Educational intervention based on the extended parallel process model improves adherence to diabetic diet and glycaemic control indices: a randomised, double-blind, controlled, factorial field trial.

Nutritional education is pivotal in the medical nutritional therapy of type 2 diabetes mellitus (T2DM). The extended parallel process model (EPPM) is a health education method for inducing desirable health behaviours. The present study aimed to investigate the effect of nutritional education based on the EPPM in T2DM patients on knowledge, attitude, practice, anthropometric indices, glycaemic factors, lipid profile and adherence to the diabetic diet. A randomised, double-blind, controlled, factorial field trial was designed for T2DM patients aged 30-59 years (n 88). Participants were randomly allocated into four groups to receive EPPM-based nutritional education through gain framed message (GFM), loss framed message (LFM), their combination (G\LFM) or usual diabetic education in the control group (CG). Participants were assessed before and after the study duration. After 3 months of intervention, eighty participants finished the study. The EPPM-based intervention increased participants' knowledge, behavioural intention, perceived sensitivity, severity, self-efficacy (P < 0·001 for all) and response efficacy (P = 0·029) in comparison with CG. GFM (P = 0·004) and G\FLM (P = 0·034) reduced carbohydrate intake and LFM (P = 0·034) and G\LFM (P = 0·047) decreased fat intake. Between-group analysis indicated interventions reduced weight (P = 0·046), BMI (P = 0·038), fasting blood sugar (P = 0·030), 2-hour postprandial blood glucose (P = 0·027) and TAG (P = 0·002) in comparison with the CG. Results were NS for protein intake, waist and hip circumference, waist:hip ratio, HbA1c, total cholesterol, LDL and HDL. Nutritional education based on EPPM could increase the knowledge and awareness of T2DM patients. Also, it could be beneficial for blood glucose amendment. Further investigations are recommended.

Application of the extended parallel process model and risk perception attitude framework to obesity knowledge and obesity prevention behaviors among Korean adults.

BACKGROUND: Perceiving oneself as obese has been associated with weight loss attempts. However, such a perception may not sufficiently drive significant weight reduction in many individuals. Hence, relying solely on the traditionally emphasized perceived risk of behavioral changes in obesity is challenging. This study used an extended parallel process model and a risk perception attitude framework to explore the influence of perceived risk and perceived efficacy on individual obesity knowledge and obesity prevention behaviors. METHODS: Data were obtained from 1,100 Korean adults aged 40-69 years through an online survey conducted in October 2022. Multinomial logistic regression and analysis of variance were employed to assess the relationships among perceived risk, perceived efficacy, obesity knowledge, and obesity prevention behaviors. RESULTS: Sex was associated with being underweight, overweight, and obese. Moreover, perceived severity was associated with obesity, whereas perceived susceptibility was associated with overweight and obese. Response efficacy was related to being overweight alone, whereas self-efficacy was associated with being underweight, overweight, and obese. The main effects of sex and perceived risk, and their interaction effect were statistically significant for obesity knowledge. Additionally, the main effects of sex, perceived risk, and perceived efficacy on obesity prevention behaviors were statistically significant. CONCLUSIONS: The extended parallel process model and risk perception attitude framework proved effective in classifying obesity based on body mass index, obesity knowledge, and obesity prevention behaviors.

Formative Research to Inform College Health Communication Campaigns About COVID-19 Prevention Behaviors.

This research aimed to inform the development of a health communication campaign to increase the uptake of COVID-19 prevention behaviors among university students. Twenty-eight students attending a mid-sized public university in the southeastern United States and 84 parents or guardians of university students were recruited. The study included an online survey assessing COVID-19 prevention behaviors, perceived susceptibility to COVID-19, perceived severity of COVID-19, and semi-structured interviews to elicit beliefs on COVID-19 prevention behaviors. Students and parents/guardians reported that getting COVID-19 was possible but not necessarily likely. COVID-19 was seen as serious and at least somewhat severe. Dominant interview themes for benefits, barriers, response efficacy, and self-efficacy related to prevention behaviors are reported. Overall, perceptions of behavioral benefits, barriers, and response efficacy were often shared by parents and students but varied across behaviors. These data provide insights for future campaign development for the control of infectious diseases among college students.

Identifying Mediators of Intervention Effects Within a Randomized Controlled Trial to Motivate Cancer Genetic Risk Assessment Among Breast and Ovarian Cancer Survivors.

BACKGROUND: A theory-guided Tailored Counseling and Navigation (TCN) intervention successfully increased cancer genetic risk assessment (CGRA) uptake among cancer survivors at increased risk of hereditary breast and ovarian cancer (HBOC). Understanding the pathways by which interventions motivate behavior change is important for identifying the intervention's active components. PURPOSE: We examined whether the TCN intervention exerted effects on CGRA uptake through hypothesized theoretical mediators. METHODS: Cancer survivors at elevated risk for HBOC were recruited from three statewide cancer registries and were randomly assigned to three arms: TCN (n = 212), Targeted Print (TP, n = 216), and Usual Care (UC, n = 213). Theoretical mediators from the Extended Parallel Process Model, Health Action Planning Approach, and Ottawa Decision Support Framework were assessed at baseline and 1-month follow-up; CGRA uptake was assessed at 6 months. Generalized structural equation modeling was used for mediation analysis. RESULTS: The TCN effects were most strongly mediated by behavioral intention alone (ß = 0.49 and 0.31) and by serial mediation through self-efficacy and intention (ß = 0.041 and 0.10) when compared with UC and TP, respectively. In addition, compared with UC, the TCN also increased CGRA through increased perceived susceptibility, knowledge of HBOC, and response efficacy. CONCLUSIONS: Risk communication and behavioral change interventions for hereditary cancer should stress a person's increased genetic risk and the potential benefits of genetic counseling and testing, as well as bolster efficacy beliefs by helping remove barriers to CGRA. System-level and policy interventions are needed to further expand access.

It is recommended that cancer survivors at increased risk for heredity seek cancer genetic risk assessment (CGRA), which includes cancer genetic counseling and genetic testing. A Tailored Counseling and Navigation (TCN) intervention successfully increased CGRA uptake among women with a history of cancer who enrolled in a randomized controlled trial. Understanding reasons for TCN's effectiveness can guide future interventions that use risk messages and behavior change techniques. We conducted mediation analyses, which enabled identification of the TCN's active components. Eligible breast and ovarian cancer survivors (n = 641) were recruited from three statewide cancer registries and were assigned to three groups: TCN, Targeted Print, and Usual Care. Mediator variables drawn from behavioral and risk communication theories were assessed at baseline and 1-month follow-up; CGRA uptake was assessed at 6 months. The strongest mediator was intention to obtain a CGRA, followed by self-efficacy, perceived risk, knowledge of hereditary breast and ovarian cancer, and perceived CGRA benefits. Risk communication and behavioral change interventions for hereditary cancer should stress a person's increased genetic risk and the potential benefits of genetic counseling and testing, as well as bolster efficacy beliefs by helping remove CGRA barriers. System-level and policy interventions are needed to further expand access.

Response to COVID-19 recommended preventive behavioral messages among Guraghe zone communities, South Ethiopia: using constructs of the Extended Parallel Process Model (EPPM).

INTRODUCTION: The World Health Organization declared COVID-19 is a pandemic disease. Countries should take standard measures and responses to battle the effects of the viruses. However, little is known in Ethiopia regarding the recommended preventive behavioral messages responses. Therefore, the study aimed to assess the response to COVID-19 recommended preventive behavioral messages. METHODS: Community-based cross-sectional study design was carried out from 1 to 20, July 2020. We recruited 634 respondents by using a systematic sampling method. Data were analyzed using Statistical Package Software for Social Sciences version 23. Association between variables were explored using a bivariable and multi variable logistic regression model. The strength of the association is presented using odds ratio and regression coefficient with 95% confidence interval. A p-value of less than 0.05 was declared statistically significant. RESULTS: Three hundred thirty-six (53.1%) of respondents had good response to recommended preventive behavioral messages. The general precise rate of the knowledge questionnaire was 92.21%. The study showed that merchant was 1.86 (p ≈ 0.01) times more likely respond to COVID-19 recommended preventive behavioral messages than government-employed. Respondents who scored one unit increase for self-efficacy and response-efficacy, the odds of responding to COVID-19 recommended preventive behavioral messages were increased by 1.22 (p < 0.001), and 1.05 times (p = 0.002) respectively. Respondents who scored one unit increase to cues to action, the odds of responding to COVID-19 recommended preventive behavioral messages were 43% (p < 0.001) less likely. CONCLUSION: Even though respondents were highly knowledgeable about COVID-19, there is a lower level of applying response to recommended preventive behavioral messages. Merchant, self-efficacy, response efficacy, and cues to action were significantly associated with response to recommended preventive behavioral messages. Like merchants, government employer should be applying preventive behavioral messages and also, participants' self and response efficacy should be strengthened to improve the response. In addition, we should be changed or modified the way how-to deliver relevant information, promoting awareness, and also using appropriate reminder systems to preventive behavioral messages.

Predicting college students' COVID-19 vaccination behavior: an application of the extended parallel process model.

The two studies reported in the paper examined (1) the extended parallel process model's (EPPM; Witte 1992) ability to predict and explain college students' COVID-19 vaccination behavior, and (2) the EPPM-related reasons for college students' COVID-19 vaccine hesitancy. Study 1 was a longitudinal study that measured the EPPM constructs at Time 1 and COVID-19 vaccine behavior two months later at Time 2. For danger control, results indicate that perceived threat and perceived efficacy positively predicted intentions and that intentions positively predicted behavior. For fear control, results indicate that perceived threat positively predicted fear, that perceived efficacy did not predict fear, and that fear negatively predicted defensive avoidance, reactance, and fatalism. Study 2 was a cross-sectional survey that assessed EPPM-related reasons for vaccine hesitancy. Results indicate that the main reasons for vaccine hesitancy were related to response efficacy (i.e., participants were concerned about the safety and effectiveness of the vaccine). The theoretical and practical implications of these results are discussed.

Differences in Perceived Threat and Efficacy in Managing Opioid Use Disorder versus Alcohol Use Disorder.

Background: Efforts to increase the availability of Medication Assisted Treatment for alcohol use disorder (AUD) and opioid use disorder (OUD) may be futile if patients lack motivation for recovery and are unwilling to seek treatment. Objectives: In this cross-sectional, online survey, we used the Extended Parallel Process Model (EPPM) to assess how participants at risk of AUD or OUD react to their perceived threat and assess their response to pharmacotherapy as a potential treatment. EPPM constructs were assessed using the Risk Based Diagnosis Scale. Descriptive statistics measure the proportion of treated vs untreated participants. Untreated participants were sorted into one of three groups categorizing perceived threat - low threat appraisal, and danger or fear control. Results: Of 411 total responses, most (n = 293[71.29%]) sorted into the AUD cohort and 118(28.71%) into the OUD cohort. Overall, 104(25.30%) had received treatment and 307(74.70%) didn't. Within the OUD cohort, there were 67 untreated participants - 16(23.88%) exhibited low threat appraisal, 13(19.40%) were likely to undergo fear control, and 38(56.72%) were likely to undergo danger control. Within the AUD cohort, there were 240 untreated participants - 75(31.25%) exhibited low threat appraisal, 100(41.67%) were likely to experience fear control, and 65(27.08%) were likely to experience danger control. Participants in the OUD cohort were more likely to undergo danger control than those in the AUD cohort (χ2 = 19.26, p < 0.05). Conclusions: This study identified perceived threat and efficacy when an individual was at risk of a SUD, but more insight into potential early interventions is needed - particularly in those individuals with polysubstance use disorder.

Design and evaluation of two educational media in the form of animation and games to promote the cutaneous leishmaniasis prevention behaviors in adolescent female.

BACKGROUND: Cutaneous leishmaniasis (CL) has social and psychological effects on different groups, especially adolescents and young girls in 98 countries of the world, in addition to the economic burden. Therefore, it is necessary to apply effective methods for CL prevention. In this study, educational messages were designed based on Extended Parallel Process Model in both forms of animation and game, whose effect on the cutaneous leishmaniasis prevention behaviors was evaluated in adolescent female students.  METHODS: This experimental study was carried out from January to September 2021 on 275 adolescent female students in Isfahan province, Iran. Cluster sampling method was used, and then the students were randomly divided into three groups, namely animation education, game education, and control groups. The educational intervention was performed with two new media in the form of animation and games. The data collected before and two months after the education through a valid and reliable researcher-made questionnaire were analyzed in SPSS24 software using statistical tests of ANOVA, Chi-square, paired t and analysis of covariance (ANCOVA). RESULTS: The mean age of the participants was 14.07 ± 0.94. The mean scores of behavior in the animation group (60.60 ± 23.00), the game group (61.70 ± 22.05), and the control group (66.13 ± 24.62) were not significantly different prior to the education. However, after the education, there was a significant difference between the animation (80.66 ± 17.62) and game groups (82.58 ± 19.07) and the control group (69.79 ± 23.29) (P < 0.001). The mean scores of model constructs following the intervention (susceptibility, severity, response efficacy, and perceived self-efficacy) significantly increased in the animation and game groups compared to that in the control group (P < 0.05). CONCLUSION: The results showed that if educational programs contain a combination of threat and efficiency messages, CL-preventive behaviors in adolescents increase. Providing similar educational content with both game and animation methods indicated that both methods had an almost same effect. Although animation production is more costly, it has the advantage of being used in periods and for other adolescents.

Behavioral responses for facemask use messages to prevent COVID-19 among residents of Bahir Dar City, Ethiopia: an application of extended parallel process model.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic causes major morbidity and mortality in the world. Timely behavioral response assessment of the community is important to shape the next effective interventions and risk communication strategies to adopt preventive behavior. Hence, this study aimed to assess behavioral responses for facemask-use messages to prevent COVID-19 and its predictors among residents of Bahir Dar City, Ethiopia, 2021 by using the Extended Parallel Process Model.  METHODS: A community-based cross-sectional study was conducted with the guide of the Extended Parallel Process Model in Bahir Dar city from March 9 to April 9, 2021. A multistage sampling technique was used, and data was collected through a face-to-face interviewer-administered questionnaire using Epicollect5. Descriptive statistics and Binary logistic regression were computed using SPSS V.25. Variable with P < 0.25 in the bivariable analysis was a candidate for multivariable analysis to control confounding effect. In multivariable analysis, variables with P < 0.05 were considered statistically significant and the result was presented using an adjusted odd ratio (AOR) with a 95% confidence interval (CI). RESULTS: A total of 616 participants with a response rate of 97.1% were included. Of the total participants, 229(37.2%) were in the danger control response. The behavioral response was affected by Occupational status [AOR (95%CI) 3.53(1.67-7.46)], the number of people living together [AOR (95%CI) 2.62(1.28-5.39)], self-control [AOR (95%CI) 1.14(1.05-1.25)], a friend for the preferred source of information [AOR (95%CI) 5.18(3.22-8.33)] and printed materials for the preferred channel [AOR (95%CI) 2.14(1.35-3.43)]. CONCLUSION: Above one-third of the participants were in the danger control response. Occupational status, number of people living together, self-control, a friend for the preferred source of information, and printed materials for the preferred channel were independent predictors of resident behavioral response to the use of facemasks. Policymakers should consider students and people who live alone. Message developers should use a friendly person to transmit messages and should prepare printed materials. Activities and strategies should also focus on self-control and perceived efficacy without ignoring the perceived threat.

Outcomes from a pilot genetic counseling intervention using motivational interviewing and the extended parallel process model to increase cascade cholesterol screening.

Familial hypercholesterolemia (FH) is an inherited condition resulting in increased risk of premature cardiovascular disease. This risk can be reduced with early diagnosis and treatment, but it can be challenging to identify individuals with FH. Cascade screening, the most efficient and cost-effective identification method, requires FH patients to communicate with their at-risk family and encourage them to pursue screening. Beyond FH, patients with conditions increasing disease risk to family members report barriers to the communication process such as insufficient knowledge of the condition and discomfort informing relatives. We conducted a pilot study of a genetic counseling intervention incorporating behavior-change principles from motivational interviewing (MI) and the extended parallel process model (EPPM) to help parents of children with FH overcome these barriers and improve cascade screening rates for FH. Of the 13 participants who completed the intervention and post-intervention surveys, 6 reported contacting and/or screening additional relatives. A large effect size in increasing communication and screening was observed (η2  = 0.20), with the mean percent of at-risk relatives contacted rising from 33% to 45%, and the mean percent screened rising from 32% to 42%. On average, 2.23 new relatives were contacted and 2.46 were screened, per participant, by the end of the study. Direct content analysis revealed that despite the open-ended nature of the goal-setting process, participant goals fell into two categories including those who set goals focused on communicating with and screening family members (n = 9) and those who set goals only focused on managing FH (n = 4). Overall, the communication and screening rates reported after the intervention were higher than previous observations in adult FH populations. These results suggest this EPPM/MI genetic counseling intervention could be a useful tool for increasing communication and cascade screening for FH. With further research on goal-setting techniques, the intervention could be refined and replicated to identify more individuals affected by FH or modified for use with other actionable genetic conditions.

Application of motivational interviewing strategies with the extended parallel process model to improve risk communication for parents of children with familial hypercholesterolemia.

Current genetic counseling practice has not been found to significantly increase risk communication between family members. A more diverse set of genetic counseling approaches may be needed. A genetic counseling intervention based on motivational interviewing principles and the extended parallel process model was utilized to increase cascade outcomes within families with familial hypercholesterolemia, a common, underdiagnosed, and treatable condition. Parents of children with familial hypercholesterolemia were invited to participate in an online pre-survey, single-session genetic counseling intervention, and post-intervention surveys as a part of the CHEERS (Cholesterol Evaluation to Explore Risk Screening) intervention. This study investigated the efficacy of a genetic counselor delivered motivational interviewing intervention and how parents of children with familial hypercholesterolemia react by assessing family member cholesterol screening and risk communication to at-risk relatives. Transcripts were audio-recorded, transcribed, and analyzed for change talk using the Motivational Interviewing Skill Code version 2.1. Participant surveys were analyzed for self-reported extended parallel process constructs and motivations. Coincidence analysis was conducted to explore differences between those with and without positive cascade outcomes within 12 months after the intervention. On average, change talk increased during the session in order of the extended parallel process constructs (perceived severity, susceptibility, response efficacy, self-efficacy). Coincidence analysis revealed that 6 of the 7 cases with positive cascade outcomes were explained by either the presence of high change talk during the intervention or presence of positive motivations shortly after, while 5 of the 5 cases without a positive outcome lacked both of these key factors that were associated with cascade outcomes. Results of this study suggest that incorporating motivational interviewing and the extended parallel process model increases change talk and that the presence of either high levels of change talk or positive motivations is associated with positive cascade outcomes.

An empirical comparison of the Extended Parallel Process Model with the Terror Management Health Model.

The Extended Parallel Process Model posits that fear-appeal messages are processed only when message recipients perceive a critical level of threat. The more recent Terror Management Health Model suggests that, in addition to level of perceived threat, the nature of the threat also influences how target audiences process fear appeals. Specifically, fear appeals that utilize the threat of death as a consequence trigger both conscious and nonconscious responses that influence message recipients' health-related decisions. Accounting for the influence of consciousness of death helps explain maladaptive responses that extant theory has been unable to explain. Results from an experiment indicate that, when the level of perceived fear was the same across participants, the Extended Parallel Process Model successfully predicted persuasive outcomes for fear appeals that utilized the threat of arrest or serious injury as a consequence of noncompliance. However, for fear appeals that utilized the threat of death as a consequence of noncompliance, as predicted by the Terror Management Health Model, ego involvement in the health-related behavior predicted persuasive outcomes more accurately than the dual fear control and danger control processes. These findings suggest that incorporating consciousness of death and ego involvement can avoid conceptual problems with the level-of-fear construct, provide a meaningful way to predict fear-appeal responses across target audiences, and explain maladaptive responses that have eluded the explanations of extant fear-appeal theories.

In this research, we compared two psychological models that explain how people respond to fear-based health promotion campaigns. The well-established Extended Parallel Process Model predicts that when faced with a fear-arousing message, audiences evaluate their self-efficacy in performing the recommended action, as well as the efficacy of the proposed action. Next, the efficacy appraisal is weighed against the perceived level of fear and the relevance of the threat to one's personal situation to determine a response to the threat. The more recently developed Terror Management Health Model states that fear of death is a special case. When faced with a fear-arousing message that utilizes threat of death as a consequence, audiences can cling to worldviews that grant them self-esteem. As such, defensiveness evoked by the fear of death is not in response to the level of perceived threat, but the qualitative nature of the threat. This worldview defense can create undesirable responses to fear appeals containing the fear of death. Results from a laboratory experiment indicate that the established model explains audience behavior for health-related messages that utilize threats with nonfatal consequences but the Terror Management Health Model is better suited to predicting behavior for messages that utilize threat of death as a consequence.

Effect of fear appeal mobile phone messaging on health behaviors of caregivers with children under-five in Ghana.

Social and Behavior Change Communication is a vital strategy in the control of malaria. However, the effectiveness of fear appeal tactic as a preventive strategy remains uncertain. This study examined the influence of a fear appeal mobile phone-based intervention, guided by Witte's Extended Parallel Process model, on malaria prevention among caregivers with children under-five. We conducted a quasi-experimental study of a 12-month intervention using a sample of 324 caregivers from two rural districts, assigned to either an intervention or control group. The intervention group received fear appeal voice Short Message Service (SMS), once a week for twelve (12) months, while caregivers in the control group received none. The results showed that exposure to the messages was associated with an increased odds of positive attitude [adjusted Odds ratio (aOR) = 2.58; 95% CI 1.61-4.15] and behavioral changes (aOR = 2.03, 95% CI 1.29-3.19). The intervention group exhibited lower odds of defensive avoidance (aOR = 0.44, 95% CI 0.29-0.68) and message minimization (aOR = 0.51, 95% CI 0.33-0.78) compared with the control group. These findings highlight the importance of communicating health messages via mobile phones using fear appeal for improving the health behaviors of caregivers. This strategy, however, may not be useful for influencing the intention of caregivers to engage in positive health practices to protect their children from malaria.

Psychological predictors of intention and avoidance of attending organized mammography screening in Norway: applying the Extended Parallel Process Model.

BACKGROUND: Mammography screening is the main method for early detection of breast cancer in Norway. Few studies have focused on psychological determinants of both attendance and non-attendance of publicly available mammography screening programs. The aim of the current study, guided by the Extended Parallel Process Model, was to examine how psychological factors influence defensive avoidance of breast cancer screening and intention to attend mammography. METHODS: Cross-sectional survey data from a community sample of women living in Norway aged ≥ 18 (N = 270), and without a history of breast cancer, was collected from September 2018 to June 2019 and used to investigate the relationships between the Extended Parallel Process Model (EPPM) constructs and two outcomes: defensive avoidance of breast cancer screening and intention to attend mammography within the next two years. After adjusting for confounding factors, the hierarchical multiple linear regression analyses was conducted to assess the ability of the independent variables based on the EPPM to predict the two outcome variables. Significance level was chosen at p < 0.05. RESULTS: Multivariate analyses showed that defensive avoidance of breast cancer screening was predicted by lower perceived susceptibility to breast cancer (ß = - 0.22, p = 0.001), lower response efficacy of mammography screening (ß = - 0.33, p = 0.001), higher breast cancer fear (ß = 0.15, p = 0.014), and checking breasts for lumps (ß = - 0.23, p = 0.001). Intention to attend mammography within the next two years was predicted by higher response efficacy of mammography screening (ß = 0.13, p = 0.032), having a lower educational level (ß = - 0.10, p = 0.041), and regular previous mammography attendance compared to never attending (ß = 0.49, p = 0.001). CONCLUSIONS: The study revealed that defensive avoidance of breast cancer screening and intention to attend mammography were not predicted by the same pattern of psychological factors. Our findings suggest future health promotion campaigns need to focus not only on the psychological factors that encourage women's decision to attend the screening, but also to counter factors that contribute to women's decision to avoid it.

Risk perceptions and attitudinal responses to COVID-19 pandemic: an online survey in Ethiopia.

BACKGROUND: Effective risk communication is one of the critical strategies in the response to COVID-19. This study examined risk perceptions and attitudinal responses to COVID-19 among the educated section of the society in Ethiopia. METHODS: An internet-based survey was conducted from April 22 to May 04, 2020, in Ethiopia. A questionnaire addressing the perception of health threat-combination of perceived vulnerability (PV) and perceived seriousness (PS), and perceived efficacy-combinations of perceived response efficacy (PRE), perceived self-efficacy (PSE), and perceived collective efficacy (PCE). The data were analyzed using SPSS 21.0. Descriptive statistics were computed after the standardization of the scores. The scores for overall efficacy and threat were split by median value and response classifications were generated through threat by efficacy interactions. For statistical significance, 95% CI and p-value < 0.05 were used. RESULTS: A total of 929 respondents submitted their responses. Eight hundred and twenty-eight (89.1%) of the respondents were male and 753 (81.1%) were Christian. The perceived threat to COVID-19 was generally low (median = 58.3). The median score for overall efficacy, PRE, and PSE were 79.8, 87.5, and 80.0, respectively. However, the median value (66.7) for PCE was relatively low. Perceived threat significantly varied by age, education, occupation, and place of residence (p < 0.05). Perceived efficacy significantly differed by gender, residence, and use of some sources of information (p < 0.05). In terms of response to COVID-19, 290 (31.2%), 239 (25.7%), 175 (18.8%) and 225 (24.2%) of the respondents were in the responsive, pro-active, avoidant, and indifferent attitudinal categories, respectively. The avoidant and indifferent groups constituted a fear control response (mal-adaptive motivation towards COVID-19 protective behavior) whereas responsive and pro-active categories formed a danger control response (self-protective motivation). These responses varied significantly by residence, region, religion, and sources of information (p < 0.05). CONCLUSIONS: Understanding people's perceived health threat and efficacy is a critical step toward creating risk communication campaigns. Hence, this study provided an insight that has the potential to inform the COVID-19 risk communication campaigns targeting the educated section of the society, by ensuring a balanced combination of threat appeals and efficacy messages for improved self-protective responses.

Risk perception related to COVID-19 among the Iranian general population: an application of the extended parallel process model.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) has emerged as a major global public health challenge. This study aimed to investigate on how people perceive the COVID-19 outbreak using the components of the Extended Parallel Process Model (EPPM) and to find out how this might contribute to possible behavioral responses to the prevention and control of the disease. METHODS: This cross-sectional study was conducted in Iran during March and April 2020. Participants were recruited via online applications using a number of platforms such as Telegram, WhatsApp, and Instagram asking people to take part in the study. To collect data an electronic self-designed questionnaire based on the EPPM was used in order to measure the risk perception (efficacy, defensive responses, perceived treat) related to the COVID-19. Descriptive statistics, chi-square, t-test and analysis of variance (ANOVA), were used to explore the data. RESULTS: A total of 3727 individuals with a mean age (SD) of 37.0 (11.1) years participated in the study. The results revealed significant differences in efficacy, defensive responses and perceived treat among different population groups particularly among those aged 60 and over. Women had significantly higher scores than men on some aspects such as self-efficacy, reactance, and avoidance but men had higher perceived susceptibility scores compared to women. Overall 56.4% of participants were engaged in danger control (preventive behavior) while the remaining 43.6% were engaged in fear control (non-preventive behavior) process. CONCLUSION: More than half of all participants motivated by danger control. This indicated that more than half of participants had high perceived efficacy (i.e., self-efficacy and response efficacy). Self-efficacy scores were significantly higher among participants who were older, female, single, lived in rural areas, and had good economic status. The results suggest that socioeconomic and demographic factors are the main determinants of the COVID-19 risk perception. Indeed, targeted interventions are essential for controlling the pandemic.

Testing threat-to-efficacy ratios in health communications about cardiovascular disease among an older population.

To test threat-to-efficacy ratios within health communications about cardiovascular disease (CVD) for older individuals. Participants were randomly assigned to one of six messages: (i) 'standard' message with 1/1 threat-to-efficacy ratio, (ii) 'low efficacy' message with 1/0 threat-to-efficacy ratio, (iii) 'low threat' message with 0/1 threat-to-efficacy ratio, (iv) 'high efficacy' message with 1/2 threat-to-efficacy ratio; (v) 'high threat' message with 2/1 threat-to-efficacy ratio and (vi) 'overload' message with 2/2 threat-to-efficacy ratio. Participants had to be of 60 years of age or older (N = 242, Male = 92, Age: M = 68.29, SD = 6.71). Advanced univariate analyses and multiple regression modelling were conducted to examine associations between the message groups, and danger- and fear-control processes, as well as the impact of threat and efficacy appraisals on the relationship between the message groups and behavioural intentions. No differences were found between the message groups for danger-control processes. Those who received the 'overload' message did report higher levels of fear, nervousness and anxiety in comparison to the 'standard' message group. For physical activity, it was found that efficacy impacted the relationship between the message groups and behavioural intentions, as participants' levels of efficacy increased and if these individuals received high levels of efficacy information, their behavioural intentions for physical activity increased. Results from this study were dissimilar to those of previous research. However, they highlighted the impact of efficacy and negative emotional reactions when communicating to older individuals about CVD and the associated health behaviours.

Mobile phone short message service (SMS) as a malaria control tool: a quasi-experimental study.

BACKGROUND: Despite the extensive implementation of control measures and achievements in morbidity reductions, malaria continues to contribute to substantial morbidity and mortality in children under-five. Innovative approaches involving the use of mobile phones have been suggested to improve health outcomes. However, evidence of its effect on reducing the prevalence of malaria is limited. This study, therefore, aimed to assess the effect of a theory-driven mHealth intervention on the prevalence of malaria among children under-five living in rural districts of Ghana. METHODS: We conducted a quasi-experimental study of a 12-month intervention using a random sample of 332 caregivers with children under-five from two rural districts, assigned to either an intervention or a control group. Caregivers in the intervention group received voice short message service (SMS) on malaria prevention based on a behavior change theory to improve their health behaviors and practice, once a week for twelve months, while caregivers in the control group received none. Pre- and post-intervention assessment of the treatment effect (ATT) on malaria in children under-five was conducted using propensity score and difference-in-difference (DiD) analyses. RESULTS: Among children whose caregivers received the intervention, the prevalence of malaria decreased from 58.4% at baseline to 37.8% at endline (difference: -20.6%; 95% CI: - 31.1, - 10.1) compared with children in the control group, where a reduction of 65.0 to 59.9% (difference - 5.1%; 95% CI: - 15.5, 5.4) was observed. The treatment effect at endline revealed a statistically significant reduction in malaria prevalence (ATT: -0.214; 95% CI: - 0.36, - 0.07) compared with the baseline (ATT: -0.035; 95% CI: - 0.16, 0.09). Overall, the intervention effect showed a significant reduction in the prevalence of malaria among children under-five was positive (DiD: - 0.154; p = 0.043). CONCLUSION: The results of the study indicate the effectiveness of mobile phone SMS as a control tool for reducing the burden of malaria in children under-five.

Prevention behaviours of oesophageal cancer: Protocol for a mixed-method study.

AIM: The aim was to implement an educational programme for the family members of patients with oesophageal cancer on prevention behaviours in Golestan province, north of Iran. DESIGN: In this mixed-method research, qualitative and quantitative studies will be conducted. METHODS: This study will be carried out using an exploratory mixed-method design in Golestan province, north of Iran in 2018-2019. The research will include three consecutive phases. At first, a qualitative study will be carried out to determine the preventive behaviour and measures of oesophageal cancer. In this phase, the participants will be selected using the purposive sampling method. Later, semi-structured interviews will be conducted with the relatives of patients with oesophageal cancer to collect the necessary qualitative data. The second phase will include a literature review based on the information collected from the first phase. Later, a researcher-made questionnaire will be designed based on the extended parallel process model. Furthermore, a comprehensive programme will be proposed about self-care of the patients with oesophageal cancer. In the third phase, a quantitative quasi-experimental research will be conducted over two groups of participants to measure the effectiveness of this programme. This research was approved by the Ethics Committee of Yazd Shahid Sadoughi University of Medical Sciences, Iran in November 2017. DISCUSSION: Educational interventions should be designed purposefully according to the needs of the target group to improve their self-care behaviours. We also expect that this research can improve the individuals' access to high-quality preventive behaviours with regard to oesophageal cancer. TRIAL REGISTRATION: The project was registered on the Iranian Registry of Clinical Trials, (registration number: IRCT20180725040588N1, date registered: 2th October 2018).

Reactions to tobacco warning labels: predictors and outcomes of adaptive and maladaptive responses.

BACKGROUND: The Extended Parallel Process Model (EPPM) responses have not been evaluated from verbal reactions to cigarette warning labels. We identified the EPPM responses in reactions to cigarette warning labels and evaluated their predictors and relationship with warning perceptions. METHODS: U.S. adult current smokers, transitioning smokers (quit in the past two years or currently quitting) and never smokers (n=1,838) saw nine of 81 cigarette warning labels. Participants freely wrote their thoughts after viewing the first label and reported perceived informativeness, negative emotions, and denial for this label. Responses were coded for the presence of the EPPM response categories. Multivariable logistic regression models described adaptive and maladaptive respondent characteristics, and linear regression models assessed the relationship between the response categories and label perceptions. RESULTS: Participants' responses contained adaptive (65.4%), maladaptive (16.5%), no response (14.7%), and mixed responses (both adaptive and maladaptive; 3.4%). Current smokers had decreased odds of adaptive response compared to never and transitioning smokers. Compared to text warnings, pictorial warnings were associated with increased odds of adaptive and decreased odds of maladaptive responses. Adaptive response was associated with increased odds of intentions to quit smoking. Adaptive respondents reported the highest levels of informativeness and negative emotions among the four response categories. CONCLUSIONS: The finding demonstrating predominantly adaptive (and few maladaptive) responses to warning labels supports the continued use of fear appeals in warning label design. The greater adaptive and lower maladaptive responses to pictorial warnings could serve as additional evidence for FDA to implement pictorial warning labels.