Predicting intentions and behaviour of Swedish 10–16-year-olds at breakfast

Barriers and facilitators to health insurance enrolment among people working in the informal sector in Morogoro, Tanzania

Background: Health insurance is a crucial pathway towards the achievement of universal health coverage. In Tanzania, health-financing reforms are underway to speed up universal health coverage in the informal sector. Despite improved Community Health Fund (iCHF) rollout, iCHF enrolment remains a challenge in the informal sector. This study aimed to explore the perspectives of local women food vendors (LWFV) and Bodaboda (motorcycle taxi) drivers on factors that challenge and facilitate their enrolment in iCHF. Methods: A qualitative study was conducted in Morogoro Municipality through in-depth interviews with LWFV (n=24) and Bodaboda drivers (n=26), and two focus group discussions with LWFV (n=8) and Bodaboda drivers (n=8). Theory of planned behaviour (TPB) constructs (attitude, subjective norms, and perceived control) provided a framework for the study and informed a thematic analysis focusing on the barriers and facilitators of iCHF enrolment. Results: The views of LWFV and Bodaboda drivers on factors that influence iCHF enrolment converged. Three main barriers emerged: lack of knowledge about the iCHF (attitude); negative views from friends and families (subjective norms); and inability to overcome challenges, such as the quality and range of health services available to iCHF members and iCHF not being accepted at non-government facilities (perceived control). A number of facilitators were identified, including opinions that enrolling to iCHF made good financial sense (attitude), encouragement from already-enrolled friends and relatives (subjective norms) and the belief that enrolment payment is affordable (perceived control). Conclusions: Results suggest that positive attitudes supported by perceived control and encouragement from significant others could potentially motivate LWFV and Bodaboda drivers to enroll in iCHF. However, more targeted information about the scheme is needed for individuals in the informal sector. There is also a need to ensure that quality health services are available, including coverage for non-communicable diseases (NCDs), and that non-government facilities accept iCHF.

Children's conformity to social norms to eat healthy: A developmental perspective

RATIONALE

Previous studies suggest injunctive norms (prompts of what people ought to do) are stronger predictors of healthy eating intentions, whereas descriptive norms (prompts of what people are doing) are stronger predictors of healthy eating behaviors. However, previous research provides little insight into why different norms influence children's health intentions and behaviors differently. In addition, no research has explored developmental differences in children's conformity to, or rejection of, different types of social normative influence. Thus, this paper adopts a developmental perspective to understand why children conform differently to descriptive and injunctive norm messaging on healthy eating.

METHOD

An experiment was done with 405 children in Germany aged 7 to 16. The research design was a 4 (social norms: descriptive vs. injunctive peer vs. injunctive authority vs. control) × 2 (developmental stage: middle childhood vs. adolescence) between-subject design. Children's healthy eating intentions and behaviors were collected as key dependent variables.

RESULTS

and conclusions: The experimental results suggest that children mainly use a descriptive norm as an information shortcut to behaving "appropriately". This should have a stronger impact on younger children than older ones, although both young and old children consider it easier to understand than an injunctive norm. The experimental results further suggest that an injunctive norm mainly influences children via activation of a motive for maintaining a positive self-image in public, rather than one of affiliation. These results are very important for social research on health, because they can explain why different social norms influence health intentions and behaviors differently. In addition, our finding that injunctive norm conformity is mainly used for impression management purposes can reconcile existing contradictory results on the impact of social norms on children.

Elementary school teachers’ behavioral intentions for healthy nutrition

Purpose

The purpose of this paper is to examine the effects of elementary school teachers’ psychological factors on their behavioral intentions for healthy nutrition in their daily life within an extended version of the theory of planned behavior (TPB).

Design/methodology/approach

The design of the study is correlation study.

Findings

Constructs in the proposal model formed accounted for of variance of intentions and behaviors successfully. Considering the entire proposed model, while personal norm is the most influential factor on intention, self-identity is the most consistent effects on teachers’ behavior. However, among the constructs of TPB, perceived behavioral control is the strongest influence on both intention and behavior.

Originality/value

In the literature, factors affecting healthy behaviors by using TPB focused on mainly children (8–10 year old) and adolescents (11–16 year old) all over the world. However, in some countries, several studies were conducted on adults (e.g. Astrøsm and Rise, 2001; Brouwer and Mosack, 2015), to the best of our knowledge, while there is no study conducted on adults including teachers in Turkey. In addition, recently, two meta-analysis studies were published: Riebl et al. (2015) and Mcdermott et al. (2015). These studies suggested that future studies related to healthy nutrition in the scope of TPB should be continued to investigate.

Applying an extended theory of planned behaviour to predict breakfast consumption in adolescents

BACKGROUND/OBJECTIVES

Breakfast skipping increases during adolescence and is associated with lower levels of physical activity and weight gain. Theory-based interventions promoting breakfast consumption in adolescents report mixed findings, potentially because of limited research identifying which determinants to target. This study aimed to: (i) utilise the Theory of Planned Behaviour (TPB) to identify the relative contribution of attitudes (affective, cognitive and behavioural) to predict intention to eat breakfast and breakfast consumption in adolescents and (ii) determine whether demographic factors moderate the relationship between TPB variables, intention and behaviour.

SUBJECTS/METHODS

Questionnaires were completed by 434 students (mean 14±0.9 years) measuring breakfast consumption (0-2, 3-6 or 7 days), physical activity levels and TPB measures. Data were analysed by breakfast frequency and demographics using hierarchical and multinomial regression analyses.

RESULTS

Breakfast was consumed everyday by 57% of students, with boys more likely to eat a regular breakfast, report higher activity levels and report more positive attitudes towards breakfast than girls (P<0.001). The TPB predicted 58% of the variation in intentions. Overall, the model was predictive of breakfast behaviours (P<0.001), but the relative contribution of TPB constructs varied depending on breakfast frequency. Interactions between gender and intentions were significant when comparing 0-2- and 3-6-day breakfast eaters only highlighting a stronger intention-behaviour relationship for girls.

CONCLUSIONS

Findings confirm that the TPB is a successful model for predicting breakfast intentions and behaviours in adolescents. The potential for a direct effect of attitudes on behaviours should be considered in the implementation and design of breakfast interventions.

Predicting Intended and Self-perceived Sugar Restriction among Tanzanian Students using the Theory of Planned Behavior

This study examines the applicability and sufficiency of the Theory of Planned Behavior (TPB) in predicting intention and self-perceived behavior with respect to avoiding between-meal intake of sugared snacks and drinks. One thousand one hundred and twenty-three Tanzanian students (mean age 26.4 years) completed self-administered questionnaires designed to measure the components of the TPB during May–July, 1999. Self-perceived sugar consumption was obtained in a subsample of respondents ( n = 228) four weeks later. The TPB provided a significant prediction of intention ( R2= 0.44), with attitude (= 0.25), subjective norms (= 0.28) and perceived behavioral control (= 0.35) significant, and subsequent behavior ( R2 = 0.15, with intention (= 0.25) and perceived behavioral control (= 0.18) significant. Frequency of past behavior explained a significant, albeit small, amount of additional variance in intention (1 percent) and behavior (4 percent). The results indicate that the TPB is applicable to the prediction of food choice-related intention and behavior among young adult students living in a non-occidental setting.

A systematic literature review and meta-analysis: The Theory of Planned Behavior's application to understand and predict nutrition-related behaviors in youth

BACKGROUND

Efforts to reduce unhealthy dietary intake behaviors in youth are urgently needed. Theory-based interventions can be effective in promoting behavior change; one promising model is the Theory of Planned Behavior (TPB).

PURPOSE

The aim of this study was to determine, using a systematic literature review, how the TPB has been applied to investigate dietary behaviors, and to evaluate which constructs are associated with dietary behavioral intentions and behaviors in youth.

METHODS

Publications were identified by searching electronic databases, contacting experts in the field, and examining an evolving Internet-based TPB-specific bibliography. Studies including participants aged 2-18years, all TPB constructs discernible and measured with a description of how the variables were assessed and analyzed, were published in English and peer-reviewed journals, and focused on nutrition-related behaviors in youth were identified. Accompanying a descriptive statistical analysis was the calculation of effect sizes where possible, a two-stage meta-analysis, and a quality assessment using tenants from the Consolidated Standards of Reporting Trials (CONSORT) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statements.

RESULTS

Thirty-four articles, including three intervention studies, were reviewed. The TPB was most often used to evaluate healthy eating and sugary snack and beverage consumption. Attitude had the strongest relationship with dietary behavioral intention (mean r=0.52), while intention was the most common predictor of behavior performance (mean r=0.38; both p<0.001). All three interventions revealed beneficial outcomes when using the TPB (e.g. η(2)=0.51 and ds=0.91, 0.89, and 0.79); extending the Theory with implementation intentions may enhance its effectiveness (e.g. η(2)=0.76).

CONCLUSIONS

Overall, the TPB may be an effective framework to identify and understand child and adolescent nutrition-related behaviors, allowing for the development of tailored initiatives targeting poor dietary practices in youth. However, support from the literature is primarily from observational studies and a greater effort towards examining these relationships within intervention studies is needed.

Intention to adhere to HIV treatment: a patient-centred predictor of antiretroviral adherence

OBJECTIVES

Despite the effectiveness of highly active antiretroviral therapy (HAART), HIV remains a major cause of mortality in the USA, largely as a result of poor HIV treatment adherence. In this study we assessed the association between five patient-centred factors and adherence to HIV treatment.

METHODS

We surveyed 244 adults at two HIV clinics in Houston, Texas between October 2009 and April 2010. Participants were given a questionnaire and their charts were reviewed for clinical data. Survey items assessed the following factors: self-assessed HIV knowledge, awareness of disease biomarkers, intention to adhere to HIV treatment, health literacy and decision-making style. The primary outcome measure was HAART adherence during the previous month. Logistic regressions were performed to calculate the effect of each factor on adherence.

RESULTS

All participants had HIV/AIDS and were on HAART at enrolment. Eight per cent of participants were female, 57% were African-American and 16% were Hispanic. Mean age was 58.1 years. Sixty-eight per cent were adherent to HAART during the last month. On univariate analysis, a preference for wanting choices, correct knowledge of recent HIV viral load level, and intention to adhere to HIV treatment were significantly associated with adherence. On multivariate analysis, only intention to adhere to HIV treatment remained statistically significant after adjusting for other factors (odds ratio 2.2; 95% confidence interval 1.1 to 4.3).

CONCLUSIONS

Intention to adhere to HIV treatment was significantly associated with self-reported adherence to HAART. Interventions that bolster patients' intentions to adhere to HIV treatment during clinical encounters may improve adherence to HAART and HIV control.

Development and validation of a measure for intention to adhere to HIV treatment

We present the development and validation of a theory-derived scale measuring patients' behavioral intention to adhere to HIV care. Adherence to HIV care includes attendance at appointments and adherence to highly active antiretroviral therapy (HAART) regimens. These two components have been independently associated with long-term HIV outcomes. Items were chosen to reflect behavioral intention as defined by the Health Action Process Approach to health-seeking behavior. Items reflecting self-reported HIV knowledge were also included after expert panel review. The study took place from October 2009 to April 2010 at two HIV clinics in Houston, Texas. Participants were 287 adults with HIV/AIDS (10.1% female, mean age 50.8); 56.5% were African-American and 17% were Hispanic. Of the total, 87.1% were on HAART at enrollment. Factor analysis of survey items resulted in the retention of two domains, knowledge and intention, based on scree plot analysis of eigenvalues. Questions with factor loadings >0.4 were retained, yielding 4 knowledge questions and 10 intention questions. The survey had good internal consistency for knowledge (Cronbach's α=0.83) and for intention (Cronbach's α=0.81). In multivariate analysis, intention was associated with HIV viral suppression, defined as HIV-1 viral load <400 RNA copies/mL, (odds ratio [OR]=1.75, 95% .confidence interval [CI]=1.00-3.07). Knowledge was also associated with HIV suppression (OR=1.55, 95%, CI=1.09-2.12). The resulting study describes the development and preliminary validation of an HIV treatment-seeking intention measure. Additional studies are needed to validate this instrument in other populations.

Environmental and cognitive correlates of adolescent breakfast consumption

OBJECTIVE

This study aimed to identify cognitive and environmental correlates of daily adolescent breakfast consumption.

METHODS

Adolescents (n=1089) aged 12-15 years in schools in Rotterdam, The Netherlands, completed a questionnaire measuring daily breakfast consumption, individual cognitions, and home environmental factors during the 2005-2006 school year. Multilevel logistic regression analysis was performed to determine the association between the environmental variables, cognitions and everyday breakfast consumption. Additionally, mediation of the effect of the environmental variables through the individual cognitions on breakfast consumption was explored.

RESULTS

Attitude, perceived behavioral control, modeling by friends and parents, and intention were associated with daily breakfast consumption. Political (breakfast rules), physical (available breakfast products), and socio-cultural (having breakfast with a parent, having the evening meal with a parent, eating the evening meal in front of the TV) environments were also associated with daily breakfast consumption. Associations of the environmental factors were partly mediated by the individual cognitions.

CONCLUSIONS

Individual cognitions and a supportive home environment are associated with adolescent breakfast consumption. Since parents primarily shape the home environment, interventions aimed at improving adolescent breakfast consumption should target the parent as well as the adolescent.

Understanding eating behaviours in Spanish women enrolled in a weight-loss treatment

AIM

To identify the beliefs and attitudes of a sample of obese and overweight Spanish women undertaking a weight-loss treatment.

BACKGROUND

Obesity is a global epidemic. Weight-loss treatments focus on changing eating behaviours; however, many patients fail to adhere to the diet. This suggests that more effective behaviour-change interventions are required to help people change their eating behaviours. According to the theory of planned behaviour (TPB) human behaviour is influenced by beliefs. Identification of people's beliefs is an essential step in the design of behaviour-change interventions.

DESIGN

A qualitative approach was employed using semi-structured interviews to interview participants. Seventeen obese and overweight Spanish women enrolled in a weight-loss treatment were recruited using a criterion sample strategy.

FINDINGS

Participants' reported beliefs referring to the benefits of losing weight and the emotions related to dieting. The more positive these beliefs were the more positive their attitude towards the diet seemed to be. Findings highlight the importance of follow-ups in creating a subjective norm to maintain a diet. Perceived behavioural control to diet seemed to be related to beliefs about social support; whereas beliefs about lack of willpower to overcome temptations seemed to decrease perceived control over eating behaviours.

CONCLUSIONS

Participants reported several beliefs and attitudes that offer plausible explanations of their eating behaviours. Data from this study seemed to fit the propositions of the TPB and could be used in further research to develop effective eating behaviour-change interventions.

RELEVANCE TO CLINICAL PRACTICE

Nurses could use the TPB to assess individuals' attitudes, beliefs and expectations when following a diet. That assessment would provide insight into what aspects are relevant for individual patients when dieting, which could lead to more effective diet behaviour-change interventions being designed.

Distinguishing among perceived control, perceived difficulty, and self-efficacy as determinants of intentions and behaviours

Perceptions of control hold a dominant position in social cognitive theories yet there is a lack of conceptual and empirical clarity regarding what kind of control is most associated with particular behaviours. Three prominent types of control are perceived control (PC), perceived difficulty (PD), and perceived confidence or self-efficacy (SE) for performing the desired behaviour. Three studies are presented with a primary goal of distinguishing PC, PD, and SE from each other, and a secondary goal of determining which of the three is the superior predictor of health-related intentions and behaviours. The first study replicates earlier work by Trafimow et al. (2002) distinguishing the three constructs for reading 1, 30, and 100 pages, and extends it to exercising one, two, four, and six times per week and also to predicting intentions to exercise 4 days per week and behaviour 1 week later. The second study examines the predictive capability of the three constructs for intentions to floss one's teeth everyday and to eat 5-10 servings of fruits and vegetables everyday and subsequently on behaviour assessed 7 days later. The third study reports a meta-analysis of the relative influence of PC, PD, and SE on behaviours when defined in conceptually consistent ways. The results of all three studies support the conceptual and empirical distinction of PC, PD, and SE and the superiority of SE as a predictor of health behaviours and intentions.

Applying the Theory of Planned Behavior to healthy eating behaviors in urban Native American youth

Background

To investigate the efficacy of the Theory of Planned Behavior (TPB) to predict healthy eating behavior in a group of urban Native American youth.

Methods

Native American boys and girls (n = 139), ages 9–18 years old, were given a self-administered survey to assess eating behavior using the TBP constructs (intention, attitude, subjective norm, barriers, self-efficacy, and perceived behavioral control). Youth were also measured for height and weight and body mass index (BMI) was calculated. Bivariate correlations and stepwise regression analyses of TBP model were performed with SPSS software.

Results

No association was found between intention and healthy eating behavior. However, independently healthy eating behavior was correlated with barriers (0.46), attitude (0.44), perceived behavioral control (0.35), and subjective norm (0.34). The most predictive barriers to eating healthy included the availability and taste of foods. Boys' eating behavior was most predicted by subjective norm, while girls' eating behavior was most predicted by barriers.

Conclusion

Lack of association between intention and healthy eating behavior suggests that factors other than intentions may drive healthy eating behaviors in urban Native American youth. Results indicate that programs promoting healthy eating to youth might focus on collaborating with families to make healthy foods more appealing to youth.

A school-based intervention to promote dietary change

PURPOSE

This study examined the effect of 2 school-based interventions on adolescents' consumption and knowledge of fish with the hypothesis that home economics education would enhance the effect of modifications in the school canteen. The school lunch intervention (SL) focused on changes in the school canteen, and the school lunch + home economics intervention (SL + HE) in addition consisted of changes in the home economics syllabus. Pupils in the 8th grade (n = 228) from 3 schools in Göteborg, Sweden, participated (control, n = 83; SL group, n = 58; SL + HE group, n = 87).

METHODS

A controlled design was used in which behavior and knowledge were assessed before and after the intervention. In contrast to much previous research of this type, measurement of behavior was based primarily on direct observation as opposed to self-reported intakes. Behavior (fish consumption) was measured individually by structured observations in the school canteen 5 times (once a week) when fish was served. Nutritional knowledge was measured by means of 10 items in a questionnaire. To analyze changes in behavior, a nonparametric statistical method assessing systematic change in paired ordered categoric variables was used.

RESULTS

At follow-up evaluation, consumption had increased significantly in the SL + HE group, a change that also differed from the control group. In addition, significant positive changes in knowledge were observed in both intervention groups, but not in controls.

CONCLUSIONS

The results suggest that dietary change was achieved by modifying conditions in the school canteen together with changing the home economics syllabus. This study shows the importance of the school in the promotion of dietary change among adolescents.

Understanding choice of milk and bread for breakfast among Swedish children aged 11-15 years: an application of the Theory of Planned Behaviour

The present study examined the influences of attitudes, social norms, perceived control and underlying beliefs on 11 to 15-year-olds' breakfast choices of milk with different fat content and high-fibre bread. All pupils in the 5th, 7th and 9th grades in Mölndal community (N=1730), Sweden, were asked to complete a questionnaire based on the Theory of Planned Behaviour. Two weeks later, they were asked to fill in a 7-day record of food consumed for breakfast. Consumption of milk and high-fibre bread was predicted from intentions, and for milk also by perceived behavioural control. Intentions were influenced by attitudes, perceptions of significant others' preferences, and perceived control. In addition, perception of the parents' consumption (descriptive norm) of the specific food played an important role. Attitudes, norms and perceived control predicted intentions to a similar extent in each age group. Attitudes to the consumption of milk and high fibre bread were influenced by beliefs about their sensory and health aspects. Females and the oldest children had greater knowledge about the healthier alternatives and the oldest children had a tendency to choose healthier options.

Psychosocial correlates of dietary intake: advancing dietary intervention

Psychosocial variables that predict dietary behavior become important targets for change in nutrition education programs. Psychosocial variables in models with higher predictability provide more effective levers to promote healthy dietary change. A review of the literature on models with psychosocial variables predicting dietary fat and fruit and vegetable consumption revealed generally low predictiveness, R2 < 0.3 (where R2 is the squared multiple correlation of the statistical model). No single theory provided models that regularly out-predicted others. When models predicted narrower categories of behavior (e.g. milk or salad consumption), predictiveness tended to be higher. Substantial problems were revealed in the psychometrics of both the independent and dependent variables. Little theory-based research has been conducted with adolescents, and the few studies done with children had low predictiveness. In order to increase the predictiveness of models, future research should combine variables from several theories, attend to the psychometrics of all variables, and incorporate variables that moderate the relationship of psychosocial to dietary behavior (e.g. genetics of taste, stage in the life course). Refinements on current research would include longitudinal designs and use of non-self-report methods of dietary behavior to supplement the self-report methods. Improved understanding of dietary behavior should lead to more effective dietary behavior change interventions.