Anke Oenema

Theory, evidence and Intervention Mapping to improve behavior nutrition and physical activity interventions.

BackgroundThe present paper intends to contribute to the debate on the usefulness and barriers in applying theories in diet and physical activity behavior-change interventions.DiscussionSince behavior theory is a reflection of the compiled evidence of behavior research, theory is the only foothold we have for the development of behavioral nutrition and physical activity interventions. Application of theory should improve the effectiveness of interventions. However, some of the theories we use lack a strong empirical foundation, and the available theories are not always used in the most effective way. Furthermore, many of the commonly-used theories provide at best information on what needs to be changed to promote healthy behavior, but not on how changes can be induced. Finally, many theories explain behavioral intentions or motivation rather well, but are less well-suited to explaining or predicting actual behavior or behavior change.For more effective interventions, behavior change theory needs to be further developed in stronger research designs and such change-theory should especially focus on how to promote action rather than mere motivation. Since voluntary behavior change requires motivation, ability as well as the opportunity to change, further development of behavior change theory should incorporate environmental change strategies.ConclusionIntervention Mapping may help to further improve the application of theories in nutrition and physical activity behavior change.

Which Intervention Characteristics are Related to More Exposure to Internet-Delivered Healthy Lifestyle Promotion Interventions? A Systematic Review

Background The Internet has become a popular medium for the delivery of tailored healthy lifestyle promoting interventions. The actual reach of Internet-delivered interventions seems, however, lower than expected, and attrition from interventions is generally high. Characteristics of an intervention, such as personally tailored feedback and goal setting, are thought to be among the important factors related to of use of and exposure to interventions. However, there is no systematic overview of which characteristics of Internet-delivered interventions may be related to more exposure. Objective The present study aims to identify (1) which potentially exposure-promoting methods and strategies are used in existing Internet interventions, (2) which objective outcome measures are used to measure exposure to Internet interventions, and (3) which potentially exposure-promoting methods and strategies are associated with better exposure. Methods A systematic review of the literature was conducted based on the Cochrane guidelines. Papers published between 1995 and 2009 were searched in the PubMed, PsycINFO, and Web of Science databases. In total, 64 studies were included that reported objective exposure measures such as completion of an initial visit, number of log-ins, and time spent on the website. Information about intervention-related characteristics (ie, interactive behavior change strategies, interactive elements for fun, peer or counsel support, email/phone contact, and regular updates of the website) that could potentially contribute to better exposure and objective exposure outcomes were abstracted from the studies and qualitative systematic descriptive analyses were performed. Results The results showed that a large variety of behavior change techniques and other exposure-promoting elements were used in the interventions and that these methods and strategies varied for the various lifestyle behaviors. Feedback, interactive elements, and email/phone contact were used most often. In addition, there was much variety and a lack of consistency in the exposure measures that were reported. Of all the categories of intervention characteristics that may be associated with better exposure, there were indications that peer and counselor support result in a longer website visit and that email/phone contact and updates of the website result in more log-ins. Conclusions Results of this qualitative systematic review indicate that of all intervention characteristics that could potentially enhance exposure, only peer support, counselor support, email/phone contact with visitors, and updates of the intervention website were related to better exposure. The diversity of intervention methods used and the inconsistency in the report of exposure measures prevented us from drawing firmer conclusions. More research is needed to identify whether other characteristics of Internet interventions are associated with greater exposure.

Effectiveness of smoking cessation interventions among adults: a systematic review of reviews.

The objective of this study was to identify the most effective intervention strategies and policies for smoking cessation among adults. The Medline and Cochrane Library databases were searched, limited to publications since January 2000. A ‘review of reviews’ approach was followed. Systematic reviews and meta-analyses were included. Reviews aimed at adolescents or specific subgroups were excluded. Two reviewers independently assessed titles and abstracts. For every intervention strategy, only the most recent publication was included. Twenty-three studies met the inclusion criteria. The included intervention strategies and policies were ranked according to their effect size, taking into account the number of original studies, the proportion of studies with a positive effect and the presence of a long-term effect. Evidence of effectiveness for the following strategies was found: group behavioural therapy [odds ratio (OR) 2.17, confidence interval (CI) 1.37–3.45], bupropion (OR 2.06, CI: 1.77–2.40), intensive physician advice (OR 2.04, Cl: 1.71–2.43), nicotine replacement therapy (OR 1.77, CI: 1.66–1.88), individual counselling (OR 1.56, CI: 1.32–1.84), telephone counselling (OR 1.56, CI: 1.38–1.77), nursing interventions (OR 1.47, CI: 1.29–1.67) and tailored self-help interventions (OR 1.42, CI: 1.26–1.61). A 10% increase in price increased cessation rates by 3–5%. Comprehensive clean indoor laws increased quit rates by 12–38%. These results show and confirm that a wide array of effective smoking cessation intervention approaches and policies can have a large impact on smoking cessation rates.

A Short Dutch Questionnaire to Measure Fruit and Vegetable Intake: Relative Validity Among Adults and Adolescents

A short food frequency questionnaire (FFQ) to assess fruit and vegetable (F&V) intake was validated. Forty-nine adults and fifty-one adolescents (12–18 years old) completed the FFQ at home, and subsequently kept diet records for seven successive days. Mean daily intake of F&V was overestimated by the FFQ as compared to the 7-day diet records. for adults, spearman correlations of at least 0.5 were observed between the two methods for intake of total fruit and intake of citrus fruit. For adolescents, acceptable spearman correlations (0.53–0.64) were observed between the two methods for total F&V intake, total fruit intake and consumption of fruit juice. Low correlations (0.22–0.35) between the FFQ and the diet records were found for vegetable intake. Relatively large percentages (22–37%) of respondents were incorrectly classified by the short FFQ as eating according to the Dutch recommendations for fruit and vegetable intake. Based on the results of the present study as well as an overview of the results of 34 earlier validation studies of F&V FFQs, it is concluded that the available FFQs have only limited capability to make valid assessment of F&V intake levels. In spite of the practical advantages of the short FFQ tested in the present study and the :similar validity scores as compared with other often used F&V FFQs, it needs further revision, especially to be used for valid measurement of vegetable intake as well as total F&V intake among adults.

A Qualitative Exploration of Reasons for Poor Hand Hygiene Among Hospital Workers Lack of Positive Role Models and of Convincing Evidence That Hand Hygiene Prevents Cross-Infection

OBJECTIVE To study potential determinants of hand hygiene compliance among healthcare workers in the hospital setting. DESIGN A qualitative study based on structured-interview guidelines, consisting of 9 focus group interviews involving 58 persons and 7 individual interviews. Interview transcripts were subjected to content analysis. SETTING Intensive care units and surgical departments of 5 hospitals of varying size in The Netherlands. PARTICIPANTS A total of 65 nurses, attending physicians, medical residents, and medical students. RESULTS Nurses and medical students expressed the importance of hand hygiene for preventing of cross-infection among patients and themselves. Physicians expressed the importance of hand hygiene for self-protection, but they perceived that there is a lack of evidence that handwashing is effective in preventing cross-infection. All participants stated that personal beliefs about the efficacy of hand hygiene and examples and norms provided by senior hospital staff are of major importance for hand hygiene compliance. They further reported that hand hygiene is most often performed after tasks that they perceive to be dirty, and personal protection appeared to be more important for compliance that patient safety. Medical students explicitly mentioned that they copy the behavior of their superiors, which often leads to noncompliance during clinical practice. Physicians mentioned that their noncompliance arises from their belief that the evidence supporting the effectiveness of hand hygiene for prevention of hospital-acquired infections is not strong. CONCLUSION The results indicate that beliefs about the importance of self-protection are the main reasons for performing hand hygiene. A lack of positive role models and social norms may hinder compliance.

A Systematic Review of Randomized Controlled Trials on the Effectiveness of Computer-Tailored Physical Activity and Dietary Behavior Promotion Programs: an Update

BackgroundA review update is necessary to document evidence regarding the effectiveness of computer-tailored physical activity and nutrition education.PurposeThe purpose of this study was to summarize the latest evidence on the effectiveness of computer-tailored physical activity and nutrition education, and to compare the results to the 2006 review.MethodsDatabases were searched for randomized controlled trials evaluating computer-tailored physical activity and nutrition education aimed at primary prevention in adults, published from September 2004 through June 2011.ResultsCompared to the findings in 2006, a larger proportion of studies found positive effects for computer-tailored programs compared to generic or no information, including those for physical activity promotion. Effect sizes were small and generally at short- or medium-term follow-up.ConclusionsThe results of the 2006 review were confirmed and reinforced. Future interventions should focus on establishing larger effect sizes and sustained effects and include more generic health education control groups and objective measurements of dietary behavior.

Strategies to Facilitate Exposure to Internet-Delivered Health Behavior Change Interventions Aimed at Adolescents or Young Adults: A Systematic Review

The Internet is considered to be a promising delivery channel of interventions aimed at promoting healthful behaviors, especially for adolescents and young adults. Exposure to these interventions, however, is generally low. A more extensive exploration of methods, strategies, and their effectiveness with regard to facilitating exposure is therefore timely, because this knowledge is crucial to improve the use of such interventions and, subsequently, to increase behavioral change. Therefore, a systematic review of the literature was conducted, resulting in 838 studies based on title selection, of which 26 studies met the eligibility criteria. The systematic review resulted in an overview of methods and strategies that have been used to facilitate exposure. Patterns of effective strategies could be observed, such as the combination of tailored communication and the use of reminders and incentives. Nevertheless, exposure-specific theories need to be developed and objective exposure measures should be tracked and reported in future studies.

The internet and nutrition education: challenges and opportunities.

Objective:To review the possibilities of using the Internet and especially the World Wide Web (WWW) in nutrition education.Results:A healthy existence is partly dependent on dietary behaviours. One way to promote health-promoting dietary habits is nutrition education. In the last decades several potentially important new channels for health communication and nutrition education have emerged, with the Internet and its WWW as the most striking example. The introduction and growth of the WWW has enabled swift and inexpensive distribution of nutrition education expertise and materials. Furthermore, the WWW has also been used for tailoring nutrition education to the personal characteristics of the user. Only few studies have investigated the effects of generic web-based nutrition education, while web-based computer-tailored nutrition education has been studied in randomised controlled trials, with promising but mixed results. Two important challenges for web-based nutrition education interventions are to realise sufficient exposure and to ensure sufficient source reliability and credibility.Conclusions:Next to the great opportunities, there are many challenges for web-based nutrition education. Some evidence for effects of web-based computer-tailored nutrition education has been reported, but more research is needed to obtain evidence for the effectiveness in real-life situations.Sponsorship:The contribution of WK was made possible by a grant from ZonMw, The Netherlands Organisation for Health Research and Development; the contribution of AO was made possible by a grant from the Netherlands Heart Foundation.

Objective and perceived availability of physical activity opportunities: differences in associations with physical activity behavior among urban adolescents

BackgroundThis study examined the associations of the perceived and objective environment with adolescent engagement in sports activities and walking and cycling in leisure time. It also explored the degree of agreement between objective and perceived availability of physical activity (PA) facilities in neighborhoods.MethodsCross-sectional data on physical activity, the perceived availability of physical activity opportunities (perceived physical environment) was assessed through a questionnaire and the objective availability of PA opportunities (objective physical environment) was obtained through GIS data. The final sample included 654 adolescents with a mean age of 14.1 (SD = 1.2) years.ResultsPerceived availability of sports facilities and parks was significantly associated with engaging in sports (OR: 1.73; 95% CI: 1.16-2.56) and with walking and cycling in leisure time (OR: 1.66; 95% CI: 1.07-2.57) respectively. Agreement between objective and perceived environment was low to moderate with Kappa values ranging from -0.005 to 0.053.ConclusionThe perceived environment was the stronger correlate of PA behavior among adolescents. There were substantial differences between assessments of objective and perceived physical environment.

An Exploration of Factors Related to Dissemination of and Exposure to Internet-Delivered Behavior Change Interventions Aimed at Adults: A Delphi Study Approach

Background The Internet is an attractive medium for delivering individualized, computer-tailored behavior change interventions to large numbers of people. However, the actual numbers of people reached seem to fall behind the high expectations. Insight into factors that determine use of and exposure to these Internet interventions is important to be able to increase the reach and improve exposure. Objective The aim was to identify potentially important factors that determine whether adults visit an Internet-delivered behavior change intervention, extend their visit, and revisit the intervention. Methods A systematic, three-round Delphi study was conducted among national and international experts from Internet intervention research and practice, e-marketing/e-commerce, Web design, and technical website development. In the first round, 30 experts completed a structured, open-ended online questionnaire assessing factors that were, in their opinion, important for a first visit, an extended visit, a revisit and for effective promotion strategies. Based on the responses in this first questionnaire, a closed-ended online questionnaire was developed for use in the second round. A total of 233 experts were invited to complete this questionnaire. Median and interquartile deviation (IQD) scores were computed to calculate agreement and consensus on the importance of the factors. The factors for which no consensus was obtained (IQD > 1) were included in the third-round questionnaire. Factors with a median score of six or higher and with an IQD ≤ 1 were considered to be important. Results Of the 62 experts invited for the first round, 30 completed the questionnaire (48% response rate); 93/233 experts completed the second-round questionnaire (40% response rate), and 59/88 completed the third round (67% response rate). Being motivated to visit an Internet intervention and perceiving the intervention as personally relevant appeared to be important factors related to a first visit. The provision of tailored feedback, relevant and reliable information, and an easy navigation structure were related to an extended visit. Provision of regular new content and the possibility to monitor personal progress toward behavior change were identified as important factors to encourage a revisit. Primarily traditional promotion strategies, like word-of-mouth by family and friends, a publicity campaign with simultaneous use of various mass media, and recommendation by health professionals, were indicated as effective ways to encourage adults to visit an Internet intervention. Conclusions This systematic study identified important factors related to the dissemination of and exposure to Internet interventions aimed at adults. In order to improve optimal use of and exposure to Internet interventions, potential users may need to be motivated to visit such an intervention and the information provided needs to be personally relevant. Furthermore, several (technical) aspects of the intervention itself need to be taken into account when developing Internet interventions.