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Zhang T, Sun Y, Wang W, Wu Y. Incidence and Influencing Factors of Anxiety and Depression in Individuals with Acute Ischemic Stroke: A Retrospective Study. ACTAS ESPANOLAS DE PSIQUIATRIA 2024; 52:268-275. [PMID: 38863058 PMCID: PMC11190444 DOI: 10.62641/aep.v52i3.1550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
BACKGROUND Acute ischemic stroke (AIS) is the most common type of stroke in clinical practice, and individuals with stroke are more prone to psychological disorders than healthy individuals. This study aims to explore the incidence of anxiety and depression and related influencing factors in individuals with AIS. METHODS In brief, 680 individuals with AIS admitted to Chun'an County First People's Hospital from January 2021 to January 2023 were selected as the research subjects, and their clinical data were retrospectively analyzed. All patients were evaluated with the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS) to observe the occurrence of anxiety and depression, and single-factor and multi-factor logistic regression were used to analyze the influencing factors of anxiety and depression. RESULTS Among the 680 individuals with AIS, there were 63 cases of mild anxiety (9.26%), 25 cases of moderate anxiety (3.68%), and 8 cases of severe anxiety (1.18%), with a total of 96 cases (14.12%) with anxiety symptoms. Additionally, there were 74 cases of mild depression (10.88%), 28 cases of moderate depression (4.12%), and 10 cases of severe depression (1.47%), with a total of 112 cases with depression (16.47%). The results of univariate analysis showed that there was a weak correlation between age, body mass index, disease duration, marital status, and the development of anxiety and depression in individuals with AIS (p > 0.05). Educational level, underlying diseases, family income, and place of residence were found to influence the development of anxiety and depression in individuals with AIS (p < 0.05). The results of multivariate logistic regression analysis showed that educational level (no higher education), underlying diseases (with), family income (<50,000 yuan/year, the average exchange rate of RMB to USD was 6.7261), and place of residence (rural area) were influencing factors for the development of anxiety and depression in individuals with AIS (p < 0.05). CONCLUSION Depression and anxiety are common psychological disorders in patients with AIS. The level of education (no higher education), underlying diseases (with), family income (<50,000 yuan/year), and place of residence (rural area) were risk factors that may lead to anxiety and depression in individuals with AIS. For those with risk factors for anxiety and depression, reasonable intervention should be continually provided to guide early disease prediction and treatment of anxiety and depression in individuals with AIS.
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Affiliation(s)
- Teng Zhang
- Department of Neurology, Chun'an County First People's Hospital, 311700 Hangzhou, Zhejiang, China
| | - Yun Sun
- Department of Neurology, Chun'an County First People's Hospital, 311700 Hangzhou, Zhejiang, China
| | - Weiwei Wang
- Department of Neurology, Chun'an County First People's Hospital, 311700 Hangzhou, Zhejiang, China
| | - Yanfei Wu
- Department of Neurology, Chun'an County First People's Hospital, 311700 Hangzhou, Zhejiang, China
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Zhang M, Guo L, Namassevayam G, Wei M, Xie Y, Guo Y, Liu Y. Factors associated with health behaviours among stroke survivors: A mixed-methods study using COM-B model. J Clin Nurs 2024; 33:2138-2152. [PMID: 38590015 DOI: 10.1111/jocn.17103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/04/2024] [Accepted: 02/28/2024] [Indexed: 04/10/2024]
Abstract
AIMS To identify factors associated with health behaviours among stroke survivors, through a multi-centre study. DESIGN A sequential mixed methods design. METHODS In the quantitative research phase, a total of 350 participants were recruited through multi-stage sampling from December 2022 to June 2023. General information questionnaires, The Stroke Prevention Knowledge Questionnaire (SPKQ), Short Form Health Belief Model Scale (SF-HBMS), Health Promoting Lifestyle Profile (HPLPII), and the WHOQOL-BREF (World Health Organization Quality of Life Questionnaire, Brief Version) were distributed across five tertiary hospitals in Henan province, China. For the qualitative research component, semi-structured interviews were conducted to explore the barriers and facilitators of health behaviour. This study adheres to the GRAMMS guidelines. RESULTS A total of 315 participants (90.0%) completed the survey. Identified barriers to health behaviour included residing in rural areas, higher scores on the Charlson Comorbidity Index (CCI) and mRS, as well as lower scores on SPKQ, SF-HBMS and WHOQOL-BREF. Twenty-four individuals participated in qualitative interviews. Twenty-eight themes were identified and categorised by frequency, covering areas such as knowledge, skills, intentions, social influences, social/professional role and identity, environmental context and resources, beliefs about capabilities, beliefs about consequences and behavioural regulation. Both quantitative and qualitative data suggested that health behaviour among stroke survivors is at a moderate level, and the identified barrier factors can be mapped into the COM-B model (Capability, Opportunity, Motivation and Behaviour). CONCLUSION The study indicates that key barriers to health behaviour among stroke survivors align with the COM-B model. These identified factors should be carefully considered in the planning of future systematic interventions aimed at improving health behaviours among stroke survivors. PATIENT OR PUBLIC CONTRIBUTION Patients were invited to completed questionnaires in the study and semi-structured interviews. The investigators provided explanation of this study' content, purpose and addressed issues during the data collection.
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Affiliation(s)
- Mengyu Zhang
- College of Nursing, Zhengzhou University, Zhengzhou, China
| | - Lina Guo
- Department of Neurology, National Advanced Stroke Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Genoosha Namassevayam
- Department of Neurology, National Advanced Stroke Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Department of Supplementary Health Sciences, Faculty of Health-Care Sciences, Eastern University, Trincomalee, Sri Lanka
| | - Miao Wei
- Department of Neurology, National Advanced Stroke Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - YuYing Xie
- College of Nursing, Zhengzhou University, Zhengzhou, China
| | - Yuanli Guo
- Department of Neurology, National Advanced Stroke Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yanjin Liu
- Department of Nursing, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Wang X, Zhang ZX, Lin BL, Jiang H, Wang W, Mei YX, Zhang C, Zhang Q, Chen SY. Mediation role of perceived social support between recurrence risk perception and health behaviour among patients with stroke in China: a cross-sectional study. BMJ Open 2024; 14:e079812. [PMID: 38355172 PMCID: PMC10868314 DOI: 10.1136/bmjopen-2023-079812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/26/2024] [Indexed: 02/16/2024] Open
Abstract
OBJECTIVES To examine whether patients who had a stroke with high recurrence risk perception would have healthier behaviour and to explore whether perceived social support would function as a mediator. DESIGN A cross-sectional study. SETTING The study was conducted in a public tertiary hospital in China. PARTICIPANTS A total of 254 patients with stroke were invited to participate, and 250 patients with stroke completed questionnaires validly. PRIMARY AND SECONDARY OUTCOME MEASURES Questionnaires were administered offline to collect data, consisting of four parts: general demographics and scales related to recurrence risk perception, perceived social support, and health behaviour. A path analysis and correlation analysis were used to analyse the data. RESULTS Out of 250 patients with stroke, 78.4% had moderately low health behaviour. The majority (70.8%) of these patients were elderly. High recurrence risk perception and high perceived social support were significantly associated with better health behaviour (all p<0.001). Perceived social support mediated the relationship between recurrence risk perception and health behaviour after controlling for age, gender, education and monthly income in the regression model (95% CI 0.263 to 0.460) and the effect value was 0.360. It was also confirmed that perceived social support had the highest mediation effect with a proportion of mediation up to 59.31%. CONCLUSIONS Recurrence risk perception and perceived social support were influential factors in promoting health behaviour. Moreover, the impact of recurrence risk perception on health behaviour was partially mediated by perceived social support. Therefore, to enhance the sustainability of health behaviour, it is crucial to inform patients with stroke about the risk of recurrence. Patients with more perception of recurrence risk can improve their recovery confidence and thus perceive more social support.
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Affiliation(s)
- Xiaoxuan Wang
- Nursing and Health school, Zhengzhou University, Zhengzhou, China
| | - Zhen-Xiang Zhang
- Nursing and Health school, Zhengzhou University, Zhengzhou, China
| | - Bei-Lei Lin
- Nursing and Health school, Zhengzhou University, Zhengzhou, China
| | - Hu Jiang
- Nursing and Health school, Zhengzhou University, Zhengzhou, China
| | - Wenna Wang
- Nursing and Health school, Zhengzhou University, Zhengzhou, China
| | - Yong-Xia Mei
- Nursing and Health school, Zhengzhou University, Zhengzhou, China
| | - Chunhui Zhang
- Nursing and Health school, Zhengzhou University, Zhengzhou, China
| | - Qiushi Zhang
- Nursing and Health school, Zhengzhou University, Zhengzhou, China
| | - Su-Yan Chen
- Nursing and Health school, Zhengzhou University, Zhengzhou, China
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Crow J, Savage M, Gardner L, Hughes C, Corbett C, Wells M, Malhotra P. What follow-up interventions, programmes and pathways exist for minor stroke survivors after discharge from the acute setting? A scoping review. BMJ Open 2023; 13:e070323. [PMID: 37311634 DOI: 10.1136/bmjopen-2022-070323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Abstract
OBJECTIVE To identify the breadth and range of follow-up interventions currently provided to people after minor stroke with a focus on the definitions used for minor stroke, intervention components, intervention theory and outcomes used. These findings will inform the development and feasibility testing of a pathway of care. DESIGN Scoping review. SEARCH STRATEGY The final search was run in January 2022. Five databases were searched-EMBASE, MEDLINE, CINAHL, British Nursing Index and PsycINFO. Grey literature was also searched. Title and abstract screening and full-text reviews were conducted by two researchers and a third was involved when differences of opinion existed. A bespoke data extraction template was created, refined and then completed. The Template for Intervention Description and Replication (TIDieR) checklist was used to describe interventions. RESULTS Twenty-five studies, using a range of research methodologies were included in the review. A range of definitions were used for minor stroke. Interventions focused largely on secondary prevention and management of increased risk of further stroke. Fewer focused on the management of hidden impairments experienced after minor stroke. Limited family involvement was reported and collaboration between secondary and primary care was seldom described. The intervention components, content, duration and delivery were varied as were the outcome measures used. CONCLUSION There is an increasing volume of research exploring how best to provide follow-up care to people after minor stroke. Personalised, holistic and theory-informed interdisciplinary follow-up is needed that balances education and support needs with adjustment to life after stroke.
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Affiliation(s)
- Jennifer Crow
- Department of Brain Sciences, Imperial College London, London, UK
- Department of Occupational Therapy, Imperial College Healthcare NHS Trust, London, UK
| | - Matthew Savage
- Department of Physiotherapy, Imperial College Healthcare NHS Trust, London, UK
| | - Lisa Gardner
- Library and Evidence Services, Imperial College London, London, UK
| | - Catherine Hughes
- Department of Physiotherapy, Imperial College Healthcare NHS Trust, London, UK
| | - Ceile Corbett
- Department of Occupational Therapy, Imperial College Healthcare NHS Trust, London, UK
| | - Mary Wells
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Nursing Directorate, Imperial College Healthcare NHS Trust, London, UK
| | - Paresh Malhotra
- Department of Brain Sciences, Imperial College London, London, UK
- Department of Neurology, Imperial College Healthcare NHS Trust, London, UK
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Sammut M, Haracz K, Shakespeare D, English C, Crowfoot G, Fini N, Nilsson M, Janssen H. Physical Activity After Transient Ischemic Attack or Mild Stroke Is Business as Usual. J Neurol Phys Ther 2022; 46:189-197. [PMID: 35727994 DOI: 10.1097/npt.0000000000000395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Regular, sustained moderate-to-vigorous physical activity (MVPA) is a recommended strategy to reduce the risk of recurrent stroke for people who have had transient ischemic attack (TIA) or mild stroke. This study aimed to explore attitudes toward, and experience of engaging in physical activity by adults following a TIA or mild stroke. METHODS Constructivist grounded theory methodology informed data collection and analysis. Interviews from 33 adults with TIA or mild stroke (mean age 65 [SD 10] years, 48% female, 40% TIA) were collected. RESULTS Business as usual characterized physical activity engagement post-TIA or mild stroke. Most participants returned to prestroke habits, as either regular exerciser or nonexerciser, with only a small number making changes. Influencing factors for physical activity participation included information, challenges, strategies, and support. Business as usual was associated with a perceived lack of information to suggest a need to change behaviors. Nonexercisers and those who decreased physical activity emphasized challenges to physical activity, while regular exercisers and those who increased physical activity focused on strategies and support that enabled participation despite challenges. DISCUSSION AND CONCLUSION Information about the necessity to engage in recommended physical activity levels requires tailoring to the needs of the people with TIA or mild stroke. Helpful information in combination with support and strategies may guide how to navigate factors preventing engagement and might influence the low level of physical activity prevalent in this population.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A376).
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Affiliation(s)
- Maria Sammut
- School of Health Sciences, University of Newcastle, Newcastle, Australia (M.S., K.H., D.S., C.E); School of Nursing and Midwifery, University of Newcastle, Newcastle, Australia (G.C.); Department of Physiotherapy, University of Melbourne, Parkville, Australia (N.F.); Centre for Rehab Innovations, University of Newcastle, Newcastle, Australia (M.N.); and Hunter New England Local Health District, Newcastle, Australia (H.J.)
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A Contemporary Review of Epidemiology, Risk Factors, Etiology, and Outcomes of Premature Stroke. Curr Atheroscler Rep 2022; 24:939-948. [PMID: 36374365 PMCID: PMC9660017 DOI: 10.1007/s11883-022-01067-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE OF REVIEW Recent data identifies increases in young ischemic and hemorrhagic strokes. We provide a contemporary overview of current literature on stroke among young patients or premature stroke along with directions for future investigation. RECENT FINDINGS Strokes in the young are highly heterogenous and often cryptogenic. Sex distribution and risk factors shift from women among the youngest age groups (< 35) to men over the age of 45, with a coinciding rise in traditional vascular risk factors. Incidence is higher in minority and socioeconomically disadvantaged populations, and the impact of stroke among these communities may be exaggerated by disparities in symptom recognition and access to care. Special diagnostic work-up may be needed, and a lower threshold for diagnosis is warranted as potential misdiagnosis is a concern and may preclude necessary triage and management. Although "premature strokes" form a relatively small proportion of total incidence, they vary greatly across subgroups and present an outsized impact on quality of life and productivity.
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Han C, Zhang L, Liu J. Development and Reliability Testing of the Stroke Patient Protection Motivation Scale. Neuropsychiatr Dis Treat 2022; 18:1341-1349. [PMID: 35813611 PMCID: PMC9270040 DOI: 10.2147/ndt.s353111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 04/09/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE A scale for evaluating the protective motivation of patients who had suffered a stroke was developed to preliminarily verify the reliability of the scale and provide scientific measurement tools for clinical professionals. METHODS A descriptive research design method was adopted. First, an initial draft of the questionnaire was formed by conducting a literature review supplemented by semi-structured interviews and modified using the Delphi method. A total of 287 patients who had suffered a stroke were selected for the formal survey using the convenience sampling method. Further item screening was performed using an item analysis and an exploratory factor analysis, and reliability testing was also performed. RESULTS The scale consisted of 34 entries in the following 6 dimensions: severity, susceptibility, internal and external rewards, response efficacy, response cost and self-efficacy. The overall Cronbach's alpha coefficient was 0.935, with correlation coefficients between dimensions and total scale scores ranging from 0.604 to 0.805 (P < 0.05) and correlation coefficients between dimensions ranging from 0.154 to 0.537 (P < 0.05). CONCLUSION The protective motivation scale prepared in this study was tested and had good reliability, so this scale can be used as a scientific tool to evaluate the implementation of secondary prevention strategies for protective motivation of patients who have suffered a stroke.
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Affiliation(s)
- Chunjie Han
- Department of Rehabilitation Medicine, Beijing Luhe Hospital of China Capital Medical University, Beijing, 101149, People's Republic of China
| | - Lingli Zhang
- Department of Neurology, Beijing Luhe Hospital of China Capital Medical University, Beijing, 101149, People's Republic of China
| | - Jihong Liu
- Department of Neurology, Beijing Luhe Hospital of China Capital Medical University, Beijing, 101149, People's Republic of China
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Sammut M, Haracz K, English C, Shakespeare D, Crowfoot G, Nilsson M, Janssen H. Participants' Perspective of Engaging in a Gym-Based Health Service Delivered Secondary Stroke Prevention Program after TIA or Mild Stroke. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:11448. [PMID: 34769964 PMCID: PMC8583419 DOI: 10.3390/ijerph182111448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 10/21/2021] [Accepted: 10/28/2021] [Indexed: 11/23/2022]
Abstract
People who have had a transient ischemic attack (TIA) or mild stroke have a high risk of recurrent stroke. Secondary prevention programs providing support for meeting physical activity recommendations may reduce this risk. Most evidence for the feasibility and effectiveness of secondary stroke prevention arises from programs developed and tested in research institute settings with limited evidence for the acceptability of programs in 'real world' community settings. This qualitative descriptive study explored perceptions of participation in a secondary stroke prevention program (delivered by a community-based multidisciplinary health service team within a community gym) by adults with TIA or mild stroke. Data gathered via phone-based semi-structured interviews midway through the program, and at the end of the program, were analyzed using constructivist grounded theory methods. A total of 51 interviews from 30 participants produced two concepts. The first concept, "What it offered me", describes critical elements that shape participants' experience of the program. The second concept, "What I got out of it" describes perceived benefits of program participation. Participants perceived that experiences with peers in a health professional-led group program, held within a community-based gym, supported their goal of changing behaviour. Including these elements during the development of health service strategies to reduce recurrent stroke risk may strengthen program acceptability and subsequent effectiveness.
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Affiliation(s)
- Maria Sammut
- School of Health Sciences, College of Health, Medicine and Wellbeing, University of New-Castle, Callaghan, NSW 2308, Australia; (K.H.); (C.E.); (D.S.); (M.N.); (H.J.)
| | - Kirsti Haracz
- School of Health Sciences, College of Health, Medicine and Wellbeing, University of New-Castle, Callaghan, NSW 2308, Australia; (K.H.); (C.E.); (D.S.); (M.N.); (H.J.)
| | - Coralie English
- School of Health Sciences, College of Health, Medicine and Wellbeing, University of New-Castle, Callaghan, NSW 2308, Australia; (K.H.); (C.E.); (D.S.); (M.N.); (H.J.)
- Priority Research Centre for Stroke and Brain Injury, Hunter Medical Research Institute, New Lambton Heights, NSW 2308, Australia
| | - David Shakespeare
- School of Health Sciences, College of Health, Medicine and Wellbeing, University of New-Castle, Callaghan, NSW 2308, Australia; (K.H.); (C.E.); (D.S.); (M.N.); (H.J.)
| | - Gary Crowfoot
- School of Nursing and Midwifery, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia;
| | - Michael Nilsson
- School of Health Sciences, College of Health, Medicine and Wellbeing, University of New-Castle, Callaghan, NSW 2308, Australia; (K.H.); (C.E.); (D.S.); (M.N.); (H.J.)
- Centre for Rehab Innovations, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Heidi Janssen
- School of Health Sciences, College of Health, Medicine and Wellbeing, University of New-Castle, Callaghan, NSW 2308, Australia; (K.H.); (C.E.); (D.S.); (M.N.); (H.J.)
- Priority Research Centre for Stroke and Brain Injury, Hunter Medical Research Institute, New Lambton Heights, NSW 2308, Australia
- Hunter New England Local Health District, Community and Aged Care Services Community Stroke Team, New Lambton Heights, NSW 2308, Australia
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Brouwer-Goossensen D, den Hertog HM, Mastenbroek-de Jong MA, van Gemert-Pijnen LJEWC, Taal E. Patient perspectives on health-related behavior change after transient ischemic attack or ischemic stroke. Brain Behav 2021; 11:e01993. [PMID: 33662179 PMCID: PMC8035466 DOI: 10.1002/brb3.1993] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 11/18/2020] [Accepted: 11/20/2020] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Unhealthy lifestyle is common among patients with ischemic stroke or TIA. Hence, health-related behavior change may be an effective way to reduce stroke recurrence. However, this is often difficult to carry out successfully. We aimed to explore patients' perspectives on health-related behavior change, support in this change, and sustain healthy behavior. METHODS We conducted a descriptive qualitative study with in-depth, semistructured interviews in eighteen patients with recent TIA or ischemic stroke. Interviews addressed barriers, facilitators, knowledge, and support of health-related behavior change framed by the protection motivation theory. All interviews were transcribed and thematically analyzed. RESULTS Patients seem unable to adequately appraise their own health-related behavior. More than half of the patients were satisfied with their lifestyle and felt no urgency to change. Self-efficacy as coping factor was the most important determinant (both barrier and facilitator). Fear as threat factor was named as facilitator for health-related behavior change by half of the patients. Most of the patients did not need support or already received support in changing health behavior. Patients indicated knowledge, guidelines, and social support as most needed to support and preserve a healthy lifestyle. CONCLUSION This study suggests that patients with recent TIA or ischemic stroke often do not have a high intention to change health-related behavior. The results fit well within the framework of the protection motivation theory. As many patients seem unable to adequately appraise their health behaviors, interventions should focus on increasing knowledge of healthy behavior and improving self-efficacy and social support.
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Affiliation(s)
| | | | | | | | - Erik Taal
- University of Twente, Twente, The Netherlands
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