTs and/or specific BCTs had a higher likelihood of decreasing BMI of youth with low SES.

Promoting informed decision-making about maternal pertussis vaccination in Centering Pregnancy group-antenatal care: A feasibility study.

PROBLEM: Effective interventions are needed to promote informed decision making about vaccination. BACKGROUND: We developed a group-antenatal care (CP; Centering Pregnancy) intervention, i.e., a session about MPV within existing group-care settings, to promote informed decision making about Maternal Pertussis Vaccination in the Netherlands. AIM: This study aimed to assess (1) to what extent the intervention was implemented as intended, (2) to what extent the intervention met the needs and wishes of pregnant individuals and midwives facilitating CP. METHODS: We conducted exploratory interviews with 6 CP facilitators and 10 CP participants to assess the implementation of the intervention, and how the intervention and its different components were perceived. Interviews were analysed using thematic analysis. In addition, we conducted a pre- and post-intervention survey amongst 35 participants, measuring knowledge about MPV, and MPV attitude and intention. RESULTS: The CP intervention was implemented as intended in 6 out of 7 groups. Participants were positive about the interactive CP-methods used to discuss MPV. Participants and facilitators evaluated the intervention as positive and relevant, although the intervention was time-consuming, and some participants had already made the de decision about MPV. Those who had not yet decided indicated that the session was helpful for their decision. DISCUSSION AND CONCLUSION: Discussing MPV in CP care settings is a feasible strategy to support decision making about MPV during pregnancy. The intervention could be improved by discussing the MPV sooner than 16-18 weeks of pregnancy. A larger-scale study is needed to assess effects on MPV uptake and informed decision making.

Fidelity, adaptation and integration of whole-school health promotion within Dutch schools: a cross-sectional survey study.

Implementing comprehensive health promotion programs in the school setting can be challenging, as schools can be considered complex adaptive systems. As a first step towards understanding what works in improving implementation for which schools and under which conditions, this study aimed to examine the degree of implementation of health promoting school (HPS) programs, in terms of five dimensions of fidelity (adherence, dose, participant responsiveness, quality of delivery and program differentiation), and the dimensions of adaptation and integration. The HPS Implementation Questionnaire was distributed among ±â€…2400 primary, secondary, secondary vocational and special needs schools in the Netherlands. Employees of 535 schools (22.3%) filled out the questionnaire. Data were analysed by descriptive statistics and ANOVA tests. The average degree of implementation was 2.55 (SD = 0.58, range = 0.68-3.90; scaled 0-4). The lowest scores were achieved for participant responsiveness and adherence, and the highest for integration and adaptation. Schools that identified as HPS reported significantly higher overall degree of implementation, adherence, dose, participant responsiveness, program differentiation and adaptation than schools that didn't. Primary schools achieved a significantly higher degree of implementation, dose, participant responsiveness, quality of delivery and integration than other school types. In conclusion, many schools work on student health and well-being to some extent, but the vast majority have much room for improvement. Higher implementation scores for schools that identified as HPS underline the value of HPS programs. A broader perspective on health and more insight into conditions for effectiveness and implementation in secondary and secondary vocational schools are needed.

Effects of an online tailored decision aid to promote informed decision making about maternal pertussis vaccination in the Netherlands: A randomized controlled trial.

INTRODUCTION: In 2019, maternal pertussis vaccination (MPV) during pregnancy was introduced in the Netherlands. New interventions to promote informed decision making (IDM) about vaccinations are highly needed, especially for new vaccinations. Decision aids (DAs) have the potential to support IDM. This study evaluates the effects of an online DA on IDM and MPV uptake. METHODS: Pregnant individuals, recruited for the randomized controlled trial (RCT), who gave informed consent (N = 1,236) were randomly assigned to the control (N = 650; no information) or intervention condition (N = 586; DA at 18 weeks pregnancy). MPV uptake and IDM were primary outcomes, decisional certainty and psychological determinants of MPV uptake were secondary outcomes. Measures were taken at 18 weeks of pregnancy (baseline) and at 20 weeks of pregnancy (post-test); intervention use was logged. Data were analysed using intention-to-treat analyses, logistic regression, and linear mixed regression models. RESULTS: Uptake of MPV was high in our sample (92.3 %). No significant effect of the DA condition on MPV uptake was found compared to the control condition. We found that the DA increased IDM (ß = 0.24, p < .004) and one of its components level of knowledge about MPV (ß = 0.31, p < .004). We also found an increase in decisional certainty (ß = 0.24, p < .004), perceived susceptibility (ß = 0.24, p < .004), severity of pertussis (ß = 0.41, p < .004), and positive affect about MPV (ß = 0.15, p < .004). There was a positive association between dose of the intervention and MPV uptake (ß = 0.05, p < .004). DISCUSSION: The DA seemed effective in promoting IDM about and determinants of MPV uptake. No main effect was found on MPV uptake, but MPV uptake was related to the level of exposure to the DA. People with high intentions towards MPV were overrepresented in the sample. However, effects on IDM were consistent among participants with different levels of MPV intention at baseline.

Possibilities and Challenges of Delivering Health-Related Small Group Interventions Online: Scoping Review.

BACKGROUND: The outbreak of the COVID-19 pandemic required the transition of health-related face-to-face group interventions to an online setting. While it seems that group outcomes can be realized in an online setting, less is known about resulting potential challenges (and advantages) and how these can be overcome. OBJECTIVE: The aim of this article is to explore what challenges and advantages may arise when providing health-related small group interventions in an online setting and how to overcome these challenges. METHODS: Scopus and Google Scholar databases were searched for relevant literature. Effect studies, meta-analyses, literature reviews, theoretical frameworks, and research reports relating to synchronous, face-to-face, health-related small group interventions, online group interventions, and video teleconferencing group interventions were identified and screened. Findings relating to potential challenges and corresponding strategies are described. In addition, potential advantages of online group settings were explored. Relevant insights were gathered until saturation of results relating to the research questions was reached. RESULTS: The literature indicated several aspects that require extra attention and preparation in the online group setting. These include the delivery of nonverbal communication and affect regulation, as well as the build-up of group cohesion and therapeutic alliance, which seem more challenging online. Yet there are strategies to overcome these challenges, such as metacommunication, collecting participant feedback, and providing guidance concerning technical accessibility. In addition, the online setting provides opportunities to reinforce group identity, such as by allowing independence and the ability to create homogeneous groups. CONCLUSIONS: While online, health-related small group interventions offer a considerable number of possibilities and benefits compared to face-to-face groups, there are also potential drawbacks to consider, which, if anticipated, can be to a great extent overcome.

360° Diagnostic Tool to Personalize Lifestyle Advice in Primary Care for People With Type 2 Diabetes: Development and Usability Study.

BACKGROUND: Various multifaceted factors need to be addressed to improve the health and quality of life of people with type 2 diabetes (T2D). Therefore, we developed a web-based decision support tool that comprises a more holistic diagnosis (including 4 domains: body, thinking and feeling, behavior, and environment) and personalized advice. This 360° diagnostic tool enables people with T2D and health care professionals at the general practice to obtain an overview of the most important T2D-related issues and, subsequently, determine the most suitable intervention for the person with T2D. OBJECTIVE: This study aimed to describe the systematic and iterative development and evaluation of the web-based 360° diagnostic tool. METHODS: We defined the requirements for the web-based 360° diagnostic tool based on previously developed tools, a literature review, and inputs from a multidisciplinary team of experts. As part of the conceptualization, we defined 3 requirements: diagnostics; feedback; and advice, consultation, and follow-up. Next, we developed and designed the content for each of these requirements. We evaluated the diagnostic part of the tool (ie, measurement instruments and visualization) with a qualitative design, in a usability study with a think-aloud strategy and interview questions, among 8 people with T2D at a Dutch general practice. RESULTS: For each of the 4 domains, specific parameters and underlying elements were selected, and measurement instruments (including clinical data and questionnaires) were chosen. Cutoff values were defined to identify high-, middle-, and low-ranking scores, and decision rules were developed and implemented using R scripts and algorithms. A traffic light color visual design was created (profile wheel) to provide an overview of the scores per domain. We mapped the interventions that could be added to the tool and developed a protocol designed as a card deck with motivational interview steps. Furthermore, the usability study showed that people with T2D perceived the tool as easy to use, useful, easy to understand, and insightful. CONCLUSIONS: Preliminary evaluation of the 360° diagnostic tool by experts, health care professionals, and people with T2D showed that the tool was considered relevant, clear, and practical. The iterative process provided insights into the areas of improvement, which were implemented. The strengths, shortcomings, future use, and challenges are also discussed.

A Digital Lifestyle Coach (E-Supporter 1.0) to Support People With Type 2 Diabetes: Participatory Development Study.

BACKGROUND: A healthy lifestyle, including regular physical activity and a healthy diet, is becoming increasingly important in the treatment of chronic diseases. eHealth interventions that incorporate behavior change techniques (BCTs) and dynamic tailoring strategies could effectively support a healthy lifestyle. E-Supporter 1.0 is an eCoach designed to support physical activity and a healthy diet in people with type 2 diabetes (T2D). OBJECTIVE: This paper aimed to describe the systematic development of E-Supporter 1.0. METHODS: Our systematic design process consisted of 3 phases. The definition phase included the selection of the target group and formulation of intervention objectives, and the identification of behavioral determinants based on which BCTs were selected to apply in the intervention. In the development phase, intervention content was developed by specifying tailoring variables, intervention options, and decision rules. In the last phase, E-Supporter 1.0 integrated in the Diameter app was evaluated using a usability test in 9 people with T2D to assess intervention usage and acceptability. RESULTS: The main intervention objectives were to stimulate light to moderate-vigorous physical activities or adherence to the Dutch dietary guidelines in people with T2D. The selection of behavioral determinants was informed by the health action process approach and theories explaining behavior maintenance. BCTs were included to address relevant behavioral determinants (eg, action control, self-efficacy, and coping planning). Development of the intervention resulted in 3 types of intervention options, consisting of motivational messages, behavioral feedback, and tailor-made supportive exercises. On the basis of IF-THEN rules, intervention options could be tailored to, among others, type of behavioral goal and (barriers to) goal achievement. Data on these variables could be collected using app data, activity tracker data, and daily ecological momentary assessments. Usability testing revealed that user experiences were predominantly positive, despite some problems in the fixed delivery of content. CONCLUSIONS: The systematic development approach resulted in a theory-based and dynamically tailored eCoach. Future work should focus on expanding intervention content to other chronic diseases and lifestyle behaviors, enhancing the degree of tailoring and evaluating intervention effects on acceptability, use, and cost-effectiveness.

The effect of emotion regulation strategies on decision-making about the maternal pertussis vaccination among pregnant women in the Netherlands: an experimental study.

OBJECTIVE: To assess whether cognitive reappraisal and acceptance are effective emotion regulation strategies to decrease the influence of negative affect on intention to accept maternal pertussis vaccination (MPV) among pregnant women in the Netherlands. METHODS: An experimental study with baseline and two follow-up measurements was conducted. Participants selected after baseline (N = 382) were randomized into two experimental groups (cognitive reappraisal, acceptance) and a control group. The effect of the experimental manipulations on negative affect was examined with multilevel analyses. A moderation analysis was performed to examine whether the manipulations moderated the association between negative affect and intention. RESULTS: All groups showed a decrease in negative affect (all p's < 0.001), with no differences between groups. A small decrease in the influence of negative affect on intention was found among those who used acceptance. CONCLUSION: No additional value of the emotion regulation strategies was found compared to the control group. However, exploratory analyses showed that acceptance seemed a promising strategy to decrease the influence of negative affect on intention to accept MPV. PRACTICE IMPLICATIONS: This study stressed the relevance for communication strategies to consider the emotions pregnant women experience during the decision-making process about the MPV.

Development of a Dynamically Tailored mHealth Intervention (What Do You Drink) to Reduce Excessive Drinking Among Dutch Lower-Educated Students: User-Centered Design Approach.

BACKGROUND: The high prevalence and adverse consequences of excessive drinking among lower-educated adolescents and young adults are public concerns in the Netherlands. Evidence-based alcohol prevention programs targeting adolescents and young adults with a low educational background are sparse. OBJECTIVE: This study aimed to describe the planned process for the theory- and evidence-based development, implementation, and evaluation of a dynamically tailored mobile alcohol intervention, entitled What Do You Drink (WDYD), aimed at lower-educated students from secondary vocational education and training (Middelbaar Beroepsonderwijs in Dutch). METHODS: We used intervention mapping as the framework for the systematic development of WDYD. It consists of the following six steps: assessing needs (step 1), formulating intervention objectives (step 2), translating theoretical methods into practical applications (step 3), integrating these into a coherent program (step 4), anticipating future implementation and adoption (step 5), and developing an evaluation plan (step 6). RESULTS: Reducing excessive drinking among Dutch lower-educated students aged 16 to 24 years was defined as the desired behavioral outcome and subdivided into the following five program objectives: make the decision to reduce drinking, set realistic drinking goals, use effective strategies to achieve drinking goals, monitor own drinking behavior, and evaluate own drinking behavior and adjust goals. Risk awareness, motivation, social norms, and self-efficacy were identified as the most important and changeable individual determinants related to excessive drinking and, therefore, were incorporated into WDYD. Dynamic tailoring was selected as the basic intervention method for changing these determinants. A user-centered design strategy was used to enhance the fit of the intervention to the needs of students. The intervention was developed in 4 iterations, and the prototypes were subsequently tested with the students and refined. This resulted in a completely automated, standalone native app in which students received dynamically tailored feedback regarding their alcohol use and goal achievement via multiple sessions within 17 weeks based on diary data assessing their alcohol consumption, motivation, confidence, and mood. A randomized controlled trial with ecological momentary assessments will be used to examine the effects, use, and acceptability of the intervention. CONCLUSIONS: The use of intervention mapping led to the development of an innovative, evidence-based intervention to reduce excessive alcohol consumption among lower-educated Dutch adolescents and young adults. Developing an intervention based on theory and empirical evidence enables researchers and program planners to identify and retain effective intervention elements and to translate the intervention to new populations and settings. This is important, as black boxes, or poorly described interventions, have long been a criticism of the eHealth field, and effective intervention elements across mobile health alcohol interventions are still largely unknown. TRIAL REGISTRATION: Netherlands Trial Registry NTR6619; https://trialsearch.who.int/Trial2.aspx?TrialID=NTR6619.

Predictors of the Acceptance of an Electronic Coach Targeting Self-management of Patients With Type 2 Diabetes: Web-Based Survey.

BACKGROUND: Type 2 diabetes (T2D) is a lifestyle-related disease whose prevalence increases with age. Diabetes self-management through mobile health (mHealth) apps enables patients with T2D to improve their health. According to the Technology Acceptance Model (TAM), technology acceptance (ie, intended use) is necessary to ensure mHealth can be implemented successfully. Therefore, the specific acceptance requirements of patients with T2D should be considered. OBJECTIVE: This cross-sectional study aims to examine the extent to which different TAM predictors are associated with the acceptance of a diabetes app including an electronic coach (eCoach; Iris app) among patients with T2D. METHODS: Using a web-based survey, data on 92 patients with T2D (mean age 62.76 years, SD 8.29 years) were collected. Acceptance of the Iris app with the TAM predictors (ie, perceived usefulness, perceived ease of use, social influence, perceived self-efficacy, perceived security, prior usage experience, perceived health, and propensity of data/information sharing) was assessed. Further, control variables (ie, gender, age, education, ethnicity, household, BMI, amount of years with diabetes, diabetes-related complaints, and medication use) were assessed. RESULTS: Multiple linear regression analyses showed that acceptance of the Iris app was positively associated with perceived usefulness (ß=.57, P<.001), social influence (subjective norm; ß=.20, P=.004), and willingness to share data (ß=.25, P<.001). In addition, acceptance regarding the Iris app was higher among patients with T2D with overweight (ß=.23, P=.01) or obese BMI (ß=.21, P=.01). The model explained 75.8% of the variance in the acceptance of the Iris app by patients with T2D. In addition, perceived usefulness of the Iris app was positively related to perceived ease of use (ß=.32, P<.001), subjective norm (ß=.26, P=.004), perceived control (ß=.19, P=.03), willingness to share data (ß=.20, P=.01) regarding the Iris app, and perceived security regarding general use of apps/smartphone/internet (ß=.15, P=.04). The model explained 58.2% of the variance in patients' perceived usefulness about the Iris app. CONCLUSIONS: Among patients with T2D, the belief that the use of the Iris app is helpful/beneficial, the willingness to share their Iris app data, and others' approval of using this app can stimulate the acceptance of this app. In addition, the belief that the use of (health) apps is reliable and secure, the belief that the use of the Iris app is easy to use, a higher perceived capability and personal control with using this app, the willingness to share their Iris app data, and others' approval of using this app can stimulate the perceived usefulness of such an app. These TAM predictors explained a high variance in acceptance and perceived usefulness of the Iris app. Implications for practice are addressed.

Improving behavioural compliance with the COVID-19 precautionary measures by means of innovative communication strategies: Social experimental studies.

OBJECTIVES: Behavioural measures such as social distancing are crucial to prevent the spread of COVID-19. People sometimes have difficulty to comply with these behavioural measures for various reasons. Insight is needed into evidence-based strategies that can promote compliance. In the present study, we examined whether behaviour change techniques (volitional help sheet (VHS), behavioural journalism (BJ) and empathy inductions (EI)) could promote behavioural compliance with the COVID-19 measures. METHODS: Three online experiments were carried out (N = 424-593) among Dutch adult citizens, using a randomized 2-group post-test and 1-week follow-up design. In each experiment, a control group was compared with the experimental condition (respectively VHS, BJ or EI condition). RESULTS: Two out of the three different strategies did result in favourable changes with regard to the compliance-related measures. The VHS contributed to changes in perceived susceptibility of others (t = -2,78; f**2 = 0,019), perceived severity (t = -3,65; f**2 = 0,032) and individual behavioural compliance measures. People exposed to the VHS were more likely to receive less visitors (w = 16638; p = 0.003)and avoid crowds (w = 16631; p = 0.003). EI increased the perceived vulnerability of others. Video-based role model stories, based on BJ did not result in any changes. CONCLUSIONS: Behaviour change strategies may contribute to promoting behavioural compliance and could be used in public health communication. The empathy induction can be used to enhance other protection motives, while the volitional help sheet effectively can help people to overcome compliance barriers. Behavioural science can add to fighting the COVID-19 pandemic.

A Tailored Web-Based Video Intervention (ParentCoach) to Support Parents With Children With Sleeping Problems: User-Centered Design Approach.

BACKGROUND: Many parents frequently struggle with undesirable or problematic behavior (ie, temper tantrums and whining) displayed by their child. To support parents in promoting positive parenting skills (ie, recognizing challenging situations and reacting appropriately), the interactive video e-learning tool ParentCoach was developed. The tool aims to teach parents generic behavioral responses by means of situational learning, tailoring, and problem solving. The first demonstration focused on sleeping problems. OBJECTIVE: The aim of this paper is to illustrate the user-centered development of ParentCoach. METHODS: We conducted usability, understandability, and acceptance tests among the target group (29 parents, 7 youth health care professionals, and 4 individuals with former lower health literacy) in different phases of the development process via focus groups, interviews, and surveys. This allowed for relevant insights on specifications and user requirements to guide the development and revision of the tool in each iteration. RESULTS: Iterative testing and development allowed for the final demonstration of ParentCoach to be experienced as a relevant and accessible parenting intervention that can be used as a stand-alone program or in combination with another program. CONCLUSIONS: This paper elaborates on the iterative development process and its benefits for the final demonstration of ParentCoach.

Change is possible: How increased patient activation is associated with favorable changes in well-being, self-management and health outcomes among people with type 2 diabetes mellitus: A prospective longitudinal study.

OBJECTIVE: To examine the relationship between risk factors for low patient activation and change in patient activation, well-being, and health outcomes in people with type 2 diabetes mellitus (T2DM). METHOD: A longitudinal prospective study was conducted with measurements at baseline and 20-week follow-up among 603 people with T2DM participating in a group-based walking intervention. Patient activation and risk factors were assessed using online questionnaires. Health outcomes were assessed in participants' general practices. RESULTS: No association was found between risk factors for activation and change in patient activation. Patient activation significantly increased (t(602) = 2.53, p = 0.012) and was associated with an increase in emotional well-being (ß = 0.22), exercise behavior (ß = 0.17), general diet behavior (ß = 0.20), and a reduction in BMI (ß = -0.28), weight (ß = -0.29), and HbA1c (ß = -0.27). CONCLUSION: Favorable changes in patient activation, self-management, well-being, and health outcomes occurred during a walking intervention, despite highly prevalent risk factors for low activation and less engagement in self-management. PRACTICE IMPLICATIONS: Group-based walking interventions might empower people with T2DM to begin taking a larger role in their self-care and improve (mental) health outcomes. Vulnerable groups of patients (with multiple risk factors for low activation) can change and presumably need this kind of interventions to be able to change.

Psychological factors associated with changes in physical activity in Dutch people with type 2 diabetes under societal lockdown: A cross-sectional study.

Aims: To investigate changes in physical activity (PA) and psychological factors during societal lockdown in people with type 2 diabetes. Methods: A cross-sectional study among Dutch adults with type 2 diabetes. Data were collected using online questionnaires. A multivariate multinomial logistic regression was performed with change in PA during societal lockdown as outcome and perceived change in stress, anxiety, perceived risk for COVID-19 infection, emotional well-being and former PA status as determinants. Results: Five hundred and sixty seven respondents filled out the questionnaire, 536 were included in the final analysis: mean age of 65.9 ± 7.9 years; mean diabetes duration 13.3 ± 8 years; 54% men; 47% reported no change in PA, 27% became less active and 26% became more active during societal lockdown. Participants who were more likely to become less active were participants who experienced more stress (OR: 2.27; 95% CI 1.25-4.13) or less stress (OR: 2.20; 95% CI 1.03-4.71). Participants who were more likely to become more active were participants who experienced more stress (OR: 2.31; 95% CI 1.25, 4.26). Participants with higher emotional well-being (OR: 0.98; 95% CI 0.97, 0.99) were less likely to become less active than to report no change in PA. Conclusions: Changes in PA in people with type 2 diabetes during societal lockdown are associated with changes in psychological factors such as perceived stress and emotional well-being. People with diabetes and their caregivers should be aware of these possible changes.

Social-psychological determinants of maternal pertussis vaccination acceptance during pregnancy among women in the Netherlands.

BACKGROUND: Maternal Pertussis Vaccination (MPV) during pregnancy became part of the National Immunization Program in the Netherlands late 2019. This study aims to identify social-psychological factors associated with MPV acceptance among Dutch women to add to the current understanding of vaccine hesitancy worldwide, and to inform the development of communication and information campaigns about MPV. METHODS: We conducted a cross-sectional study using an online survey among 611 women (174 pregnant women, 205 women who had given birth in the past two years and 232 women of 20-35 years old). The primary and secondary outcomes were vaccination intention and attitude towards MPV, respectively. Pearson's correlation and regression analyses were used to examine social-psychological and socio-demographic determinants of the outcomes. RESULTS: Vaccination intention was most explained by attitudes towards MPV, beliefs about safety, moral norm and the belief about the effectiveness of MPV (R2 = 0.79). Other factors associated were injunctive norm, anticipated regret of vaccinating, and decisional certainty. Attitudes towards MPV were further explained by descriptive norm, risk perceptions of side effects, and risk perceptions of the baby getting pertussis when not vaccinating, and fear of MPV and of the disease (R2 = 0.76). Finally, pregnant women had a significantly lower intention and less positive attitude towards MPV than non-pregnant women. CONCLUSIONS: Communication about MPV should address the most important determinants of MPV intention and attitude, i.e. beliefs about safety and effectiveness and moral norms. Furthermore, such information may benefit from taking into account affective feelings of pregnant women such as anticipated regret and fear towards MPV. Further research could explore this. The timing of communication about MPV can be important as determinants of MPV acceptance may vary depending on pregnancy status.

The effect of using a mobile application ("WhiteTeeth") on improving oral hygiene: A randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of the WhiteTeeth mobile app, a theory-based mobile health (mHealth) program for promoting oral hygiene in adolescent orthodontic patients. METHODS: In this parallel randomized controlled trial, the data of 132 adolescents were collected during three orthodontic check-ups: at baseline (T0), at 6-week follow-up (T1) and at 12-week follow-up (T2). The intervention group was given access to the WhiteTeeth app in addition to usual care (n = 67). The control group received usual care only (n = 65). The oral hygiene outcomes were the presence and the amount of dental plaque (Al-Anezi and Harradine plaque index), and the total number of sites with gingival bleeding (Bleeding on Marginal Probing Index). Oral health behaviour and its psychosocial factors were measured through a digital questionnaire. We performed linear mixed-model analyses to determine the intervention effects. RESULTS: At 6-week follow-up, the intervention led to a significant decrease in gingival bleeding (B = -3.74; 95% CI -6.84 to -0.65) and an increase in the use of fluoride mouth rinse (B = 1.93; 95% CI 0.36 to 3.50). At 12-week follow-up, dental plaque accumulation (B = -11.32; 95% CI -20.57 to -2.07) and the number of sites covered with plaque (B = -6.77; 95% CI -11.67 to -1.87) had been reduced significantly more in the intervention group than in the control group. CONCLUSIONS: The results show that adolescents with fixed orthodontic appliances can be helped to improve their oral hygiene when usual care is combined with a mobile app that provides oral health education and automatic coaching. Netherlands Trial Registry Identifier: NTR6206: 20 February 2017.

A Mobile App (WhiteTeeth) to Promote Good Oral Health Behavior Among Dutch Adolescents with Fixed Orthodontic Appliances: Intervention Mapping Approach.

BACKGROUND: The insertion of fixed orthodontic appliances increases the risk of dental caries, particularly in adolescents. Caries can be prevented through good oral health behavior. To support adolescents with fixed orthodontic appliances and for promoting oral health behavior, we developed a theory- and evidence-based mHealth program, the WhiteTeeth app. OBJECTIVE: The objective of our paper was to describe the systematic development and content of the WhiteTeeth app. METHODS: For systematic development of the program, we used the intervention mapping (IM) approach. In this paper, we present the results of applying the first 5 steps of IM to the design of an mHealth program: (1) identifying target behaviors and determinants through problem analysis, including a literature search, a survey study, and semistructured interviews, to explore adolescent oral health behavior during orthodontic therapy; (2) defining program outcomes and objectives; (3) selecting theoretical methods and translating them into practical strategies for the program design; (4) producing the program, including a pilot test with 28 adolescents testing the acceptability and usability of the WhiteTeeth app; and (5) planning implementation and adoption. RESULTS: On the basis of our literature search, we identified fluoride use and control of dental plaque levels (eg, tooth brushing and proxy brush usage) as target behaviors for preventing caries. Next, we identified important and changeable determinants of oral health behavior that fitted the theoretical concepts of the Health Action Process Approach (HAPA) theory. The HAPA theory, the self-regulation theory, and the results of the semistructured interviews were used to define the program objectives, that is, the performance and change objectives. After defining the objectives, we identified multiple behavior change techniques that could be used to achieve these objectives, such as providing oral health information and feedback, prompting self-monitoring, coaching of set actions and coping plans, and sending reminders. We translated these methods into practical strategies, such as videos and a brushing timer. Next, we combined these strategies into a single program resulting in the WhiteTeeth app (which is available on both iTunes and Google Play stores as "Witgebit"). Adolescents with fixed orthodontic appliances and dental professionals were included in the development process to increase the success of implementation. The pilot test revealed that the app users appreciated and liked the app. The WhiteTeeth app can be integrated into current orthodontic care. CONCLUSIONS: IM allowed us to identify multiple techniques that have been shown to be the most effective in initiating behavior change, but have not yet been incorporated into existing orthodontic apps. The WhiteTeeth app contains all these techniques, which makes it a unique and promising home-based app for promoting oral health in adolescents with fixed orthodontic appliances.

Effect Evaluation of a Web-Based Coaching Intervention to Support Implementation of Sex Education Among Secondary School Teachers: Randomized Controlled Trial.

BACKGROUND: The quality of implementation is important to ensure the effectiveness of behavioral change interventions in practice. Implementing such programs with completeness and adherence is not an automatic process and may require additional support. In school settings, the support teachers receive during implementation is often limited and appears to fall short when attempting to preserve completeness and adherence in program delivery. With the aim to improve completeness and adherence of teachers' delivery of a sexual health promoting intervention ("Long Live Love" [LLL]) in secondary education, a Web-based e-coach was developed ("lesgevenindeliefde.nl"or"teachinglove.nl"). The effectiveness of the e-coach, as part of a broader implementation strategy, in influencing teachers' implementation was evaluated. OBJECTIVE: This study aimed to report on the effect evaluation to determine the effect of the Web-based e-coach on teacher implementation of a school-based sex education program called LLL and on its determinants. METHODS: A cluster randomized controlled trial (e-coaching vs waiting list control) was conducted with a baseline assessment (T0) and follow-up (T1) 2 weeks after completing the LLL program. A total of 43 schools with 83 teachers participated in the study. In the follow-up, 38 schools participated, 23 in the e-coaching condition with 41 teachers and 15 in the control condition with 26 teachers. Multilevel regression analysis was used to evaluate the effect of the e-coaching website on implementation behavior, namely, completeness and adherence to LLL implementation, and on its determinants. RESULTS: The e-coaching intervention was not found to have an effect on teachers' implementation behavior; teachers assigned to the experimental e-coaching website did not score higher on completeness (P=.60) or adherence (P=.67) as compared with teachers in the control condition. When comparing the 30 teachers who made actual use of the e-coaching website with the 37 teachers who did not, no significant differences were found either (P≥.54). In addition, there was no effect of e-coaching on the determinants of teacher implementation behavior (t67-75≤0.69; P≥.22). CONCLUSIONS: E-coaching was not found to be effective in enhancing completeness of and adherence to LLL by teachers. The lack of effect may be attributed to the intervention content, the limited use, or the study design itself. The e-coaching intervention may not have adequately addressed adherence and completeness of LLL to bring about behavioral change. Furthermore, the e-coaching intervention was not or insufficiently used by teachers. A possible biased sample of motivated, able teachers may have agreed to participate in the study, and a possible "ceiling effect" may have been present because of the high implementation grade. This, however, does not imply that Web-based coaching in itself is an ineffective strategy to promote adherence and completeness of program implementation. A process evaluation is required as follow-up. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number ISRCTN11754581; http://www.isrctn.com/ISRCTN11754581 (Archived by WebCite at http://www.webcitation.org/70C5TUOOh).