1
|
Palsola M, Araújo-Soares V, Hardeman W, Haukkala A, Heino MTJ, Sniehotta F, Sund R, Vasankari T, Hankonen N. Evaluating the Let's Move It intervention programme theory for adolescents' physical activity: Theorized psychosocial mechanisms of behavioural changes. Br J Health Psychol 2024. [PMID: 39317658 DOI: 10.1111/bjhp.12744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 08/01/2024] [Indexed: 09/26/2024]
Abstract
OBJECTIVES Behaviour change theories have extensively been used in health behaviour change interventions and their programme theories. However, they are rarely evaluated in randomized field studies. The Let's Move It intervention targeted various psychosocial constructs to increase adolescents' physical activity. A theory-based process evaluation aiming to illuminate the trial findings as well as to test the programme theory used is conducted. Specifically, we investigate whether the intervention influenced the theorized determinants of change immediately post-intervention and after 1 year, and whether these determinants were associated with changes in physical activity. DESIGN A cluster-randomized controlled trial (n = 1166). METHODS We measured theorized determinants with self-report, and physical activity (PA) with accelerometry and self-report. The effects are evaluated with repeated measures ANOVA and regression models. RESULTS No changes were detected in most theorized determinants but intervention arm reported higher enactment of behaviour change techniques used during intervention immediately post-intervention and lower descriptive norms for PA throughout. Autonomous motivation was associated with PA immediately post-intervention. CONCLUSIONS The lack of intervention effects may be due to many factors, for example insensitive measures, ceiling effects. However, reporting these null effects advances understanding of behaviour change processes. We introduce methodologic possibilities for future intervention programme theory evaluation efforts.
Collapse
Affiliation(s)
- Minttu Palsola
- Faculty of Social Sciences, Tampere University, Tampere, Finland
- Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
| | - Vera Araújo-Soares
- Division of Prevention, Center for Preventive Medicine and Digital Health (CPD), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- University of Twente, Enschede, The Netherlands
| | - Wendy Hardeman
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Ari Haukkala
- Helsinki Collegium for Advanced Studies, University of Helsinki, Helsinki, Finland
| | - Matti Toivo Juhani Heino
- Faculty of Social Sciences, Tampere University, Tampere, Finland
- Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
| | - Falko Sniehotta
- Division of Prevention, Center for Preventive Medicine and Digital Health (CPD), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- University of Twente, Enschede, The Netherlands
- NIHR Policy Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Reijo Sund
- University of Eastern Finland, Kuopio, Finland
| | - Tommi Vasankari
- UKK Institute for Health Promotion Research, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Nelli Hankonen
- Faculty of Social Sciences, Tampere University, Tampere, Finland
- Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
| |
Collapse
|
2
|
Aulbach MB, Puukko S, Palsola M, Haukkala A, Sund R, Vasankari T, Hankonen N. How does a school-based intervention impact students' social cognitions on reducing sedentary behavior over 14 months? PSYCHOL HEALTH MED 2024; 29:1235-1249. [PMID: 38013166 DOI: 10.1080/13548506.2023.2285734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/15/2023] [Indexed: 11/29/2023]
Abstract
Despite sedentary behavior being ubiquitous in students and detrimental to health, interventions specifically targeting it are mostly restricted to leisure time screen time reduction. With six weekly sessions alongside a poster campaign and an additional teacher intervention, the Let's Move It trial delivered environmental and psychological strategies to increase physical activity (PA) and reduce sedentary behavior (SB) in vocational schools, an understudied environment for behavioral interventions. Participants in the intervention arm considerably reduced sedentary time post-intervention. To investigate how social cognitions about restricting SB, as defined by the Reasoned Action Approach, change in intervention and control arms, self-reported data on social cognitions was collected as part of a cluster-randomized controlled trial from 1166 students (59% female, mage = 18.7 years, range: 16-49) in six vocational schools before, post-intervention, and 14 months post-baseline. Data were analyzed using mixed between-within repeated measures ANOVA. We found greater improvements in intention (F(1, 833) = 9.69; η2p = 0.01; p = .018) and descriptive norms (F(1, 831) = 13.25; η2p = 0.016; p < .001) in the intervention than control arm, but these effects depended on the included control variables. Generally, intervention effects leveled off from post-intervention to follow-up. The Let's Move It intervention for SB reduction showed modest, short-lived effects on social cognitions, indicating that changes in behavior are likely due to other factors like changes to the classroom environment. Optimally, SB reduction interventions should not only change behavior but produce robust changes in conscious intentions to restrict one's sitting, so that positive effects generalize to other contexts.
Collapse
Affiliation(s)
- Matthias Burkard Aulbach
- Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
- School of Science, Aalto University, Espoo, Finland
- Department of Psychology, Paris-Lodron-University of Salzburg, Salzburg, Austria
| | - Sarmite Puukko
- Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Minttu Palsola
- Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Ari Haukkala
- Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
- Helsinki Collegium of Advanced Studies, University of Helsinki, Helsinki, Finland
| | - Reijo Sund
- Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Tommi Vasankari
- UKK Institute for Health Promotion Research, Tampere University, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Nelli Hankonen
- Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| |
Collapse
|
3
|
Ryan M, Alliott O, Ikeda E, Luan J, Hofmann R, van Sluijs E. Features of effective staff training programmes within school-based interventions targeting student activity behaviour: a systematic review and meta-analysis. Int J Behav Nutr Phys Act 2022; 19:125. [PMID: 36153617 PMCID: PMC9509574 DOI: 10.1186/s12966-022-01361-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/02/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evaluations of school-based activity behaviour interventions suggest limited effectiveness on students' device-measured outcomes. Teacher-led implementation is common but the training provided is poorly understood and may affect implementation and student outcomes. We systematically reviewed staff training delivered within interventions and explored if specific features are associated with intervention fidelity and student activity behaviour outcomes. METHODS We searched seven databases (January 2015-May 2020) for randomised controlled trials of teacher-led school-based activity behaviour interventions reporting on teacher fidelity and/or students' device-measured activity behaviour. Pilot, feasibility and small-scale trials were excluded. Study authors were contacted if staff training was not described using all items from the Template for Intervention Description and Replication reporting guideline. Training programmes were coded using the Behaviour Change Technique (BCT) Taxonomy v1. The Effective Public Health Practice Project tool was used for quality assessment. Promise ratios were used to explore associations between BCTs and fidelity outcomes (e.g. % of intended sessions delivered). Differences between fidelity outcomes and other training features were explored using chi-square and Wilcoxon rank-sum tests. Random-effects meta-regressions were performed to explore associations between training features and changes in students' activity behaviour. RESULTS We identified 68 articles reporting on 53 eligible training programmes and found evidence that 37 unique teacher-targeted BCTs have been used (mean per programme = 5.1 BCTs; standard deviation = 3.2). The only frequently identified BCTs were 'Instruction on how to perform the behaviour' (identified in 98.1% of programmes) and 'Social support (unspecified)' (50.9%). We found moderate/high fidelity studies were significantly more likely to include shorter (≤6 months) and theory-informed programmes than low fidelity studies, and 19 BCTs were independently associated with moderate/high fidelity outcomes. Programmes that used more BCTs (estimated increase per additional BCT, d: 0.18; 95% CI: 0.05, 0.31) and BCTs 'Action planning' (1.40; 0.70, 2.10) and 'Feedback on the behaviour' (1.19; 0.36, 2.02) were independently associated with positive physical activity outcomes (N = 15). No training features associated with sedentary behaviour were identified (N = 11). CONCLUSIONS Few evidence-based BCTs have been used to promote sustained behaviour change amongst teachers in school-based activity behaviour interventions. Our findings provide insights into why interventions may be failing to effect student outcomes. TRIAL REGISTRATION PROSPERO registration number: CRD42020180624.
Collapse
Affiliation(s)
- Mairead Ryan
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
- Faculty of Education, University of Cambridge, Cambridge, UK
| | - Olivia Alliott
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Erika Ikeda
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Jian'an Luan
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Riikka Hofmann
- Faculty of Education, University of Cambridge, Cambridge, UK
| | | |
Collapse
|
4
|
da Silva Bandeira A, Pizani J, de Sousa ACFC, da Silva JA, Minatto G, Barbosa Filho VC, Silva KS. Implementation of a school-based physical activity intervention for Brazilian adolescents: a mixed-methods evaluation. Health Promot Int 2021; 37:6327059. [PMID: 34297827 DOI: 10.1093/heapro/daab091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The effectiveness of physical activity interventions can be improved through examining the aspects related to their implementation. However, little such evidence has been collected, particularly in low- and middle-income countries. This study aimed to evaluate the implementation of a school-based physical activity intervention with qualitative and quantitative data from different actors (students, teachers and parents) involved in developing the program. The program was conducted in 2017 with three main components: (i) teacher training, (ii) environmental changes and (iii) educational actions. Mixed-method evaluation was performed by an independent evaluation team using a validated indicator matrix for the implementation process, including the self-reported information of students, teachers and parents, as well as interviews with teachers. In the 3 eligible schools, 350 adolescents (51% girls) answered the implementation questionnaire, as did 45 parents (84% mothers), and 47 teachers (70% female). In the qualitative analysis, 18 teachers participated. Categorical analysis found that the intervention was considered feasible by teachers. In general, teachers had a more positive perception of the implementation than did students. The lack of engagement from the school community and parents and the busy schedule of teachers were indicated to be the main difficulties. In conclusion, despite the teachers' motivation, some barriers prevented the successful implementation of the program.
Collapse
Affiliation(s)
- Alexsandra da Silva Bandeira
- Research Group in Physical Activity and Health, Department of Physical Education, Federal University of Santa Catarina, Campus Universitário Reitor João David Ferreira Lima, CEP, Florianópolis, Santa Catarina 88040-900, Brazil
| | - Juliana Pizani
- Research Group in Physical Activity and Health, Department of Physical Education, Federal University of Santa Catarina, Campus Universitário Reitor João David Ferreira Lima, CEP, Florianópolis, Santa Catarina 88040-900, Brazil
| | - Ana Caroline Ferreira Campos de Sousa
- Research Group in Physical Activity and Health, Department of Physical Education, Federal University of Santa Catarina, Campus Universitário Reitor João David Ferreira Lima, CEP, Florianópolis, Santa Catarina 88040-900, Brazil
| | - Jaqueline Aragoni da Silva
- Research Group in Physical Activity and Health, Department of Physical Education, Federal University of Santa Catarina, Campus Universitário Reitor João David Ferreira Lima, CEP, Florianópolis, Santa Catarina 88040-900, Brazil
| | - Giseli Minatto
- Research Group in Physical Activity and Health, Department of Physical Education, Federal University of Santa Catarina, Campus Universitário Reitor João David Ferreira Lima, CEP, Florianópolis, Santa Catarina 88040-900, Brazil
| | - Valter Cordeiro Barbosa Filho
- Federal Institute of Education, Science and Technology of Ceara, Aracati Campus, Rodovia CE-040, Km 137,1, s/n-Aeroporto, Aracati-CE, Ceará 62800-000, Brazil
| | - Kelly Samara Silva
- Research Group in Physical Activity and Health, Department of Physical Education, Federal University of Santa Catarina, Campus Universitário Reitor João David Ferreira Lima, CEP, Florianópolis, Santa Catarina 88040-900, Brazil
| |
Collapse
|
5
|
Huang SW, Chang TY. Social Image Impacting Attitudes of Middle-Aged and Elderly People toward the Usage of Walking Aids: An Empirical Investigation in Taiwan. Healthcare (Basel) 2020; 8:healthcare8040543. [PMID: 33316995 PMCID: PMC7763066 DOI: 10.3390/healthcare8040543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/20/2020] [Accepted: 11/23/2020] [Indexed: 11/23/2022] Open
Abstract
The elderly need the assistance of walking aids due to deterioration of their physical functions. However, they are often less willing to use these aids because of their worries about how others may think of them. Not using professional walking aids often makes elderly people fall easily when walking. This study explores the behavioral intention factors of middle-aged people (45–64 years old) and elderly people (65 years and older) that affect the use of walking aids. Based on the Theory of Reasoned Action (TRA), subjective norms, attitude toward usage, behavior intention, safety, and usefulness were combined with social image to establish the research framework. This study used questionnaire surveys both in paper form assisted by volunteers and in online electronic form. A total of 457 questionnaires were collected. Data analysis was carried out in three stages: descriptive analysis, measurement model verification, and structural equation model analysis. The results showed that social image had a significant impact on the attitude toward using walking aids. Factors such as attitude toward usage, subjective norms, and safety of walking aids also had a significant positive impact on behavioral intention. Finally, through the research results, some suggestions are proposed for stakeholders to improve the elderly’s concerns about the social image of using walking aids.
Collapse
Affiliation(s)
- Shao-Wei Huang
- Graduate School of Design, National Yunlin University of Science and Technology, Yunlin 640, Taiwan;
| | - Tsen-Yao Chang
- Department of Creative Design, National Yunlin University of Science and Technology, Yunlin 640, Taiwan
- Correspondence:
| |
Collapse
|
6
|
Hankonen N, Absetz P, Araújo-Soares V. Changing activity behaviours in vocational school students: the stepwise development and optimised content of the 'let's move it' intervention. Health Psychol Behav Med 2020; 8:440-460. [PMID: 34040880 PMCID: PMC8114352 DOI: 10.1080/21642850.2020.1813036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/11/2020] [Indexed: 11/17/2022] Open
Abstract
Background: School-based interventions that increase physical activity (PA) in a sustainable way are lacking. Systematic and participatory, theory and evidence-based intervention development may enhance the effectiveness of complex behavioural interventions in the long term. However, detailed descriptions of the intervention development process are rarely openly published, hindering transparency and progress in the field. Aims: To illustrate a stepwise process to develop intervention targeting PA and sedentary behaviour (SB) among older adolescents, and to describe the final, optimised version of the intervention, detailing content of sessions by theoretical determinants and techniques. Methods: Two established intervention development frameworks (Intervention Mapping and Behaviour Change Wheel) were integrated, leading to a comprehensive evidence and theory-based process. It was informed by empirical studies, literature reviews, expert and stakeholder consultation, including scenario evaluation and component pre-testing. In all steps, contextual fit and potential for sustainability were ensured by stakeholder engagement. Results: As a large majority of youth opposed decreasing screen time, increasing PA and decreasing SB were defined as target behaviours, with peers and the school context including classroom practices as key social environments in influencing youth PA (problem specification, step 1). Behavioural diagnosis (step 2) identified a variety of determinants in the domains of capability (e.g. self-regulation skills), motivation (e.g. outcome expectations) and environmental opportunities. These were organised into an intervention theory integrating several formal theories, including Self-Determination Theory. Theory-aligned principles guided material design (Step 3). Feasibility RCT allowed optimisation into a final intervention protocol (step 4). Conclusions: Intervention elements target students directly, and indirectly by changing teacher behaviour and the school and wider environment. A systematic development and optimisation led to a high potential for sustainability. The detailed intervention content, with specification of the hypothesised mechanisms, allows for other researchers to replicate, adapt or refine parts or the whole intervention, considering specific target groups and (sub-)cultures.
Collapse
Affiliation(s)
- Nelli Hankonen
- Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
| | - Pilvikki Absetz
- Department of Public Health and Clinical Nutrition, University of Eastern Finland, Joensuu, Finland
| | | |
Collapse
|
7
|
Rollo S, Prapavessis H. A Combined Health Action Process Approach and mHealth Intervention to Increase Non‐Sedentary Behaviours in Office‐Working Adults—A Randomised Controlled Trial. Appl Psychol Health Well Being 2020; 12:660-686. [DOI: 10.1111/aphw.12201] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/16/2020] [Accepted: 03/24/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Scott Rollo
- The University of Western Ontario London Ontario Canada
| | | |
Collapse
|
8
|
Toomey E, Hardeman W, Hankonen N, Byrne M, McSharry J, Matvienko-Sikar K, Lorencatto F. Focusing on fidelity: narrative review and recommendations for improving intervention fidelity within trials of health behaviour change interventions. Health Psychol Behav Med 2020; 8:132-151. [PMID: 34040865 PMCID: PMC8114368 DOI: 10.1080/21642850.2020.1738935] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/16/2020] [Indexed: 01/29/2023] Open
Abstract
Background: Interventions to change behaviour have substantial potential to impact positively on individual and overall public health. Despite an increasing focus on health behaviour change intervention research, interventions do not always have the desired effect on outcomes, while others have diluted effects once implemented into real-life settings. There is little investment into understanding how or why such interventions work or do not work. Methodological inadequacies of trials of behavioural interventions have been previously suggested as a barrier to the quality and advancement of behavioural research, with intervention fidelity acknowledged as a key area for improvement. However, there is much ambiguity regarding the terminology and conceptualisation of intervention fidelity and a lack of practical guidance regarding how to address it sufficiently, particularly within trials of complex behavioural interventions. Objectives: This article outlines specific issues concerning intervention fidelity within trials of health behaviour change interventions and suggests practical considerations and specific recommendations for researchers, with examples from the literature presented. Conclusions: Recommendations pertain to (1) clarifying how fidelity is defined and conceptualised, (2) considering fidelity beyond intervention delivery, (3) considering strategies to both enhance and assess fidelity, (4) making use of existing frameworks and guidance, (5) considering the quality and comprehensiveness of fidelity assessment strategies, (6) considering the balance between fidelity and adaptation and (7) reporting the use of fidelity enhancement and assessment strategies and their results. Suggestions for future research to improve our understanding of, and ability to, address fidelity in behaviour change interventions are also provided.
Collapse
Affiliation(s)
- E. Toomey
- Health Behaviour Change Research Group, School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - W. Hardeman
- Health Promotion Research Group, School of Health Sciences, University of East Anglia, Norwich, UK
| | - N. Hankonen
- Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
| | - M. Byrne
- Health Behaviour Change Research Group, School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - J. McSharry
- Health Behaviour Change Research Group, School of Psychology, National University of Ireland Galway, Galway, Ireland
| | | | - F. Lorencatto
- Centre for Behaviour Change, University College London, London, UK
| |
Collapse
|
9
|
Heino MTJ, Knittle K, Fried E, Sund R, Haukkala A, Borodulin K, Uutela A, Araujo-Soares V, Vasankari T, Hankonen N. Visualisation and network analysis of physical activity and its determinants: Demonstrating opportunities in analysing baseline associations in the Let's Move It trial. Health Psychol Behav Med 2019; 7:269-289. [PMID: 34040851 PMCID: PMC8114395 DOI: 10.1080/21642850.2019.1646136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 07/16/2019] [Indexed: 01/07/2023] Open
Abstract
Background: Visualisations and readily-accessible web-based supplementary files can improve data reporting and transparency. In this paper, we make use of recent developments in software and psychological network analysis to describe the baseline cohort of a trial testing the Let's Move It intervention, which aimed to increase physical activity (PA) and reduce sedentary behaviours (SB) among vocational school students. Methods: At baseline, 1166 adolescents, distributed across 6 school clusters and four educational tracks, completed measures of PA and SB, theoretical predictors of these behaviours, and body composition. Within a comprehensive website supplement, which includes all code and analyses, data were tabulated and visualised, and network analyses explored relations between predictor variables and outcomes. Results: Average daily moderate-to-vigorous PA was 65 min (CI95: 57min-73 min), and SB 8h44 min (CI95: 8h04min-9h24 min), with 25.8 (CI95: 23.5-28.0) interruptions to sitting. Cluster randomisation appeared to result in balanced distributions for baseline characteristics between intervention and control groups, but differences emerged across the four educational tracks. Self-reported behaviour change technique (BCT) use was low for many but not all techniques. A network analysis revealed direct relationships between PA and behavioural experiments, planning and autonomous motivation, and several BCTs were connected to PA via autonomous motivation. Visualisation uncovered a case of Simpson's paradox. Conclusions: Data-visualisation and data exploration techniques (e.g. network analysis) can help reveal the dynamics involved in complex multi-causal systems - a challenging task with traditional data presentations. The benefits of presenting complex data visually should encourage researchers to publish extensive analyses and descriptions as website supplements, which would increase the speed and quality of scientific communication, as well as help to address the crisis of reduced confidence in research findings. We hope that this example will serve as a template for other investigators to improve upon in the future.
Collapse
Affiliation(s)
| | - Keegan Knittle
- Faculty of Social Sciences, University of HelsinkiHelsinki, Finland
| | - Eiko Fried
- Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
| | - Reijo Sund
- Faculty of Health Sciences, University of Eastern FinlandKuopio, Finland
| | - Ari Haukkala
- Faculty of Social Sciences, University of HelsinkiHelsinki, Finland
| | - Katja Borodulin
- Faculty of Social Sciences, University of HelsinkiHelsinki, Finland
| | - Antti Uutela
- Faculty of Social Sciences, University of HelsinkiHelsinki, Finland
| | - Vera Araujo-Soares
- Institute of Health and Society, Medical Faculty, Newcastle University, Newcastle upon Tyne, UK
| | | | - Nelli Hankonen
- Faculty of Social Sciences, University of HelsinkiHelsinki, Finland
| |
Collapse
|