Predicting sun-protective intentions and behaviours using the theory of planned behaviour: a systematic review and meta-analysis

Outdoor workers' perceptions of skin cancer prevention: a qualitative study

OBJECTIVES

Outdoor workers are at increased risk for skin cancer and melanoma. This qualitative study aimed to explore outdoor workers' perspectives and experiences of primary (i.e. sun protection) and secondary prevention, i.e. skin self-examination (SSE) of skin cancer.

METHODS

Purposive, snowball, and theoretical sampling was used to recruit outdoor workers in Kentucky and Indiana. Semi-structured interviews via telephone or videoconference of approximately 45 min were conducted with interviewer probes and questions about perceptions of cancer risk, prevention, and screening techniques conducted, perceived barriers and facilitators, and preferences for health dissemination venues. The recordings were transcribed verbatim and de-identified. Analysis involved constructivist grounded theory coding strategies. Using peer debriefing and consensus building around themes, the researcher established a codebook for all interviews to utilize within Dedoose software for systematizing and organizing data.

RESULTS

Eighteen interviews were conducted. Interviewees (N = 18) ranged in age from 35 to 78 yr, with 3 females. Outdoor industries included agriculture, maintenance, and grounds maintenance. Themes derived from the data showed the underlying factors and perceptions that influence outdoor workers to conduct primary and secondary cancer prevention activities. The level of alarm attributed to disease and the level of trust in information contribute to intentions to conduct activities. The intentions and trust toward healthcare institutions and providers drive the primary or secondary prevention behaviors. Cultural and contextual factors included masculinity and self-sufficiency, familial and occupational priorities, and community ties.

CONCLUSIONS

These data provide a basis for developing future communications and interventions to decrease skin cancer incidence in outdoor workers. They indicate that secondary prevention and building self-efficacy in conducting SSE should be emphasized in tandem or over primary skin cancer prevention methods in this population. Trusted local healthcare providers should primarily provide prevention information, and materials should utilize testimonials from the local community to best influence this population. Communications and training interventions are needed in this population to induce a proactive level of alarm about cancer and result in the performance of SSE.

Identifying foci for safety messages targeting child injury from driving quad bikes: A critical beliefs analysis of parental beliefs in Australia

INTRODUCTION

In Australia, between 2017-2021, 16% of quad bike fatalities involved children. Trauma statistics highlight that public awareness of the risks associated with children driving quads is required. Consistent with the Step approach to Message Design and Testing (SatMDT) and, in particular, Steps 1 and 2, this study sought to identify critical beliefs influencing parental intentions to allow their children to drive a quad bike and develop message content. The critical beliefs analysis was based on eliciting the Theory of Planned Behavior's (TPB) behavioral, normative, and control beliefs.

METHODS

An online survey was distributed via parenting blogs, social media posts, and snowballing of the researchers' network list. Parents who participated (N = 71; 53F, 18 M), were aged between 25-57 years (M = 40.96, SD = 6.98), had at least one child aged between 3 to 16 years, and currently resided in Australia.

RESULTS

The critical beliefs analysis identified four critical beliefs that significantly predicted parental intentions to allow their child to drive a quad bike. These beliefs included a behavioral belief (the perceived advantage that allowing their child to drive a quad bike would enable tasks to be completed), two normative beliefs (the perception that one's parents and partner would likely approve of allowing their child to drive a quad bike), and one control belief (a perceived barrier to allowing one's child to drive a quad that was associated with being aware of an increasing cultural concern around the safety of quad bikes).

CONCLUSIONS

Findings contribute to insights regarding parental beliefs underpinning their intention to allow their child to drive a quad bike, an area previously lacking in research evidence.

PRACTICAL APPLICATIONS

With child-use posing a high-risk activity for children, this study provides an important contribution that may help to inform future safety messaging targeting children's use of quad bikes.

An application of a series of theory-based educational intervention based on the health belief model on skin cancer prevention behaviors in female high school students

Background

Cancer is a leading cause of death globally and the second cause of death in developed countries. Having a rising incidence, skin cancer is the most prevalent cancer in Iran. Long-term UV radiations, particularly during childhood and adolescence, is a major cause of skin cancers. The Theory of Planned Behavior as the most precise indicator of behavior, contains motivational factors affecting behavior. This theory has been successful in predicting factors related to chronic diseases, especially cancer. As this model was successful in assessing sun-protective behaviors in previous studies, this study was designed to figure out how a theory-based educational intervention can affect the skin cancer prevention practices of Iranian female high school students.

Methods

This experimental investigation was carried out 2019-2020 using multistage cluster sampling method on 400 female high school students in Fasa, Fars, Iran. A questionnaire consisting of demographic data and a questionnaire including the components of the Theory of Planned Behavior was used to assess skin cancer preventative behaviors of both the trial and control groups of the study. An educational program based on the Theory of Planned Behavior was held for the experimental group for eight weeks regarding skin cancer preventive behaviors. The two groups completed questionnaires three months following the intervention for a second time.

Results

The study's findings revealed that prior to the intervention, there was no considerable distinction between the two study groups with regard to knowledge, attitude, subjective norms, perceived behavioral control, behavioral intentions, and skin cancer prevention behaviors; yet, three months later, the experimental group demonstrated increases in each of the mentioned variables with a significant difference. In contrast, the control group showed no discernible difference.

Conclusions

The findings of this investigation highlighted the success of the Theory of Planned Behavior for designing educational interventions aimed at encouraging skin cancer prevention in a population of female high school students.

Skin Cancer-Related Health Behavior Interventions in the Context of the Health Belief Model

The incidence of skin cancer is increasing around the world every year. Although there are many reasons for the occurrence of skin cancer, UV radiation caused by sunlight is seen as the most important factor. Therefore, reducing exposure to UV radiation should be a top priority for skin cancer prevention. In addition, different demographic features also affect the amount of UV exposure. These include age, gender and professional groups. On the other hand, people can be exposed to UV radiation voluntarily. Sunbathing or using tanning devices can be shown as examples for this. For these reasons, interventions to reduce exposure to UV radiation should focus on demographic features and the desire to tan. At the same time, it is emphasized in the literature that theory-based and systematic interventions are more effective than others. In this context, we think that the Health Belief Model, which is an effective psychosocial model for health behaviors, will be useful in developing sun protection behaviors. In this review, interventions based on the Health Belief Model in the context of tanning behavior, age, gender, and outdoor activities for the prevention of skin cancer and the improvement of sun protection behaviors have been discussed.

Sun-safe behavior and perceptions during winter sports: an Austrian study based on the Theory of Planned Behavior

As a preventable disease, skin cancer is a public health issue in Austria. Most sun-safety studies focus on people's activities in summer, but little is known about sun-protective behavior in winter. Based on the Theory of Planned Behavior (TPB), this study examines psychological perceptions among people who engage in winter sports in Austria. Following a TPB-based belief elicitation study, a consequent survey was conducted among 114 participants (51.8% female; M_age = 29.54 years) in South Austria. Intention, attitude, subjective norm, perceived behavioral control, and risk perception showed strong and significant associations with sun-safe behavior among people who engage in winter sports. The TPB framework explained a large portion of variance in sun-safe behavior (75%) and intention (73%). Gender differences have been identified in TPB-variables as well as several beliefs. Based on the utility of the TPB, our findings suggest guidelines for sun-safety in winter sports settings. Gender differences are in line with previous research, highlighting the vulnerability of men to sun damage during winter sports.

Charitable donations and the theory of planned behaviour: A systematic review and meta-analysis

Given the predominance of the theory of planned behaviour (TPB) to represent the psychological determinants underlying people's charitable decisions, the present study synthesised the model's key relationships, using meta-analysis, and tested the predictive utility of the model for charitable giving encompassing donations of blood, organs, time, and money. Given its relevance to altruistic decisions, the impact of moral norm was assessed also. A systematic literature review identified 117 samples (from 104 studies) examining donation intentions and/or prospective behaviour using TPB measures. The sample-weighted average effects for all associations were moderate-to-strong with perceived behavioural control (PBC) most strongly associated with intention (r+ = 0.562), followed by moral norm (r+ = 0.537), attitude (r+ = 0.507), and subjective norm (r+ = 0.472). Intention (r+ = 0.424) showed stronger associations with prospective behaviour than PBC (r+ = 0.301). The standard TPB predictors explained 44% of variance in intention (52% including moral norm). Intention and PBC explained 19% of variance in behaviour. A number of TPB associations showed differences when analysed for moderator variables such as length of follow-up for prospective behaviour and type of target behaviour. Stronger associations were found for the (subjective and moral) norm-intention associations among some of the different types of giving behaviours, especially for donating organs and time. Overall, the large proportion of variance explained by the TPB predictors especially for intention highlights those cognitions associated with people's plans to give, informative for charities reliant on people's propensity to give.

Applying the theory of planned behavior to investigate type 2 diabetes patients' intention to receive injection therapy

Objectives

This study applied the theory of planned behavior (TPB) in shared decision making (SDM) to understand behavioral intention in patients with type 2 diabetes with regard to injection therapy for blood sugar control.

Methods

A cross sectional study was conducted. Two hundred and fifty-four patients with type 2 diabetes participated this study and were interviewed by pharmacists in different clinics. A patient decision aid (PDA) entitled "Should I receive injection therapy regarding my type 2 diabetes condition?" was developed for this study and served as interview agenda which comprised 18 items to inquire their willingness to use injection therapy and related considerations during the SDM process.

Results

The questionnaires were revised using item analysis, exploratory factor analysis, and a criteria of Cronbach's α > 0.7. This resulted in three constructs for all questionnaires that fit the TPB model. Attitude (β = 0.432; P < 0.001) and PBC (β = 0.258; P < 0.001) were directly correlated with intention. TPB explained 35.2% of the variance in intention toward the use of injection therapy.

Conclusions

Attitude and PBC toward injection therapy positively and significantly influence the patients' intention to use injection therapy.

Practical implications

These findings identify a key association for understanding behavioral intention in patients with type 2 diabetes with regard to blood sugar control during SDM.

Drivers of young adults' voluntary compliance with COVID-19 protective measures: results from a multi-method study

BACKGROUND

With the easing of governmental COVID-19 restrictions, promoting voluntary public compliance with protective measures becomes essential for the pandemic evolution. A highly relevant target group for such health promotion are adolescents and young adults since they showed a strong decline in compliance throughout the pandemic. Building on an extended version of the Theory of Planned Behavior, this article investigates drivers of young people's intentions to engage in voluntary COVID-19 measures in phases of re-opening.

METHODS

We conducted a sequential multi-method study among 14- to 29-year-olds in Germany: (1) a semi-standardized online survey (N = 88) to examine underlying beliefs and (2) a standardized online survey (N = 979) to identify influencing factors of compliance. The pre-study addressed the respondents' perceptions about wearing a mask, social distancing, and avoiding crowded locations (open-ended questions). Responses for all protective measures were aggregated to identify general behavioral, normative, and control beliefs about COVID-19 protective measures. In order to gain generalizable insights into the factors determining voluntary compliance intentions in younger adults, we conceptualized the model constructs in the subsequent standardized online survey as formative measures based on their underlying beliefs. PLS-SEM was used to examine the effects of attitudes, subjective norms, perceived behavioral control, risk perceptions, and knowledge on young people's intentions to comply (main study). Furthermore, a multi-group analysis was conducted to investigate differences between compliers and non-compliers.

RESULTS

The pre-study revealed that young people's instrumental attitudes not only cover reasons of protection but also aspects of self-presentation (e.g., being a role model). The main study showed that besides knowledge and perceived severity of illness, instrumental attitude is the strongest predictor of intention to comply. The influence is even stronger in the group of non-compliers.

CONCLUSION

This article highlights the importance of theory-based campaign planning and provides practical guidance to health communicators on how to increase voluntary compliance with COVID-19 protective measures in adolescents and young adults. The findings demonstrate the great potential of combining the Theory of Planned Behavior with risk perception and knowledge to gain deeper insights into the feelings and thoughts of younger target groups during a health crisis.

Influence of Social and Psychosocial Factors on Summer Vacationers’ Sun Protection Behaviors, the PRISME Study, France

Objectives: Summer intermittent sun exposure is a major risk factor for melanoma. Socioeconomic position, cognitive and psychosocial factors play a role in sun protection behaviors but the underlying mechanisms are unknown. This study aimed to measure the influence of educational level on sun protection behaviors in French summer vacationers on the Mediterranean coastline, and to identify the mediating psychosocial factors in this pathway.

Methods: In summer 2019, French vacationers aged 12–55 staying in coastline campsites were asked about their holiday sun protection behaviors, their knowledge, attitudes, perceived control, and social norm relative to sun protection. A structural equation model measured the direct and indirect effects of educational level on protection behaviors via cognitive and psychosocial factors.

Results: Sun protection during vacation increased with educational level. Theoretical knowledge partially mediated this association, from 22% to 86%, particularly for intermediate educational levels.

Conclusion: Our results highlight the importance of implementing suitable sun prevention interventions for vacationers, especially those with a lower socioeconomic position. Improving theoretical knowledge around sun protection may be an important part of broader efforts to encouraging improved preventive behaviors.

The Moderating Power of Impulsivity: A Systematic Literature Review Examining the Theory of Planned Behavior

The theory of planned behavior (TPB) states that behavioral intention is the best predictor of actual behavior change. However, intention explains only a portion of the variance in behavior. Of specific interest is the question of which moderating or mediating variables can be leveraged to aid health promotion interventions utilizing the tenets of behavioral economics (delay discounting and commitment contracts) in the intention–behavior pathway. Impulsivity has been postulated to fill this role and may be applied to multiple behaviors. We aim to determine if impulsivity moderates the association between intention and actual behavior in the TPB, to discover what other variables may moderate or mediate this association, and to apply the findings to future studies in the field of behavioral economics. To this end, a systematic review was conducted using the PubMed, PsychINFO, and Embase online databases. Eligible studies in peer-reviewed journals published prior to November 2021 were selected. Thirty-three studies were included in the final review, examining physical activity, diet, preventive health, mental health, addiction, and medication adherence behaviors. Three main concepts emerged: (1) impulsivity moderates the association between intention and behavior change; (2) self-efficacy moderates the association between intention and behavior change; and (3) planning and self-efficacy contribute to moderated mediation. This review demonstrates a gap in the literature regarding the application of the TPB to the intention–behavior pathway for health behaviors. Future studies in behavioral economics may leverage the variables of impulsivity, self-efficacy, and planning to predict follow-through in this area and to develop targeted change initiatives.

Habit Facilitates Actioning Sun Protective Behavior Intentions

Skin cancer is highly burdensome, but preventable with regular engagement in sun protective behaviors. Despite modest effectiveness of sun-protective behavior promotional efforts thus far, rates of engagement in sun-protective behaviors remain low. More is needed to understand motivation for using sunscreen, wearing sun-protective clothing, and seeking shade. This study tested whether the links of intention and habit strength with behavior differed between sun-protective behaviors. It was hypothesized that sun protective behaviors would be predicted by both habit and intention and that intention-behavior associations would be weaker for people with stronger habits. Participants residing in Queensland, Australia (N = 203; 75.96% female; M age = 37.16 years, SD = 14.67) self-reported their intentions and habit strength about sun-protective behavior for the next 7 days. Participants were followed-up 7 days later to self-report their sun-protective behavior. Multilevel modeling, accounting for nesting of multiple behaviors within-person, revealed that habit moderated the intention strength - behavior association and this moderation effect did not differ as a function of which behavior was being predicted. People with strong or moderate habit strength tended to act in line with their intentions; however, for people with very weak habits (2 SD < M), there was less alignment between their intention and behavior. These findings suggest that habit plays a facilitative role in the implementation of strong sun protective behavior intentions. Interventions should consider how to encourage intention and habit to enhance sun-protective behaviors and reduce the burden of skin cancer from sun exposure.Supplemental data for this article is available online at https://doi.org/10.1080/08964289.2021.1903380 .

Examining intentions to engage in sun protective behaviors among Latino day laborers: An application of the theory of planned behavior

Background: The past two decades has revealed an unprecedented increasing incidence of skin cancer within the Latinx population. Although Latino day laborers (LDLs) are at heightened risk for developing skin cancer because of the outdoor work in which they engage, there is limited research examining their intentions to engage in sun protective behaviors (SPBs). Therefore, this study sought to assess the explanatory power of the theory of planned behavior (TPB) to identify attitudinal, subjective norms, and perceived behavioral control factors associated with intentions to engage in SPB among LDLs.

Methods: This cross-sectional retrospective study consists of a non-random convenience,community-based, sample of 137 LDLs residing in Mississippi and Illinois. Data were collected using a self-report survey centered on health practices and sun-protective behaviors.

Results: Findings revealed that five significant factors shaped intentions to engage in SPBs, including barriers to engaging in SPBs (β =.30, P<0.001), benefits of engaging in SPBs (β =.27,P<0.001), education (β=0.20, P<0.01), and acculturation (β=0.18, P≤0.05). The independent variables tested in the model accounted for 42% of the change in intentions to engage in SPBs.

Conclusion: This study demonstrates TPB’s usefulness for predicting future intentions to engage in SPBs among LDLs. Moreover, the strongest factor associated with predicting intentions to engage in SPBs among LDLs was perceived behavioral control. Thus, since SPBs are malleable, emphasis is placed on implementing interventions for this population that promote intentions and address perceived behavioral control.

Theory of Planned Behavior Analysis of Social Distancing During the COVID-19 Pandemic: Focusing on the Intention-Behavior Gap

BACKGROUND

As COVID-19 continues to spread globally, it is important to understand psychological factors that may influence compliance with social distancing.

PURPOSE

The present study examined whether Theory of Planned Behavior (TPB) constructs were associated with social distancing, with a focus on exploring moderators of the intention-behavior relationship.

METHODS

Using a longitudinal design, U.S. adults (N = 507) self-reported TPB constructs and social distancing behavior at baseline and 3 months later. Participants were from 48 U.S. States and the District of Columbia and were on average 50.39 years old (SD = 15.32, range = 18-80). The majority were Non-Hispanic White (71.6%), had a bachelor's degree or higher (55.3%), and resided in suburban areas (55.8%).

RESULTS

While positive attitudes toward social distancing increased over time (p = .002), subjective norms weakened (p < .001) and perceived behavioral control (PBC) remained stable (p = .22). Interestingly, despite an increase in intentions from baseline to follow-up (p < .001), there was a significant decrease in social distancing behavior over time (p < .001). Consistent with the TPB, baseline attitudes (p < .001), subjective norms (p < .001), and PBC (p < .001) for social distancing were all associated with baseline intentions to social distance. In turn, baseline intentions were significantly associated with social distancing behavior at follow-up (p < .001). Younger adults (p < .001) and non-White participants (p = .002) displayed a greater intention-behavior gap relative to older and White participants. In contrast, participants with more stable intentions over time displayed a stronger intention-behavior relationship (p < .001).

CONCLUSIONS

Targeting individuals' attitudes, norms, and PBC may effectively promote protective behaviors intended to mitigate the spread of COVID-19 and similar viral outbreaks. Future research should examine effective strategies for translating social distancing intentions into actions.

Preventive Behaviors During the COVID-19 Pandemic: Associations With Perceived Behavioral Control, Attitudes, and Subjective Norm

Background: The coronavirus disease 2019 (COVID-19) is a highly contagious and potentially fatal infectious disease that has swept the globe. To reduce the spread, it is important to engage in preventive behaviors recommended by health authorities, such as washing your hands, wearing a face mask, and social distancing. Aim: In the present study, we draw from the Theory of Planned Behavior (TPB) to examine the associations between perceived behavioral control, attitudes, and subjective norm and whether people engage in eight different preventive behaviors. Methods: For each of the preventive behaviors (washing hands; using hand sanitizer; not touching your face; social distancing; wearing a face mask; disinfecting surfaces; coughing in your elbow; staying home if sick), we conducted separate logistic regressions predicting whether the participants (N = 2,256; age range = 1898 years) reported engaging in the behavior from their perceived behavioral control, attitudes, and subjective norm. Results: We found that perceived behavioral control, attitudes, and subjective norm had independent significant associations with each preventive behavior. Moderation analyses revealed that for most behaviors the associations with perceived behavioral control were stronger for older adults than for younger adults. Limitation: The present study was cross-sectional; future longitudinal studies and interventions are needed to disentangle directionality. Conclusion: Our findings suggest several ways to increase adherence to health behaviors that reduce the spread of coronavirus and other infectious diseases.

The Impact of Theory in HPV Vaccination Promotion Research: A Systematic Review and Meta-Analysis

OBJECTIVE

Numerous studies examined HPV vaccination promotional strategies. However, an overview of theory use, a synthesis of strategies' effectiveness and an examination of the moderating influence of theory are absent.

DATA SOURCE

We retrieved studies from Academic Search Complete, Business Source Complete, PubMed, PsycINFO, Web of Science, CMMC, CINAHL, and MEDLINE.

STUDY INCLUSION AND EXCLUSION CRITERIA

1) peer-reviewed articles written in English, 2) experimental or quasi-experimental, 3) measure HPV vaccination-related outcomes, 4) had to contain a control condition and report statistics necessary for conversion (for meta-analysis only).

DATA EXTRACTION

70 and 30 studies were included for the systematic review and meta-analysis respectively.

DATA SYNTHESIS

Four major categories were coded: study information, theory use, type of theory, and outcomes. Two independent coders coded the sample (Cohen's Kappa ranged from .8 to 1).

RESULTS

Most of the studies were based in the U.S. (77%, k = 54) with convenient samples (80%, k = 56), targeted toward females (46%, k = 32), and around a quarter did not employ any theories (47%, k = 33). Among theory-driven studies, the most commonly used were Framing (22%, k = 19), Health Belief Model (HBM; 13%, k = 12), and Narrative (7%, k = 6). Among controlled studies, promotional strategies were significantly more effective compared to the control (r+ = .25, p < .001). Strategies guided by the information, motivation, behavioral skills model (IMB) were more effective (r+ = .75, p < .001) than studies guided by framing theory (r+ = -.23, p < .001), HBM (r+ = .01, p < .001), and other theories (r+ = .11, p < .001).

CONCLUSION

This review contributes to HPV vaccination promotion literature by offering a comprehensive overview of promotional strategies and practical suggestions for future research and practices.

A Qualitative Exploration of Parental Perceptions Regarding Children's Sun Exposure, Sun Protection, and Sunburn

Sun protection among children is of utmost importance since sunburn in early life is a major risk factor for skin cancer development. Because parents play a vital role in enhancing sun safety among children, this study explored parental perceptions concerning sun exposure, sun protection behaviors, and sunburn in children. Additionally, the context in which children experience sunburn in order to assist the development, optimization, and targeting of sun safety interventions for parents is revealed. A qualitative study design, using a semi-structured interview guide addressing several themes (e.g., sun exposure, sun protection, and sunburn experiences), was used. Data were collected in the Netherlands in the fall of 2019. Parents were recruited via purposive sampling at schools, youth services centers, and social media. Execution, transcription, and coding of the interviews was done by two researchers, using the qualitative analyzing program Nvivo (interrater reliability of d = 0.84). In total, 26 interviews were performed (n = 17 mothers, n = 17 daughters, aged between 4 and 11 years). Parental perceptions and recall of their child's lifetime sunburn were frequent, even though all parents reported using at least one sun protection measure during sun exposure situations and parents seemed often unaware of their child's sunburn. Moreover, parents reported an overreliance on sunscreen, often failing to adequately protect their children's skin. Water-related activities, a lack of shade, and misconceptions regarding UV-index were often related to sunburn. In addition, unexpected sun exposure or longer exposure duration than initially planned were reported as challenging situations. The majority of parents had positive perceptions regarding tanned skin for both themselves as for children. This study provides directions for skin cancer prevention efforts targeted at both parents and their children. Since a lack of knowledge regarding sufficient sun protection measures and sunburn occurrence in various situations was reported, educational efforts are warranted. Additionally, focusing on clothing, shade-seeking, and adequate sunscreen use is recommended to increase children's sun safety. By intervening in the physical environment as well (e.g., providing shady areas), sun protection barriers can be reduced. Lastly, the general positive attitude toward tanned skin evident in this study is certainly worthy of attention in future interventions.

A theory of planned behavior-enhanced intervention to promote health literacy and self-care behaviors of type 2 diabetic patients

Background

Improved health literacy and awareness could help type 2 diabetic patients to control the disease complications.

Objective

The current study aimed to evaluate the impact of theory-based educational intervention on health literacy and self-care behaviors of type 2 diabetic patients in Tonekabon city.

Methods

This randomized controlled trial study was conducted at health care centers in Tonekabon city, Iran, from April 5, 2017, to October 22, 2018. Using multistage random sampling, 166 patients with type 2 diabetes divided into two groups: theory-based intervention (n = 83) and custom education (n = 83). The data collection tools consisted of demographic information, Theory of Planned Behavior (TPB) measures, health literacy for Iranian adults (HELIA) and summary of diabetes self-care activities (SDSCA). The five 45-minute group training sessions based on the baseline assessment and model constructs along with the targeted pamphlet and m-health strategy were designed for the experimental group. Data were analyzed using chi-square, independent and paired t-test and Analysis of covariance (ANCOVA).

Results

After controlling for pre-test effect, there was a significant difference between the two groups in terms of mean scores of attitudes, subjective norms, perceived behavior control and intention in post-test (P < 0.001). Also, after controlling for the pre-test effect, the results showed a significant difference in the self-care domain in the post-test (P < 0.001). Finally, after controlling for the pre-test variable effect, covariance analysis reflects significant difference in total health literacy score and its dimension at posttest (P < 0.001).

Conclusions

Applying TPB based education is suggested to maintain and improve self-care behaviors and health literacy in type 2 diabetic patients and other chronic diseases.

Why? What? How? Using an Intervention Mapping approach to develop a personalised intervention to improve adherence to photoprotection in patients with Xeroderma Pigmentosum

Background: Intervention Mapping (IM) is a systematic approach for developing theory-based interventions across a variety of contexts and settings. This paper describes the development of a complex intervention designed to reduce the dose of ultraviolet radiation (UVR) reaching the face of adults with Xeroderma Pigmentosum (XP), by improving photoprotection. XP is a genetic condition that without extreme UVR photoprotection, leads to high risk of developing skin cancer.

Methods: The IM protocol of 6 steps was applied, involving comprehensive mixed-methods formative research. Key stakeholders (XP clinical staff and Patient and Public Involvement Panel), were instrumental at every step. Behaviour change methods were informed by the IM taxonomy, therapeutic approaches (e.g. ACT, CBT) and coded according to the taxonomy of behaviour change techniques (version 1).

Results: We designed a personalised modular intervention to target psychosocial determinants of photoprotective activities that influence the amount of UVR reaching the face. Content was developed to target determinants of motivation to protect and factors preventing the enactment of behaviours. Participants received personalised content addressing determinants/barriers most relevant to them, as well as core ‘behaviour-change’ material, considered important for all (e.g. SMART goals). Core and personalised content was delivered via 7 one-to-one sessions with a trained facilitator using a manual and purpose designed materials: Magazine; text messages; sunscreen application video; goal-setting tools (e.g. UVR dial and face protection guide); activity sheets. Novel features included use of ACT-based values to enhance intrinsic motivation, targeting of emotional barriers to photoprotection, addressing appearance concerns and facilitating habit formation.

Conclusion: IM was an effective approach for complex intervention design. The structure (e.g. use of matrices) tethered the intervention tightly to theory and evidence-based approaches. The significant amount of time required needs to be considered and may hinder translation of IM into clinical and non-academic settings.

A discrete emotion with discrete effects: effects of anger on depth of information processing

There is relative paucity in the comprehensive study of anger and information processing. Emotions can impact the depth of information processing and anger is a powerful high-certainty emotion. Yet, the magnitude of the effects of anger on the depth of information processing has not been summarized. This scholarship performs a meta-analytic synthesis to report the effect of anger on the depth of information processing as compared to one of the four contrast groups: neutral control, sadness, happiness, and fear. A systematic search identified 26 articles with a total of 39 unique studies and 113 effect sizes. The evaluation revealed that anger did not have a significant effect on depth of information processing for any of the emotional comparison groups. Furthermore, the presence of publication bias was only found for one analysis. These complex results indicate that anger is an exceedingly nuanced emotion. The implications of the study and future scholarship are discussed.

Vaccine hesitancy and perceived behavioral control: A meta-analysis

OBJECTIVES

The World Health Organization recognizes that vaccine hesitancy is a top threat to the public health. To address vaccine hesitancy, much research guided by behavioral theories attempted to examine factors that contribute to vaccination intentions. The current study synthesizes the summary effects of attitude, norms and perceived behavioral control on vaccination intentions.

METHODS

We searched five databases with relevant keyword combinations without time constraints. A sample of 5149 participants was included for final analysis.

RESULTS

Attitude, norms and perceived behavioral control were significant predictors of vaccination intentions with attitude being the strongest. Type of recipient significantly moderated the PBC-intention relationship, while norm-intention correlations were significantly moderated by type of norm measures. Formative belief elicitation research had no moderating influences.

CONCLUSION

Our findings demonstrate clear support for the utility of theory of planned behavior in explaining vaccine hesitancy. Research is needed on how interventions can change these constructs to motivate vaccination.

Predictors of Fall Protective Behaviors Among Iranian Community-Dwelling Older Adults: An Application of the Protection Motivation Theory

Purpose

The protection motivation theory (PMT) is a common framework understanding the use of protective behaviors. The aim of this study was to assess the predictors of fall protective behaviors among community-dwelling older adults, Iran.

Methods

The cross-sectional study was conducted in Qom, Iran, from May to October 2018. Three hundred older people were selected from retirement centers via stratified sampling method. Data were collected by a questionnaire containing items on socio-demographic information, Falls Behavioral (FaB) Scale, and PMT constructs scale. Data analysis was performed using descriptive statistics and structural equation modeling.

Results

The mean (SD) age of the participants was 64.6 (5.5) and the majority were male (77.7%). Level of perceived fall threat was lower than perceived efficacy of fall protective behaviors. There was a significant relationship between protection motivation and fall protective behaviors (β= 0.515, t-value= 13.650). Coping appraisals (β= 0.409, t-value= 7.352) and fear (β= 0.194, t-value= 2.462) were associated with motivation. The model explained approximately 27% of the variance in fall protective behaviors. The goodness of fit index of 0.48 indicating the model good fit.

Conclusion

The results indicated that protection motivation, coping appraisals and reasonable fear are considered as the strongest predictors of fall protective behaviors among older people. The results can help health care providers to develop appropriate interventions to fall prevention among older people.

Intention to seek esthetic dental treatment and the theory of planned behavior in Saudi dental students and the general population

STATEMENT OF PROBLEM

Tooth shade is of major concern for patients when receiving esthetic dental treatment. Understanding the motivating factors that drive patients' intentions to seek esthetic dental treatment helps in planning services.

PURPOSE

The purpose of this cross-sectional study was to assess the relationship between the intention to seek esthetic dental treatment and the theory of planned behavior (TPB), including attitude regarding tooth shade, perceived ability to seek treatment, and subjective norms of how others perceive tooth shade.

MATERIAL AND METHODS

The study included first-year dental students and clinic patients in a Saudi dental school (N=283). The shade of the maxillary central incisors was clinically assessed by using the Crystaleye spectrophotometer, and the L*, a*, and b* values were recorded. Participants were asked to select a shade that represented how others perceived their shades by using the VITA classical shade guide and to respond to a self-administered questionnaire based on a TPB assessing attitude regarding shade (9 items), perceived ability to seek esthetic treatment (7 items) on a 5-point Likert scale, and intention to seek esthetic treatment. The internal consistency of the TPB items was assessed, and scores were calculated. Logistic regression analysis was used to assess factors associated with the intention to seek esthetic treatment, including the TPB components controlled for L*, a*, and b* values in addition to age (α=.05).

RESULTS

Of all participants, 49.5% indicated that they intended to seek esthetic treatment. The most commonly perceived shades were B1, B2, A2, A1, and A3 (76%). In adjusted regression, the intention to seek esthetic treatment was significantly associated with a more positive attitude regarding shade (OR=2.31, 95% CI=1.54, 3.47) and a lower b* value (OR=0.74, 95% CI=0.59, 0.93), but not with shade coordinates (P values of L*=.94, a*=.64, and b*=.13).

CONCLUSIONS

Intention to seek esthetic dental treatment was associated with a positive attitude regarding the importance of shade and a greater perception of having a less yellow shade, regardless of the shade.

From Values to Behavior: Proposition of an Integrating Model

Human values are at the heart of our lives. We all hold a set of values that influence our actions. The protection of the natural environment is no exception to this rule. That is why the study of human values is key to reaching the imperative of sustainability. In this conceptual paper, we aim to (1) integrate the key theories and models explaining the influence of human values on behavior and to (2) identify factors that might have previously been overlooked. Drawing from a range of disciplines, this article proposes an integrated model mapping the influence of human values on behavior. It also puts forward the concept of consequences as an emerging factor that could play an important role in this relationship. Recommendations are to extend the research to an empirical investigation of the model and to develop the definition of the concept of consequences and the role they play in the influence of values on consumer behavior.

Psychological correlates of adherence to photoprotection in a rare disease: International survey of people with Xeroderma Pigmentosum

OBJECTIVES

Xeroderma pigmentosum (XP) is an extremely rare genetic disorder (approximately 100 known cases in the United Kingdom), where DNA damage caused by ultraviolet radiation in daylight cannot be repaired. Adherence to photoprotection is essential to prevent skin cancer. We investigated psychological correlates of photoprotection in the XP population of Western Europe and the United States.

DESIGN

Cross-sectional survey of adults with XP and caregivers of patients <16 years and those with cognitive impairment in the United Kingdom, Germany, the United States, and France (n = 156).

METHODS

Photoprotection activities to protect the face and body when outdoors; avoidance of going outside during daylight hours; intention; self-efficacy; and social support were assessed using measures developed for this study. Participants answered questions about their illness representations of XP (BIPQ); beliefs about photoprotection (BMQ); automaticity (i.e., without conscious effort) (SRBAI); clinical and demographic characteristics. Ordinal logistic regressions determined factors associated with photoprotection.

RESULTS

One third did not achieve optimal face photoprotection. After controlling for demographic and clinical factors, modifiable correlates of higher photoprotection included greater perceived control of XP, stronger beliefs in necessity and effectiveness of photoprotection, and higher intention. Avoidance of going outside was associated with greater photoprotection concerns, more serious illness consequences, and higher XP-related distress. Greater automaticity and higher self-efficacy were associated with better protection across all outcomes.

CONCLUSIONS

Approximately half of all known cases across three European countries participated. Identified modifiable predictors of photoprotection may be targeted by interventions to reduce the incidence of skin cancers in the immediate future, when a treatment breakthrough is unlikely. Statement of contribution What is already known on this subject? Adherence to photoprotection in other populations at elevated risk from skin cancer is poor; however, the level in XP is unknown. Research across chronic conditions shows that adherence to treatment and lifestyle recommendations are influenced by illness perceptions, self-efficacy, and treatment beliefs. Studies on photoprotection conducted with the general population have found that perceived risk, perceptions of ultraviolet radiation (UVR) protection, self-efficacy for the behaviour, and automaticity (behaviours that are enacted with little conscious awareness) are related to better photoprotection. What does this study add? This is the first international survey to examine adherence and its correlates in people with XP (an under-researched group at very high risk of fatal skin cancer). Adherence varies and at least one third have potential for improvement. Perceptions about XP, photoprotection beliefs, self-efficacy, intention, and automaticity were associated with photoprotection of the face and body when outdoors. Negative emotional representations of XP were associated with avoidance of going outside during daylight hours.

Effectiveness of a theory-based sun-safe randomised behavioural change trial among Australian adolescents

OBJECTIVE

Sun safety is crucial for preventing skin cancer. This study evaluated a school-based intervention based on the theory of planned behaviour (TPB), which aimed to encourage sun-protective behaviour among adolescents.

METHODS

Secondary school students (N = 382; 61.1% female; M_age  = 13.73 y) in Queensland, Australia, participated in the study. Schools were randomly allocated to an intervention or control group. The intervention focussed on fostering positive attitudes, increasing perceptions of normative support, and strengthening control perceptions. Participants completed questionnaires assessing the TPB variables and sun-protective behaviour (weekday and weekend) 1 week before intervention (time 1), 1 week after intervention (time 2), and 4 weeks after intervention (time 3).

RESULTS

With baseline between-group differences in TPB variables matched, repeated-measures multivariate analysis of variance was used to evaluate the Time × Condition effects across time. Multigroup comparisons using path models traced the intervariable changes. From times 1 to 3, a significant improvement in weekend sun-protective behaviour was identified in the intervention group (but not the control group), whereas cognitions showed no significant changes across time for either conditions. Multigroup comparisons on path coefficients between the intervention and control group participants indicated that the intervention group members formed stronger positive associations between perceived behavioural control and intention at time 2 and between perceived control and behaviour at time 3.

CONCLUSION

The significant behavioural change on weekends highlights the value of targeting control perceptions, which may encourage adolescents' sun-protective behaviour. Further studies are needed to understand the absence of significant changes in weekday sun-safe behaviour among this at-risk cohort.

A theory of planned behavior-based intervention to improve quality of life in patients with knee/hip osteoarthritis: a randomized controlled trial

Osteoarthritis (OA) is a common chronic disorder among elderly people that affects joints such as the knee and hip in particular. The objective of the current study was to examine the efficacy of an intervention based on a theory of planned behavior (TPB) in improving health-related quality of life in middle-age and older adults with this condition. One hundred twenty patients diagnosed with knee/hip OA were recruited from a general hospital. Measures administered at baseline were the SF-12, EuroQol (EQ-5D), Osteoarthritis Knee and Hip Quality of Life (OAKHQoL), and TPB questionnaire. Also assessed were body mass index (BMI), Kellgren-Lawrence Scale, six-minute walk test (SMWT), muscle strength, range of motion (ROM), and joint tenderness and swelling. Participants were randomly assigned to either the intervention (n = 60) or the control group (n = 60). The intervention group received an educational program based on TPB that was administered over 1 month. The control group did not receive this treatment. Three months after the intervention, both groups were reevaluated and comparisons made. Compared to the no-treatment control group, those in the intervention group scored higher on HRQoL, both general and specific, at 3-month follow-up (p < 0.01). The only exception was the vitality domain. Significant differences were also found on the TPB questionnaire, the SMWT, and muscle strength in the expected direction (p < 0.05). While those in the intervention group improved significantly on all clinical measures from pre-test to post-test, those in the control group showed improvement only on BMI and joint tenderness. This TPB-based intervention was found to be efficacious in improving HRQoL and several clinical parameters in patients with knee/hip OA. Studies are needed to examine the effectiveness of this intervention in patients with other chronic medical conditions.

A state of the science on influential factors related to sun protective behaviors to prevent skin cancer in adults

Skin cancer rates have risen over the past decades, making it imperative that adults understand the need for protection from sun exposure. Though some risk factors have been identified as predictive for skin cancers, there is a lack of synthesized information about factors that influence adults in their decisions to engage in sun protective behaviors. The purpose of this paper is to present the current state of the science on influential factors for sun protective behaviors in the general adult population. A rigorous literature search inclusive of a generally White, Caucasian, and non-Hispanic adult population was performed, and screening yielded 18 quantitative studies for inclusion in this review. Findings indicate that modifiable and non-modifiable factors are interdependent and play a role in sun protective behaviors. This study resulted in a proposed conceptual model for affecting behavioral change in sun protection including the following factors: personal characteristics, cognitive factors, family dynamics, and social/peer group influences. These factors are introduced to propose tailored nursing interventions that would change current sun protective behavior practice. Key implications for nursing research and practice focus on feasibility of annual skin cancer screening facilitated by advanced practice nurses, incorporating the identified influential factors to reduce skin cancer risk and unnecessary sun exposure.

Research on Skin Cancer-Related Behaviors and Outcomes in the NIH Grant Portfolio, 2000-2014: Skin Cancer Intervention Across the Cancer Control Continuum (SCI-3C)

Importance

The Surgeon General's Call to Action to Prevent Skin Cancer broadly identified research gaps, but specific objectives are needed to further behavioral intervention research.

Objective

To review National Institute of Health (NIH) grants targeting skin cancer-related behaviors and relevant outcomes.

Design, Setting, and Participants

A portfolio analysis of the title, abstract, specific aims, and research plans of identified grant applications from 2000 to 2014 targeting skin cancer-related behaviors or testing behavioral intervention effects on cancer-relevant outcomes along the cancer continuum.

Main Outcomes and Measures

Funding trends were compared along the cancer control continuum, with respect to investigator demographics and use of theory, technology, policy, and changes to environmental surroundings (built environment).

Results

A total of 112 submitted applications met inclusion criteria; of these, 40 (35.7%) were funded, and 31 of the 40 were interventions. Comparing the 40 funded grants with the 72 unfunded grants, the overall success rates did not differ significantly between male (33.3%) and female (37.3%) investigators, nor did the frequency of R01 awards (36.7% and 28.1%, respectively). Among intervention awards, most (24 of 31) addressed prevention. Fewer awards targeted detection alone or in conjunction with prevention (3) or cancer survivorship (4), and no grant addressed emotional sequelae or adherence behavior related to diagnosis or treatment. Fewer than half of funded grants aimed for clinically related targets (eg, sunburn reduction). Use of theory and technology occurred in more than 75% of grants. However, the full capability of proposed technology was infrequently used, and rarely did constructs of the proposed behavior change theory clearly and comprehensively drive the intervention approach. Policy or environmental manipulation was present in all dissemination grants but was rarely used elsewhere, and 19.4% included policy implementation and 25.8% proposed changes in built environment.

Conclusions and Relevance

Grant success rate in skin cancer-related behavioral science compares favorably to the overall NIH grant success rate (approximately 18%), and the success rate of male and female investigators was not statistically different. However, gaps exist in behavioral research addressing all points of the skin cancer control continuum, measuring interventions that hit clinically related targets, and leveraging technology, theory, and environmental manipulation to optimize intervention approach.