L. van Osch

The Influence of User Characteristics and a Periodic Email Prompt on Exposure to an Internet-Delivered Computer-Tailored Lifestyle Program

Background The Internet is a promising medium in the field of health promotion for offering tailored and targeted lifestyle interventions applying computer-tailored (CT) techniques to the general public. Actual exposure to CT interventions is not living up to its high expectations, as only a (limited) proportion of the target group is actually using these programs. Objective To investigate exposure to an Internet-delivered, CT lifestyle intervention, targeting physical activity, fruit and vegetable intake, smoking behavior, and alcohol intake, we focused on three processes: first use, prolonged use, and sustained use. The first objectives were to identify user characteristics that predict initiation of an online CT lifestyle program (first use) and completion of this program (prolonged use). Furthermore, we studied the effect of using a proactive strategy, consisting of periodic email prompts, on program revisits (sustained use). Methods The research population for this study consisted of Dutch adults participating in the Adult Health Monitor, offered by the regional public health services. We used a randomized controlled trial design to assess predictors of first use, prolonged use, and sustained use. Demographics and behavioral characteristics, as well as the strategy used for revisiting, were included as predictors in the model. Results A total of 9169 participants indicated their interest in the new program and 5168 actually logged in to the program. Participants significantly more likely to initiate one of the CT modules were male, older, and employed, and had a lower income, higher body mass index, and relatively unhealthy lifestyle. Participants significantly more likely to complete one of the CT modules were older and had a higher income and a relatively healthier lifestyle. Finally, using a proactive strategy influenced sustained use, with people from the prompting condition being more likely to revisit the program (odds ratio 28.92, 95% confidence interval 10.65–78.52; P < .001). Conclusions Older, male, and employed participants, and those with a lower income, higher body mass index, and a relatively unhealthy lifestyle were more likely to initiate a CT module. Module completers predominantly had a higher income and age. The current program therefore succeeded in reaching those people who benefit most from online lifestyle interventions. However, these people tended to disengage from the program. This underlines the importance of additional research into program adjustments and strategies that can be used to stimulate prolonged program use. Furthermore, sending periodic email prompts significantly increased revisits to the program. Though promising, this effect was modest and needs to be further examined, in order to maximize the potential of periodic email prompting. Trial Registration Nederlands Trial Register (NTR: 1786) and Medical Ethics Committee of Maastricht University and the University Hospital Maastricht (NL2723506809/MEC0903016); http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1786 (Archived by WebCite at http://www.webcitation.org/65hBXA6V7)

Program Completion of a Web-Based Tailored Lifestyle Intervention for Adults: Differences between a Sequential and a Simultaneous Approach

Background Unhealthy lifestyle behaviors often co-occur and are related to chronic diseases. One effective method to change multiple lifestyle behaviors is web-based computer tailoring. Dropout from Internet interventions, however, is rather high, and it is challenging to retain participants in web-based tailored programs, especially programs targeting multiple behaviors. To date, it is unknown how much information people can handle in one session while taking part in a multiple behavior change intervention, which could be presented either sequentially (one behavior at a time) or simultaneously (all behaviors at once). Objectives The first objective was to compare dropout rates of 2 computer-tailored interventions: a sequential and a simultaneous strategy. The second objective was to assess which personal characteristics are associated with completion rates of the 2 interventions. Methods Using an RCT design, demographics, health status, physical activity, vegetable consumption, fruit consumption, alcohol intake, and smoking were self-assessed through web-based questionnaires among 3473 adults, recruited through Regional Health Authorities in the Netherlands in the autumn of 2009. First, a health risk appraisal was offered, indicating whether respondents were meeting the 5 national health guidelines. Second, psychosocial determinants of the lifestyle behaviors were assessed and personal advice was provided, about one or more lifestyle behaviors. Results Our findings indicate a high non-completion rate for both types of intervention (71.0%; n = 2167), with more incompletes in the simultaneous intervention (77.1%; n = 1169) than in the sequential intervention (65.0%; n = 998). In both conditions, discontinuation was predicted by a lower age (sequential condition: OR = 1.04; P < .001; CI = 1.02-1.05; simultaneous condition: OR = 1.04; P < .001; CI = 1.02-1.05) and an unhealthy lifestyle (sequential condition: OR = 0.86; P = .01; CI = 0.76-0.97; simultaneous condition: OR = 0.49; P < .001; CI = 0.42-0.58). In the sequential intervention, being male (OR = 1.27; P = .04; CI = 1.01-1.59) also predicted dropout. When respondents failed to adhere to at least 2 of the guidelines, those receiving the simultaneous intervention were more inclined to drop out than were those receiving the sequential intervention. Conclusion Possible reasons for the higher dropout rate in our simultaneous intervention may be the amount of time required and information overload. Strategies to optimize program completion as well as continued use of computer-tailored interventions should be studied. Trial Registration Dutch Trial Register NTR2168

Decision-making on preimplantation genetic diagnosis and prenatal diagnosis: a challenge for couples with hereditary breast and ovarian cancer

STUDY QUESTION How do couples with a BRCA1/2 mutation decide on preimplantation genetic diagnosis (PGD) and prenatal diagnosis (PND) for hereditary breast and ovarian cancer syndrome (HBOC)? SUMMARY ANSWER BRCA couples primarily classify PGD and/or PND as reproductive options based on the perceived severity of HBOC and moral considerations, and consequently weigh the few important advantages of PGD against numerous smaller disadvantages. WHAT IS KNOWN ALREADY Awareness of PGD is generally low among persons at high risk for hereditary cancers. Most persons with HBOC are in favour of offering PGD for BRCA1/2 mutations, although only a minority would consider this option for themselves. Studies exploring the motivations for using or refraining from PGD among well-informed BRCA carriers of reproductive age are lacking. We studied the reproductive decision-making process by interviewing a group of well-informed, reproductive aged couples carrying a BRCA1/2 mutation, regarding their decisional motives and considerations. STUDY DESIGN, SIZE, DURATION This exploratory, qualitative study investigated the motives and considerations taken into account by couples with a BRCA1/2 mutation and who have received extensive counselling on PGD and PND and have made a well-informed decision regarding this option. Eighteen couples took part in focus group and dyadic interviews between January and September 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS Semi-structured focus groups were conducted containing two to four couples, assembled based on the reproductive method the couple had chosen: PGD (n = 6 couples) or conception without testing (n = 8 couples). Couples who had chosen PND for BRCA (n = 4) were interviewed dyadically. Two of the women, of whom one had chosen PND and the other had chosen no testing, had a history of breast cancer. MAIN RESULTS AND THE ROLE OF CHANCE None of the couples who opted for PGD or conception without testing found the use of PND, with possible pregnancy termination, acceptable. PND users chose this method because of decisive, mainly practical reasons (natural conception, high chance of favourable outcome). Motives and considerations regarding PGD largely overlapped between PGD users, PND users and non-users, all mentioning some significant advantages (e.g. protecting the child and family from the mutation) and many smaller disadvantages (e.g. the necessity of in vitro fertilization (IVF), low chance of pregnancy by IVF/PGD). For female carriers, the safety of hormonal stimulation and the time required for PGD before undergoing preventive surgeries were important factors in the decision. Non-users expressed doubts about the moral justness of their decision afterwards and emphasized the impact the decision still had on their lives. LIMITATIONS, REASON FOR CAUTION The interviewed couples were at different stages in their chosen trajectory, up to 3 years after completion. This may have led to recall bias of original motives and considerations. Couples who did not actively seek information about PGD were excluded. Therefore the results may not be readily generalizable to all BRCA couples. WIDER IMPLICATIONS OF THE FINDINGS The perceived severity of HBOC and, for female carriers, the safety of hormonal stimulation and the time frames for PGD planning before preventive surgeries are essential items BRCA couples consider in reproductive decision-making. The emotional impact of this decision should not be underestimated; especially non-users may experience feelings of doubt or guilt up to several years afterwards. PGD counselling with tailored information addressing these items and decisional support in order to guarantee well-informed decision-making is needed. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by the Dutch breast cancer foundation Stichting Pink Ribbon, grant number 2010.PS11.C74. None of the authors have competing interests to declare. TRIAL REGISTRATION NUMBER Not applicable.

Passive cancer detection and medical help seeking for cancer symptoms: (in)adequate behavior and psychosocial determinants.

The present study explored the performance and psychosocial determinants of passive cancer detection behavior, that is, attentiveness to cancer symptoms, and medical help seeking, and investigated potential dependency between these two behaviors. A detailed telephone survey was conducted among 459 respondents, aged 55 years or older. The survey assessed passive detection behavior and appropriately timed medical help seeking, regarding 14 cancer symptoms. Knowledge of cancer symptoms and various other psychosocial determinants were also measured. Knowledge of cancer symptoms and adequate passive detection behavior was low to moderate. Timely medical help-seeking behavior was low to moderate for urgent symptoms but relatively high for prolonged symptoms. Overall, women had higher knowledge levels, paid more attention to cancer symptoms, and performed more timely help seeking than men. Passive detection behavior was positively associated with premotivational awareness factors (knowledge and awareness), female gender, and perceived advantages. Timely medical help seeking was positively related to cognitive motivational factors (perceived advantages, self-efficacy expectations, and intention) and negatively related to educational level and perceived susceptibility to cancer. Furthermore, a strong positive association was found between the performance of passive detection behavior and timely medical help seeking. The suboptimal levels of knowledge and performance of early cancer detection behaviors found in this study emphasize a need for educational efforts in the area of early cancer detection. The effectiveness of these efforts may benefit from considering the distinct sets of determinants of passive detection behavior and medical help seeking.

Is Action Planning Helpful for Smoking Cessation? Assessing the Effects of Action Planning in a Web-Based Computer Tailored Intervention

Background and objectives: The aim of this study was to examine the efficacy of a web-assisted computer-tailored smoking cessation intervention, an action planning (AP) intervention in which potential quitters were encouraged to form action plans (e.g., plan a quit date) and execute them (e.g., remove ashtrays). We also investigated whether the AP intervention resulted in more AP and plan execution than a similar, control intervention without the supplementary AP component. Methods: In a randomized controlled trial, the AP intervention (N = 977) was compared with the control intervention (N = 1,005) in terms of self-reported continued abstinence (CA) and point prevalence abstinence (PPA) six months after baseline. AP, plan execution, and opinion of the intervention were measured one month after baseline. Results: Complete-case logistic regression analysis showed that the AP intervention had a significant effect on CA (OR = 2.01; CI 1.08–3.84, p = .02), whereas intention-to-treat analysis showed a borderline significant effect (OR = 1.68; CI .96–2.92, p = .07). Sixteen percent of the experimental group achieved CA compared to 10% of the control group. The AP intervention had no effect on PPA. The experimental group also showed significantly more AP and plan execution at one month. Execution of plans was associated with smoking cessation. Conclusions: The effects of the AP intervention on CA, AP, and execution of plans were encouraging. The potential for widespread use of web-based interventions means that even small behavioral effects may have an impact on public health. We recommend that the intervention be intensified and improved.

Awareness and attitude regarding reproductive options of persons carrying a BRCA mutation and their partners.

STUDY QUESTION To what extent are BRCA mutation carriers and their partners in the Netherlands aware about preimplantation genetic diagnosis (PGD) and prenatal diagnosis (PND) as reproductive options and what is their attitude towards these options? SUMMARY ANSWER Awareness of PGD (66%) and PND (61%) among BRCA mutation carriers and their partners is relatively high and 80% and 26%, respectively, of BRCA carriers and their partners find offering PGD and PND for hereditary breast and ovarian cancer (HBOC) acceptable. WHAT IS KNOWN ALREADY Internationally, awareness of PGD among persons with a genetic cancer predisposition appears to be relatively low (35%) and although acceptability is generally high (71%), only a small proportion of mutation carriers would consider using PGD (36%). However, for HBOC, there are no studies available that investigated the perspective of individuals with a confirmed BRCA1/2 mutation and their partners about PGD and PND including demographic and medical correlates of awareness and acceptability. STUDY DESIGN, SIZE, DURATION A cross-sectional survey was completed by 191 participants between July 2012 and June 2013. Participants were recruited through patient organizations (88%) and the databases of two Clinical Genetics departments in the Netherlands (12%). PARTICIPANTS/MATERIALS, SETTING, METHODS Male and female BRCA carriers and their partners completed an online survey, which assessed demographic and medical characteristics, and awareness, knowledge, acceptability and consideration of PGD and PND as main outcomes. Correlations between demographic and medical characteristics and the main outcomes were investigated. MAIN RESULTS AND ROLE OF CHANCE The majority of respondents were female (87%), of reproductive age (86%) and about half reported a desire for a child in the future. About two-thirds (66%) were aware of PGD and 61% of PND for HBOC. PGD knowledge was moderate (5.5 on a 9-point scale) and acceptability of PGD and PND for HBOC was 80% and 26%, respectively. A minority would personally consider using PGD (39%) or PND (20%). Individuals with a higher educational level were more likely to be aware of PGD (P < 0.001) and PND (P < 0.001) and persons with a more immediate child wish were more often aware of PGD (P = 0.044) and had more knowledge about PGD (P = 0.001). PGD acceptability was positively associated with knowledge about PGD (P = 0.047), and PND acceptability was higher among partners in comparison to carriers (P = 0.001). Participants with a history of cancer and with a higher perceived seriousness of breast and ovarian cancer were more likely to consider using PGD (P = 0.003 and P < 0.001 respectively) or PND (P = 0.021 and P = 0.017 respectively). LIMITATIONS, REASONS FOR CAUTION The response rate (23%) of participants invited by the clinical genetics departments was low, probably related to a simultaneous study that used a similar recruitment strategy within the same target group, which may have resulted in selection bias. Moreover, PGD knowledge was measured with an instrument that is not yet validated since to date such an instrument is not available in the literature. Finally, the cross-sectional design of this study limits us from drawing any causal conclusions. WIDER IMPLICATIONS OF THE FINDINGS Improvement of information provision remains needed, in order to timely inform all couples with HBOC about the available reproductive options and enable them to make a balanced reproductive decision. This may limit the risk of negative psychological impact due to decisional conflict and possible regret. STUDY FUNDING/COMPETING INTEREST(S) The Dutch breast cancer foundation Stichting Pink Ribbon (grant number 2010.PS11.C74). None of the authors have competing interests to declare. TRIAL REGISTRATION NUMBER Not applicable.

Professionals' knowledge, attitude and referral behaviour of preimplantation genetic diagnosis for hereditary breast and ovarian cancer

Hereditary breast and ovarian cancer caused by a BRCA1/2 mutation is the most frequent indication for preimplantation genetic diagnosis (PGD) in the Netherlands. The extent to which involved professionals are informed about this option, however, is unclear. The few available international studies mostly represent a limited range of professionals, and suggest that their knowledge about PGD for hereditary cancer syndromes is sparse and referral for PGD is based on limited understanding. A cross-sectional survey assessing awareness, knowledge, acceptability and PGD-referral for BRCA was completed by 188 professionals involved in the field of breast and ovarian cancer or reproduction. One-half of professionals were aware of PGD for BRCA, and most had a low to moderate level of knowledge. A total of 86% considered PGD for BRCA acceptable and 48% had referred patients with BRCA for PGD. Awareness and knowledge was higher among professionals who worked at a university hospital (compared with a general hospital). Knowledge of PGD was positively associated with discussing and referring for PGD, and PGD acceptability was associated with previous awareness. Although PGD counselling is the primary responsibility of the geneticist, other involved professionals may be gatekeepers as patients rely on them for raising awareness and referral.

Kennis van kankersymptomen en de rol van psychosociale factoren bij tijdig medisch hulpzoekgedrag

Doel: In de huidige studie werd onderzoek gedaan naar de kennis van kankersymptomen, de adequaatheid van medisch hulpzoekgedrag en de psychosociale voorspellers van dit gedrag onder Nederlandse 55-plussers.Methode: Deze longitudinale studie werd uitgevoerd binnen een pretest-posttest design. Deelnemers (N= 493) werden per e-mail verzocht twee online vragenlijsten in te vullen. Kennis van kankersymptomen werd gemeten aan de hand van herinnering (recall) en herkenning (recognition). Verschillen tussen demografische groepen en voorspellers van medisch hulpzoekgedrag werden geanalyseerd.Resultaten: De herkenning van kankersymptomen was aanzienlijk hoger dan de herinnering. Vrouwen, samenwonenden, hoger opgeleiden en individuen met ervaring met kanker hadden de meeste kennis van kankersymptomen. Tijdig medisch hulpzoekgedrag was adequaat voor chronische symptomen, maar onvoldoende voor urgente symptomen. Weinig ervaring met kanker, weinig waargenomen nadelen en een hoge intentie aangaande medisch hulpzoekgedrag bleken het medisch hulpzoekgedrag significant te voorspellen. De invloed van herkenning van kankersymptomen werd gemedieerd door motivationele factoren, terwijl er geen causale relatie was tussen herinnering en tijdig medisch hulpzoekgedrag.Conclusie: Herkenning van kankersymptomen is een sterkere voorspeller van medisch hulpzoekgedrag dan herinnering. Aangezien de invloed van herkenning werd gemedieerd door motivationele factoren, is het aan te bevelen in toekomstige interventies zowel kennis als motivationele factoren te beïnvloeden. Toekomstige interventies moeten daarnaast worden gericht op minder bekende kankersymptomen en symptomen waarbij medisch hulpzoekgedrag veelvuldig wordt uitgesteld.AbstractKnowledge of cancer symptoms and the influence of psychosocial factors on timely medical help-seeking Aim: The aim of the present study was to assess the recall and recognition of cancer symptoms, timely medical helpseeking and its predictors amongst Dutch individuals aged 55 years and older.Method: The study had a longitudinal cohort pretest-posttest design. Respondents (N= 493) were asked by e-mail to fill out two online questionnaires. Knowledge of cancer symptoms was measured by means of recall and recognition. Differences between demographic groups and predictors of timely medical help-seeking were identified.Results: Recognition of cancer symptoms was considerably better than recall. Women, cohabitants, highly educated individuals, and those with cancer experience had the highest knowledge of cancer symptoms. Timely medical help-seeking for prolonged symptoms was sufficient in opposite to urgent symptoms. A low level of cancer experience, few perceived disadvantages, and a high intention towards medical help-seeking were significant predictors of timely medical help-seeking. The influence of recognition was mediated by motivational factors. No causal relationship was found between recall and medical help-seeking.Conclusion: Recognition is a stronger predictor of timely medical help-seeking than recall. Because the influence of recognition was mediated by motivational factors, future interventions should focus on influencing both knowledge and motivational factors. Future interventions should also address poorly known cancer symptoms and symptoms for which patient delay frequently occurs.