Psychosocial determinants of consistent condom use among university students in Sudan: findings from a study using the Integrated Change Model.

Unprotected sex is common among university students in Sudan, thus increasing risks for sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV). As little is known about the psychosocial determinants of consistent condom use among this population, this study was designed to identify them. The Integrated Change Model (ICM) was applied in a cross-sectional design to identify in 218 students (aged 18-25 years) from Khartoum which items distinguish condom users from non-condom users. Condom users differed significantly from non-condom users in having more HIV and condom use-related knowledge, higher perception of susceptibility to HIV, reporting more exposure to condom use cues, having a less negative attitude towards condom use (attitude cons), experiencing social support and norms favouring condom use and having higher condom use self-efficacy. Binary logistic regression showed that peer norms favouring condom use in addition to HIV-related knowledge, condom use cues, negative attitude and self-efficacy were the factors uniquely associated with consistent condom use among university students in Sudan. Interventions seeking to promote consistent condom use among sexually active students could benefit from increasing knowledge about HIV transmission and prevention, raising HIV-risk perception, using condom use cues, addressing perceived condom disadvantages and enhancing students` self-efficacy to avoid unprotected sex. Moreover, such interventions should raise students` perceptions of their peers` beliefs and behaviours favouring condom use and seek health care professionals` and religious scholars` support for condom use.

The Effects of Online Access to General Practice Medical Records Perceived by Patients: Longitudinal Survey Study.

BACKGROUND: Patient online access to medical records is assumed to facilitate patient empowerment and advance patient-centered health care. However, to date, the actual effects of online access to medical records perceived by patients and other outcomes are insufficiently empirically tested. OBJECTIVE: This study aimed to investigate the effects of online access to medical records on patient empowerment, informed decision-making, and the patient-provider relationship perceived by patients. METHODS: A nationwide, 2-wave, longitudinal survey study was conducted among Dutch adults (N=2402). Linear regression analyses were performed. In model 1, the perceived effects of online access to medical records (measured at T1 [first measurement; July 2021]) on 16 outcomes (measured at T2 [second measurement; January 2022]), which were associated with the use of online access to general practice medical records in previous research, were investigated. Model 2 included sociodemographic factors and patient characteristics as confounders. RESULTS: Users indicated more strongly than nonusers that online access to medical records would increase their participation in health care, improve the relationship with their general practitioner, and support informed decision-making. These results were robust when adjusted for the influence of confounders. Effect sizes were very small, with unstandardized regression coefficients (B) ranging between -0.39 and 0.28. Higher digital and health literacy were associated with higher ratings of almost all effects. CONCLUSIONS: Online access to medical records has the potential to empower patients and foster informed decision-making among patients. The effects in this study were small but might grow over time. Other factors, such as the attitude of general practitioners toward online access to medical records, might moderate these effects. The results indicate that the potential benefits of online access to medical records might be unevenly distributed. We suggest future exploration of the conditions under which online access to medical records can improve health care system functioning and efficiency without increasing health inequality.

The ISAC Paradigm to Tame Oral Cancer in Saudi Arabia: A Quasi-experimental Study.

Late detection of oral cancer (OC) cases in Saudi Arabia is concerning. It reduces survival rate and complicates treatment. The ISAC intervention was developed to bridge the gaps observed in dentists' practice of OC examination and patient education. The ISAC stands for I, informing patients of OC screenings; S, screening for OC; A, advising high-risk patients to quit risk factors; and C, connecting patients to advanced services. This study tested the potential effect of the ISAC in influencing dentists' cognitive and behavioral skills, to enhance early detection and prevention of OC. A quasi-experimental study was conducted among dental interns (DIs) at dental setting to test the effect on comprehensive oral cancer examination score (COCE), awareness, self-efficacy, descriptive-norms, and self-reported behavior. Data were collected through triangulation of methods pre and post the intervention at two-months. Multiple linear mixed effects regression models were utilized for data analysis. Between October 2020 and April 2021, 47 DIs participated in the study. The final model showed the significant effects of time (ISAC) on COCE (95% CI = 25.12-29.42, P < .001). DIs had a significant improvement in awareness, self-efficacy, descriptive norms, and self-reported behavior. The findings showed promising effects of the intervention toward the early detection and prevention of OC. Dentists, dental organizations, and policymakers in areas with a high risk of OC could benefit from the current intervention which contributes to capacity building and improved community health. A pragmatic study with a robust design is needed to test the effectiveness of the intervention on a wider scale.

Identifying Active Ingredients, Working Mechanisms, and Fidelity Characteristics Reported in Smoking Cessation Interventions in Dutch Primary Care: A Systematic Review.

BACKGROUND: Evidence-based smoking cessation interventions provided by healthcare professionals can be successful in helping citizens to quit smoking. Yet, evidence is needed about the active ingredients of these interventions, how these ingredients work and how they are implemented in practice. Such knowledge is required to effectively support healthcare professionals to optimally put evidence-based smoking cessation interventions to (inter)national practice. OBJECTIVE: To identify active ingredients (including behavior change techniques), mechanisms of action and implementation fidelity reported in smoking cessation interventions in Dutch primary care settings and to relate these to intervention effectiveness. METHODS: A systematic review was conducted by searching nine national intervention or funding databases, five international scientific databases and consulting 17 national smoking cessation experts. Out of 1066 identified manuscripts, 40 interventions were eligible for this review. Based on published protocols, information regarding behavior change techniques and mechanisms of action was systematically abstracted. Additionally, information regarding study characteristics and other active ingredients, effects on smoking behavior and implementation fidelity was abstracted. Comparative effectiveness concerning abstracted intervention characteristics was qualitatively explored. RESULTS: Active ingredients, mechanisms of action and implementation fidelity were moderately to poorly reported. Interventions applying behavior change techniques and interventions with a single behavioral target (i.e. smoking-only versus multiple behaviors) seemed to provide stronger evidence for successfully changing smoking behavior. CONCLUSION: Attention to and reporting on interventions' active ingredients (e.g. behavior change techniques), mechanisms of action and implementation fidelity are prerequisites for developing more effective evidence-based smoking cessation interventions to be successfully implemented in primary healthcare. IMPLICATIONS: This systematic review provides an overview of smoking cessation interventions in Dutch primary care settings, identified since the year 2000. Smoking cessation support is offered in various forms, but our qualitative findings show that interventions including more behavior change techniques and interventions targeting only smoking cessation (compared to multiple behaviors) might be more effective. Results also show that-based on available intervention reports-it is difficult to distinguish patterns of active ingredients (such as behavior change techniques), mechanisms of action and fidelity of implementation in relation to interventions' effectiveness. This means (quality of) reporting on these intervention characteristics should improve.

Do professional perspectives on evidence-based smoking cessation methods align? A Delphi study among researchers and healthcare professionals.

The use of evidence-based smoking cessation interventions (SCIs) can significantly increase the number of successful smoking cessation attempts. To obtain an overview of the knowledge and viewpoints on the effectiveness and use of SCIs, a three-round online Delphi study was conducted among researchers and primary care professionals (PCPs). The four objectives of this study are to gain an overview of (i) the criteria important for recommending SCIs, (ii) the perceptions of both groups on the effectiveness of SCIs, (iii) the factors to consider when counseling different (high-risk) groups of smokers and (iv) the perceptions of both groups on the use of e-cigarettes as an SCI. We found a high level of agreement within groups on which smoker characteristics should be considered when recommending an SCI to smokers. We also found that PCPs display a lower degree of consensus on the effectiveness of SCIs. Both groups see a value in the use of special protocols for different (high-risk) groups of patients, but the two groups did not reach consensus on the use of e-cigarettes as a means to quit. Making an inventory of PCPs' needs regarding SCIs and their usage may provide insight into how to facilitate a better uptake in the primary care setting.

Dentists' perceptions and usability testing toward the implementation of the ISAC, a comprehensive oral cancer intervention in dental practices: a qualitative study in Jazan region, Saudi Arabia.

OBJECTIVE: We aimed to explore dentists' perceptions toward the implementation of a comprehensive intervention (ISAC) for the early detection and prevention of oral cancer in a dental clinic. METHODS: The ISAC intervention was presented to ten purposefully sampled dentists in Jazan Dental School (JDS). Participating dental interns were asked to practice the ISAC intervention whilst thinking aloud. A semi-structured interview technique was used to allow free expression of participants' perceptions related to the ISAC intervention and to control the flow of topics. Fleuren's framework theory informed the analysis. The interviews were transcribed verbatim and analyzed using the deductive-inductive framework analysis. RESULTS: Practicing the ISAC intervention was perceived to enhance the early detection and prevention of oral cancer. Serving community needs and engaging community groups were perceived to be related to a high relevance and compatibility of the ISAC intervention. Being a comprehensive intervention with well-defined objectives and being built on relevant data from the participants' community and having dentists as a target group were the perceived relative advantages of the ISAC intervention compared to other programs. A supportive environment, gender-concordance, use of regional trainers, standard examination form and collaboration with other sectors were perceived to be the facilitators. Competition with clinical time, use of different examination forms and low organizational leader interests were perceived as impeding factors against effective implementation in a real-world context. Reward, easy to practice, feeling confidence and satisfaction, advertisement as well as use of a role model approach were perceived to be motivating factors. CONCLUSIONS: Integrating data from representers of different participant groups during intervention conceptualization and development are critical for the intervention compatibility and acceptability. The study findings showed the opportunities of intertwining the intrinsic motivators of satisfaction and altruism existing in the target group and the extrinsic motivator of official diagnostic skill, certification that may boost and sustain the behavior change. Intervention features that influence perceived relevance, compatibility, relative advantage and motivation may be of great importance for intervention practice.

Effects of an Explicit Value Clarification Method With Computer-Tailored Advice on the Effectiveness of a Web-Based Smoking Cessation Decision Aid: Findings From a Randomized Controlled Trial.

BACKGROUND: Smoking continues to be a driver of mortality. Various forms of evidence-based cessation assistance exist; however, their use is limited. The choice between them may also induce decisional conflict. Offering decision aids (DAs) may be beneficial; however, insights into their effective elements are lacking. OBJECTIVE: This study tested the added value of an effective element (ie, an "explicit value clarification method" paired with computer-tailored advice indicating the most fitting cessation assistance) of a web-based smoking cessation DA. METHODS: A web-based randomized controlled trial was conducted among smokers motivated to stop smoking within 6 months. The intervention group received a DA with the aforementioned elements, and the control group received the same DA without these elements. The primary outcome measure was 7-day point prevalence abstinence 6 months after baseline (time point 3 [t=3]). Secondary outcome measures were 7-day point prevalence of abstinence 1 month after baseline (time point 2 [t=2]), evidence-based cessation assistance use (t=2 and t=3), and decisional conflict (immediately after DA; time point 1). Logistic and linear regression analyses were performed to assess the outcomes. Analyses were conducted following 2 (decisional conflict) and 3 (smoking cessation) outcome scenarios: complete cases, worst-case scenario (assuming that dropouts still smoked), and multiple imputations. A priori sample size calculation indicated that 796 participants were needed. The participants were mainly recruited on the web (eg, social media). All the data were self-reported. RESULTS: Overall, 2375 participants were randomized (intervention n=1164, 49.01%), of whom 599 (25.22%; intervention n=275, 45.91%) completed the DAs, and 276 (11.62%; intervention n=143, 51.81%), 97 (4.08%; intervention n=54, 55.67%), and 103 (4.34%; intervention n=56, 54.37%) completed time point 1, t=2, and t=3, respectively. More participants stopped smoking in the intervention group (23/63, 37%) than in the control group (14/52, 27%) after 6 months; however, this was only statistically significant in the worst-case scenario (crude P=.02; adjusted P=.04). Effects on the secondary outcomes were only observed for smoking abstinence after 1 month (15/55, 27%, compared with 7/46, 15%, in the crude and adjusted models, respectively; P=.02) and for cessation assistance uptake after 1 month (26/56, 46% compared with 18/47, 38% only in the crude model; P=.04) and 6 months (38/61, 62% compared with 26/50, 52%; crude P=.01; adjusted P=.02) but only in the worst-case scenario. Nonuse attrition was 34.19% higher in the intervention group than in the control group (P<.001). CONCLUSIONS: Currently, we cannot confidently recommend the inclusion of explicit value clarification methods and computer-tailored advice. However, they might result in higher nonuse attrition rates, thereby limiting their potential. As a lack of statistical power may have influenced the outcomes, we recommend replicating this study with some adaptations based on the lessons learned. TRIAL REGISTRATION: Netherlands Trial Register NL8270; https://www.trialregister.nl/trial/8270. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/21772.

A Web-Based Computer-Tailored Program to Improve Treatment Adherence in Patients With Type 2 Diabetes: Randomized Controlled Trial.

BACKGROUND: Adherence to core type 2 diabetes mellitus (T2DM) treatment behaviors is suboptimal, and nonadherence is generally not limited to one treatment behavior. The internet holds promise for programs that aim to improve adherence. We developed a computer-tailored eHealth program for patients with T2DM to improve their treatment adherence, that is, adherence to both a healthy lifestyle and medical behaviors. OBJECTIVE: The objective of this study is to examine the effectiveness of the eHealth program in a randomized controlled trial. METHODS: Patients with T2DM were recruited by their health professionals and randomized into either the intervention group, that is, access to the eHealth program for 6 months, or a waiting-list control group. In total, 478 participants completed the baseline questionnaire, of which 234 gained access to the eHealth program. Of the 478 participants, 323 were male and 155 were female, the mean age was 60 years, and the participants had unfavorable BMI and HbA1c levels on average. Outcome data were collected through web-based assessments on physical activity (PA) levels, caloric intake from unhealthy snacks, and adherence to oral hypoglycemic agents (OHAs) and insulin therapy. Changes to separate behaviors were standardized and summed into a composite change score representing changes in the overall treatment adherence. Further standardization of this composite change score yielded the primary outcome, which can be interpreted as Cohen d (effect size). Standardized change scores observed in separate behaviors acted as secondary outcomes. Mixed linear regression analyses were conducted to examine the effectiveness of the intervention on overall and separate treatment behavior adherence, accommodating relevant covariates and patient nesting. RESULTS: After the 6-month follow-up assessment, 47.4% (111/234) of participants in the intervention group and 72.5% (177/244) of participants in the control group were retained. The overall treatment adherence improved significantly in the intervention group compared with the control group, reflected by a small effect size (d=0.27; 95% CI 0.032 to 0.509; P=.03). When considering changes in separate treatment behaviors, a significant decrease was observed only in caloric intake from unhealthy snacks in comparison with the control group (d=0.36; 95% CI 0.136 to 0.584; P=.002). For adherence to PA (d=-0.14; 95% CI -0.388 to 0.109; P=.27), OHAs (d=0.27; 95% CI -0.027 to 0.457; P=.08), and insulin therapy (d=0.35; 95% CI -0.066 to 0.773; P=.10), no significant changes were observed. These results from the unadjusted analyses were comparable with the results of the adjusted analyses, the per-protocol analyses, and the sensitivity analyses. CONCLUSIONS: Our multibehavior program significantly improved the overall treatment adherence compared with the control group. To further enhance the impact of the intervention in the personal, societal, and economic areas, a wide-scale implementation of our eHealth intervention is suggested. TRIAL REGISTRATION: Netherlands Trial Register NL664; https://www.trialregister.nl/trial/6664.

Exploring Determinants of Condom Use among University Students in Sudan.

Increasing numbers of university students in Sudan are at risk of contracting HIV because of their engagement in condomless sex. A comprehensive and culturally accepted condom promotion program could potentially reduce this threat substantially. However, little is known about the sociocognitive determinants of condom use in this population: information that is required to develop such HIV prevention programs. Therefore, in August 2014, we conducted 30 semi-structured individual interviews with male and female students (both currently sexually active and nonactive) to explore determinants of condom use based on the I-Change model. Data were analyzed using Nvivo 10. The results suggest that barriers to condom use among university students include misconceptions about condom use, negative attitudes toward condom use, lack of social support, low self-efficacy to use condoms, and poor action planning. Sexual health promotion should, therefore, address these aspects to successfully promote condom use among sexually active students and subsequently reduce the risk of HIV transmission.

Exploring factors influencing recruitment results of nurses recruiting diabetes patients for a randomized controlled trial.

BACKGROUND: Effective recruitment of patients by health professionals is challenging but pivotal to the success of clinical trials. Many trials fail to include the required number of participants, which affects the power of the study, generalizability of results, and timely dissemination of positive outcomes. Existing research is inconclusive regarding factors influencing recruitment results, and most research does not focus on perceptions of recruiting health professionals themselves. Therefore, thorough evaluations of recruitment facilitators and barriers in trials are needed in order to optimize future patient recruitment in trials. We observed divergent recruitment results among nurses who recruited diabetes patients to our trial, which examined the effectiveness of an eHealth programme. Therefore, we aimed to describe nurses' recruitment results and related shifts over time, and to qualitatively explore factors influencing nurses' recruitment results. METHODS: Nurses' recruitment results and related temporal shifts were derived from trial data (NTR6840). Based on their recruitment results, nurses were categorized as non-, low-, medium-, or high-recruiters. Subsequently, a subset of nurses per group participated in an individual semi-structured telephone interview. Interviews were analysed using NVivo software, applying an inductive coding approach. RESULTS: Ninety-six nurses participated in our trial and recruited on average seven patients (range: 0-32). Fifteen nurses did not recruit any patients. Most patients were recruited close to recruitment onset. Nurses who did not recruit patients close to recruitment onset generally ended up recruiting no patients. Data show a relatively high number of early recruited patients that progressively declined over time. High-recruiters were generally successful throughout the entire recruitment period. Recruitment facilitators and barriers comprised organizational, study, patient, and especially recruiter characteristics. Contrary to non- and low-recruiters, medium- and high-recruiters reported more in-depth knowledge about the study and trial requirements, expressed more personal participation-related benefits and fewer barriers, and incorporated more recruitment activities, reminders, and barrier-focused coping strategies. CONCLUSION AND IMPLICATIONS: To optimize patient recruitment to clinical trials, suggested intervention targets include the continued inclusion of recruiters after initial recruitment onset and the encouragement of early recruitment success. A personalized approach may aid recruiters to become and remain successful. Primarily, it is important to provide recruiters with sufficient information on trial requirements and to address salient benefits for participation in the trial, both for themselves and for their patients. Finally, teaching recruiters skills on how to overcome barriers may further enhance motivation and recruitment capacities.

Effectiveness of Message Frame-Tailoring in a Web-Based Smoking Cessation Program: Randomized Controlled Trial.

BACKGROUND: The content of online computer-tailored interventions is often determined to match an individual's characteristics, beliefs, and behavioral factors. These content-tailored interventions lead to better message processing and a higher likelihood of behavior change such as smoking cessation. However, a meta-analysis of online computer-tailored interventions showed that effect sizes, albeit positive, remain small, suggesting room for improvement. A promising strategy to enhance the effectiveness of online computer-tailored interventions is to tailor the message frame (ie, how a message is communicated) based on the preferred communication style of the user in addition to content-tailoring. One factor that determines an individual's communication style preference is the need for autonomy; some individuals prefer an autonomy-supportive communication style (offering choice and use of suggestive language), whereas others might prefer a directive communication style, which is replete with imperatives and does not provide choice. Tailoring how messages are presented (eg, based on the need for autonomy) is called message frame-tailoring. OBJECTIVE: The aim of the present study was to test the effectiveness of message frame-tailoring based on the need for autonomy, in isolation and in combination with content-tailoring, within the context of an online computer-tailored smoking cessation intervention. The primary outcome measure was the 7-day point-prevalence of smoking abstinence. Secondary outcomes were perceived message relevance, self-determined motivation to quit smoking, and sociocognitive beliefs. METHODS: A randomized controlled trial with a 2 (message frame-tailoring vs no message frame-tailoring) by 2 (content-tailoring vs no content-tailoring) design was conducted among adult smokers intending to quit smoking (N=273). RESULTS: Structural equation modeling revealed that the content-tailored condition increased smoking abstinence rates 1 month after the start of the intervention (beta=.57, P=.02). However, neither message frame-tailoring nor its interaction with content-tailoring significantly predicted smoking abstinence. In our model, message frame-tailoring, content-tailoring, as well as their interaction significantly predicted perceived relevance of the smoking cessation messages, which consequently predicted self-determined motivation. In turn, self-determined motivation positively affected attitudes and self-efficacy for smoking cessation, but only self-efficacy consequently predicted smoking abstinence. Participants in the control condition perceived the highest level of message relevance (mean 4.78, SD 1.27). However, messages that were frame-tailored for individuals with a high need for autonomy in combination with content-tailored messages led to significantly higher levels of perceived message relevance (mean 4.83, SD 1.03) compared to those receiving content-tailored messages only (mean 4.24, SD 1.05, P=.003). CONCLUSIONS: Message frame-tailoring based on the need for autonomy seems to be an effective addition to conventional content-tailoring techniques in online smoking cessation interventions for people with a high need for autonomy; however, this is not effective in its current form for people with a low need for autonomy. TRIAL REGISTRATION: Dutch Trial Register (NL6512/NRT-6700); https://www.trialregister.nl/trial/6512.

Spoken Animated Self-Management Video Messages Aimed at Improving Physical Activity in People With Type 2 Diabetes: Development and Interview Study.

BACKGROUND: Web-based tailored interventions are a promising approach to help people with type 2 diabetes successfully adopt regular physical activity. Spoken animation seems to be effective regardless of the characteristics of the user and may be a relevant strategy to communicate complex health information. OBJECTIVE: The objectives of our study were to evaluate (1) pretesting communication elements and user appreciation, and (2) the applied behavior change techniques of the previously designed spoken animated video messages in a tailored self-management program for people with type 2 diabetes. METHODS: We conducted semistructured interviews with patients with type 2 diabetes recruited from general practices located in different socioeconomic status urban neighborhoods. Based on the pretesting key communication elements of Salazar's model, we asked participants about the spoken animated video messages' attractiveness, comprehensibility, acceptance, believability, involvement, and relevance and to what extent the video messages motivated them to become more physically active. We also assessed participants' intention to use the spoken animated video messages and to recommend them to others. To evaluate participants' appreciation of the different applied behavior change techniques, we conducted a post hoc analysis of the qualitative data using the MAXQDA program. Transcripts were coded by 2 coders using iterative qualitative content analysis methods to uncover key health communication issues. RESULTS: Of 23 patients who expressed an interest in participating, 17 met the inclusion criteria and 15 took part in the interviews. The positive appreciation of the comprehensibility, believability, and personalization was supported by participants' statements on behavior change techniques and other communication elements. Reinforcement of and feedback on participants' answers were positively evaluated as was the simplicity and concreteness of the spoken animated video messages. Most participants indicated reasons for not feeling motivated to increase their physical activity level, including being already sufficiently physically active and the presence of other impeding health factors. CONCLUSIONS: Spoken animated video messages should be simple, short, concrete, and without the use of medical terminology. Providing positive reinforcement, feedback on participants' answers, examples that match user characteristics, and the possibility to identify with the animation figures will enhance involvement in the health message. To connect more with patients' needs and thereby increase the perceived relevance of and motivation to use an animated video program, we suggest offering the program soon after diabetes mellitus is diagnosed. We recommend piloting behavior change techniques to identify potential resistance.

Developing an aftercare decision aid; assessing health professionals' and patients' preferences.

Personalising aftercare for curatively treated breast cancer patients is expected to improve patient satisfaction with care. A patient decision aid can support women in making decisions about their aftercare trajectory, but is currently not available. The aim of this study was to assess the needs of patients and health professionals with regard to an aftercare decision aid to systematically develop such a decision aid. Focus groups with patients and individual interviews with health professionals were digitally recorded and coded using the Framework analysis. Although most patients felt few aftercare options were available to them, health professionals reported to provide various options on the patients' request. Patients reported difficulty in expressing their need for options to their health professional. Although most patients were unfamiliar with decision aids, the majority preferred a paper-based patient decision aid, while most health professionals preferred an online tool. The practical implications for the intended patient decision aid are: that a digital tool with paper-based element should be developed, the patient decision aid should facilitate both rational and intuitive processes and should provide insight in patients' preferences concerning aftercare to discuss these explicitly.

The Effectiveness of a Computer-Tailored E-Learning Program for Practice Nurses to Improve Their Adherence to Smoking Cessation Counseling Guidelines: Randomized Controlled Trial.

BACKGROUND: Improving practice nurses' (PN) adherence to smoking cessation counseling guidelines will benefit the quality of smoking cessation care and will potentially lead to higher smoking abstinence rates. However, support programs to aid PNs in improving their guideline uptake and adherence do not exist yet. OBJECTIVE: The aim of this study was to assess the effects of a novel computer-tailored electronic learning (e-learning) program on PNs' smoking cessation guideline adherence. METHODS: A Web-based randomized controlled trial (RCT) was conducted in which an intervention group (N=147) with full access to the e-learning program for 6 months was compared with a control group (N=122) without access. Data collection was fully automated at baseline and 6-month follow-up via online questionnaires, assessing PNs' demographics, work-related factors, potential behavioral predictors based on the I-Change model, and guideline adherence. PNs also completed counseling checklists to retrieve self-reported counseling activities for each consultation with a smoker (N=1175). To assess the program's effectiveness in improving PNs' guideline adherence (ie, overall adherence and adherence to individual counseling guideline steps), mixed linear and logistic regression analyses were conducted, thus accommodating for the smokers being nested within PNs. Potential effect moderation by work-related factors and behavioral predictors was also examined. RESULTS: After 6 months, 121 PNs in the intervention group (82.3%, 121/147) and 103 in the control group (84.4%, 103/122) completed the follow-up questionnaire. Mixed linear regression analysis revealed that counseling experience moderated the program's effect on PNs' overall guideline adherence (beta=.589; 95% CI 0.111-1.068; PHolm-Bonferroni =.048), indicating a positive program effect on adherence for PNs with a more than average level of counseling experience. Mixed logistic regression analyses regarding adherence to individual guideline steps revealed a trend toward moderating effects of baseline levels of behavioral predictors and counseling experience. More specifically, for PNs with less favorable scores on behavioral predictors (eg, low baseline self-efficacy) and high levels of counseling experience, the program significantly increased adherence. CONCLUSIONS: Results from our RCT showed that among PNs with more than average counseling experience, the e-learning program resulted in significantly better smoking cessation guideline adherence. Experienced PNs might have been better able to translate the content of our e-learning program into practically applicable counseling strategies compared with less experienced colleagues. Less favorable baseline levels of behavioral predictors among PNs possibly contributed to this effect, as there was more room for improvement by consulting the tailored content of the e-learning program. To further substantiate the effectiveness of e-learning programs on guideline adherence by health care professionals (HCPs), it is important to assess how to support a wider range of HCPs. TRIAL REGISTRATION: Netherlands Trial Register NTR4436; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4436 (Archived by WebCite at http://www.webcitation.org/6zJQuSRq0).

Subgroups Among Smokers in Preparation: A Cluster Analysis Using the I-Change Model.

BACKGROUND: Investigating potential sub-stages of change could provide important information that could be used to improve the tailoring of smoking cessation interventions to individual smokers' profiles. Smokers in the preparation stage may be most interesting, as they are most likely to participate in smoking cessation interventions. OBJECTIVE: To examine whether Dutch adult smokers in the preparation stage of change, i.e. motivated to quit smoking within one month, can be organized into subgroups. METHODS: Data from 753 smokers who participated in an effectiveness trial of a web-based, computer-tailored smoking cessation programme were subjected to secondary analysis. Cluster analyses were based on respondents' baseline responses to items on pros and cons of quitting and quitting self-efficacy. Chi-squared tests and ANOVA were used to compare the baseline characteristics of the resulting clusters. Logistic and multinomial regression were used for longitudinal comparisons of clusters with respect to smoking abstinence and stage transition at six-week and six-month follow-ups. RESULTS: Four clusters were identified; Classic, Unprepared, Progressing and Disengaged Preparers. Cross-sectional and longitudinal analyses validated these clusters: they differed with respect to the clustering variables, gender, cigarette dependence and educational level. Disengaged Preparers were less likely than Progressing Preparers to report smoking abstinence at six months (OR = 0.28; p < .05). CONCLUSIONS: These results suggest that smoking cessation interventions tailored to the preparation stage of change, i.e. the set of cognitions usually present in preparers, are only appropriate for the subgroup we defined as Classic Preparers. The other clusters might need different interventions as they display different cognition sets.

Dutch practice nurses' adherence to evidence-based smoking cessation treatment guidelines.

Background: Practice nurses in general practice sub-optimally adhere to evidence-based smoking cessation treatment guidelines, but factors explaining their adherence have not yet been investigated. Understanding such factors is important to develop interventions improving practice nurses' smoking cessation guideline adherence and patients' subsequent cessation success. This study explored the association between different socio-cognitive and predisposing factors, and practice nurses' adherence to the Dutch smoking cessation guideline in general (i.e. overall adherence) and to each guideline step individually (i.e. step-based adherence). Methods: A cross-sectional study was conducted among practice nurses (N = 157) in January-March 2015 via web-based questionnaires, assessing constructs from the Integrated Change Model. Spearman's correlations and linear regression analysis were used to identify potential determinants of overall guideline adherence; Mann-Whitney U-tests and logistic regression analyses were used to identify potential determinants of step-based adherence. Results: On average five out of nine steps were completely adhered to by practice nurses; and step-based adherence ranged from 34% to 75%. Overall guideline adherence was associated with high levels of self-efficacy to use a guideline (ß = 0.32, P = 0.00), and step-based adherence was additionally associated with spending more time on counselling. Regression results showed positive associations between self-efficacy (8/9 steps) and perceived advantages (7/9 steps) with step-based adherence. Conclusion: This study quantitatively confirmed practice nurses' sub-optimal guideline adherence and found associations between socio-cognitive (self-efficacy and perceived advantages) and predisposing factors (time spent on counselling), and guideline adherence. Detailed insights in these factors offer preliminary directions for intervention development to improve practice nurses' adherence to evidence-based smoking cessation guidelines.

Exploring consensus on how to measure smoking cessation. A Delphi study.

BACKGROUND: Different criteria regarding outcome measures in smoking research are used, which can lead to confusion about study results. Consensus in outcome criteria may enhance the comparability of future studies. This study aims (1) to provide an overview of tobacco researchers' considered preferences regarding outcome criteria in randomized controlled smoking cessation trials, and (2) to identify the extent to which researchers can reach consensus on the importance of these outcome criteria. METHODS: A three-round online Delphi study was conducted among smoking cessation experts. In the first round, the most important smoking cessation outcome measures were collected by means of open-ended questions, which were categorized around self-reported and biochemical validation measures. Experts (n = 17) were asked to name the outcome measures (as well as their assessment method and ideal follow-up period) that they thought were important when assessing smoking-related outcomes. In the second (n = 48) and third rounds (n = 37), a list of outcome measures-identified in the first round-was presented to experts. Asking them to rate the importance of each measure on a seven-point scale. RESULTS: Experts reached consensus on several items. For self-reports, experts agreed that prolonged abstinence (6 or/and 12 months), point prevalence abstinence (7 days), continuous abstinence (6 months), and the number of cigarettes smoked (7 days) are important outcome measures. Experts reached consensus that biochemical validation methods should not always be used. The preferred biochemical validation methods were carbon monoxide (expired air) and cotinine (saliva). Preferred follow-ups included 6 and/or 12 months, with or without intermediate measurements. CONCLUSIONS: Findings suggest only partial compliance with the Russell standard and that more outcome measures may be important (including seven-day point-prevalence abstinence, number of cigarettes smoked, and cotinine when using biochemical validation). This study showed where there is and is not consensus, reflecting the need to develop a more comprehensive standard. For these purposes we provided suggestions for the Russell 2.0 standard.

The Missing=Smoking Assumption: A Fallacy in Internet-Based Smoking Cessation Trials?

INTRODUCTION: In this study, penalized imputation (PI), a common approach to handle missing smoking status data and sometimes referred to as "missing=smoking," is compared with other missing data approaches using data from internet-based smoking cessation trials. Two hypotheses were tested: (1) PI leads to more conservative effect estimates than complete observations analysis; and (2) PI and multiple imputation (MI) lead to similar effect estimates under balanced (equal missingness proportions among the trial arms) and unbalanced missingness. METHODS: First, the outcomes of 22 trials included in a recent Cochrane review on internet-based smoking cessation interventions were reanalyzed using only the complete observations, and after applying PI. Second, in a simulation study outcomes under PI, complete observations analysis, and two types of MI were compared. For this purpose, individual patient data from one of the Cochrane review trials were used. Results of the missing data approaches were compared with reference data without missing observations, upon which balanced and unbalanced missingness scenarios were imposed. RESULTS: In the reanalysis of 22 trials, relative risks (RR = 1.15 [1.00; 1.33]) after PI were nearly identical to those under complete observations analysis (RR = 1.14 [0.98; 1.32]). In the simulation study, PI was the only approach that led to deviations from the reference data beyond its 95% confidence interval. CONCLUSIONS: Analyses after PI led to pooled results equivalent to complete observations analyses. PI also led to significant deviations from the reference in the simulation studies. PI biases the reported effects of interventions, favoring the condition with the lowest proportion of missingness. Therefore, more sophisticated missing data approaches than PI should be applied.

Dealing With Missing Behavioral Endpoints in Health Promotion Research by Modeling Cognitive Parameters in Cost-Effectiveness Analyses of Behavioral Interventions: A Validation Study.

Cost-effectiveness analyses (CEAs) of behavioral interventions typically use physical outcome criteria. However, any progress in cognitive antecedents of behavior change may be seen as a beneficial outcome of an intervention. The aim of this study is to explore the feasibility and validity of incorporating cognitive parameters of behavior change in CEAs. The CEA from a randomized controlled trial on smoking cessation was reanalyzed. First, relevant cognitive antecedents of behavior change in this dataset were identified. Then, transition probabilities between combined states of smoking and cognitions at 6 weeks and corresponding 6 months smoking status were obtained from the dataset. These rates were extrapolated to the period from 6 to 12 months in a decision analytic model. Simulated results were compared with the 12 months' observed cost-effectiveness results. Self-efficacy was the strongest time-varying predictor of smoking cessation. Twelve months' observed CEA results for the multiple tailoring intervention versus usual care showed € 3188 had to be paid for each additional quitter versus € 10,600 in the simulated model. The simulated CEA showed largely similar but somewhat more conservative results. Using self-efficacy to enhance the estimation of the true behavioral outcome seems a feasible and valid way to estimate future cost-effectiveness.

Barriers and facilitators to end-of-life communication in advanced chronic organ failure.

AIM: The aim of this quantitative, cross-sectional study was to identify barriers and facilitators to end-of-life communication experienced by family caregivers of patients with advanced chronic organ failure and to examine agreement in barriers and facilitators between family caregivers and patients. METHODS: Patients and family caregivers were interviewed using the barriers and facilitators questionnaire. Agreement was determined using intraclass correlation coefficients for continuous variables and Cohen's kappa for categorical variables. RESULTS: A total of 158 patients and family caregiver dyads were included. The most important barriers for family caregivers were related to uncertainty about expected care and focus on staying alive instead of dying. The facilitators were related to trust in and competence of their physician and earlier experiences with death in their (social) environment. For most barriers and facilitators, agreement between patients and family caregivers was fair to moderate. CONCLUSION: Differences in barriers and facilitators between patients and family caregivers ask for an individual approach to facilitate end-of-life communication.