Mental health of healthcare workers during the first year of the COVID-19 pandemic in the Netherlands: a longitudinal study

Purpose

In March 2020, the WHO declared COVID-19 a pandemic. Previous virus outbreaks, such as the SARS outbreak in 2003, appeared to have a great impact on the mental health of healthcare workers. The aim of this study is to examine to what extent mental health of healthcare workers differed from non-healthcare workers during the first year of the COVID-19 pandemic.

Methods

We used data from a large-scale longitudinal online survey conducted by the Corona Behavioral Unit in the Netherlands. Eleven measurement rounds were analyzed, from April 2020 to March 2021 (N = 16,615; number of observations = 64,206). Mental health, as measured by the 5-item Mental Health Inventory, was compared between healthcare workers and non-healthcare workers over time, by performing linear GEE-analyses.

Results

Mental health scores were higher among healthcare workers compared to non-healthcare workers during the first year of the pandemic (1.29 on a 0-100 scale, 95%-CI = 0.75-1.84). During peak periods of the pandemic, with over 100 hospital admissions or over 25 ICU admissions per day and subsequently more restrictive measures, mental health scores were observed to be lower in both healthcare workers and non-healthcare workers.

Conclusion

During the first year of the COVID-19 pandemic, we observed no relevant difference in mental health between healthcare workers and non-healthcare workers in the Netherlands. To be better prepared for another pandemic, future research should investigate which factors hinder and which factors support healthcare workers to maintain a good mental health.

Mental models of the protein shift: Exploring consumers' perceptions of the transition

The protein transition is one of today's major societal challenges to mitigate climate change. To support lasting consumer engagement, it has been suggested to look into consumers' understanding of the protein transition to identify barriers that go beyond the practical issues of changing one's diet. The current study explored consumers' mental models of how the transition unfolds to examine which factors consumers perceive as important drivers of the transition. With a fixed set of factors and actors identified with a questionnaire, Dutch consumers (N = 214) mapped their mental models. The content and structure of the mental models were analyzed with a focus on how consumers perceive their own role. Animal well-being and environmental concerns were most often included as important drivers. The findings showed a lack of consensus about which actor(s) drive the transition (i.e., none of the actors were included by a majority of the participants). This diffusion of responsibility may be a barrier for consumers to act. Moreover, the relative simplicity of the observed mental models suggests that consumers do not yet employ systems thinking. A systems thinking mindset may help consumers understand how the system behind the transition works and how their individual contributions matter. Two avenues to encourage consumer engagement were identified: 1) emphasizing the responsibility of different actors and what consumers can contribute, and 2) encouraging a systems thinking mindset.

Understanding public support for COVID-19 pandemic mitigation measures over time: Does it wear out?

Background

COVID-19 mitigation measures intend to protect public health, but their adverse psychological, social, and economic effects weaken public support. Less favorable trade-offs may especially weaken support for more restrictive measures. Support for mitigation measures may also differ between population subgroups who experience different benefits and costs, and decrease over time, a phenomenon termed "pandemic fatigue."

Methods

We examined self-reported support for COVID-19 mitigation measures in the Netherlands over 12 consecutives waves of data collection between April 2020 and May 2021 in an open population cohort study. Participants were recruited through community panels of the 25 regional public health services, and through links to the online surveys advertised on social media. The 54,010 unique participants in the cohort study on average participated in 4 waves of data collection. Most participants were female (65%), middle-aged [57% (40-69 years)], highly educated (57%), not living alone (84%), residing in an urban area (60%), and born in the Netherlands (95%).

Results

COVID-19 mitigation measures implemented in the Netherlands remained generally well-supported over time [all scores >3 on 5-point scale ranging 1 (low)-5 (high)]. During the whole period studied, support was highest for personal hygiene measures, quarantine and wearing face masks, high but somewhat lower for not shaking hands, testing and self-isolation, and restricting social contacts, and lowest for limiting visitors at home, and not traveling abroad. Women and higher educated people were more supportive of some mitigation measures than men and lower educated people. Older people were more supportive of more restrictive measures than younger people, and support for more socially restrictive measures decreased most over time in higher educated people or in younger people.

Conclusions

This study found no support for pandemic fatigue in terms of a gradual decline in support for all mitigation measures in the first year of the pandemic. Rather, findings suggest that support for mitigation measures reflects a balancing of benefits and cost, which may change over time, and differ between measures and population subgroups.

Mental health of healthcare workers during the first year of the COVID-19 pandemic in the Netherlands

Purpose

In March 2020, the WHO declared COVID-19 a pandemic. Previous virus outbreaks, such as the SARS outbreak in 2003, appeared to have a great impact on the mental health of healthcare workers. The aim of this paper is to study to what extent mental health of healthcare workers differed from non-healthcare workers during the first year of the COVID-19 pandemic.

Methods

We used data from a large-scale longitudinal online survey conducted by the Corona Behavioral Unit in the Netherlands. Eleven measurement rounds were analyzed, from April 2020 to March 2021 (N = 16,657; number of observations=64,316). Mental health, as measured by the 5-item Mental Health Inventory, was compared between healthcare workers and non-healthcare workers over time, by performing linear GEE-analyses.

Results

Mental health scores were higher among healthcare workers compared to non-healthcare workers during the first year of the pandemic (1.29 on a 0-100 scale; 95%-CI=0.75-1.84). During peak periods of the pandemic, with over 100 hospital admissions or over 25 ICU admissions per day and subsequently more restrictive measures, mental health scores were observed to be lower in both healthcare workers and non-healthcare workers.

Conclusions

During the first year of the COVID-19 pandemic, we observed no relevant difference in mental health between healthcare workers and non-healthcare workers in the Netherlands. To be better prepared for another pandemic, future research should investigate which factors hinder and which factors support healthcare workers to maintain a good mental health.

Key messages

• During the first year of the COVID-19 pandemic, we observed no relevant difference in mental health between healthcare workers and non-healthcare workers in the Netherlands.

• During peak periods of the pandemic, mental health was observed to be poorer in both healthcare workers and non-healthcare workers.

How do people understand the spread of COVID-19 infections? Mapping mental models of factors contributing to the pandemic

OBJECTIVE

To describe the mental models people hold about the COVID-19 pandemic, with a focus on how they understand the factors that drive the spread of COVID-19 and what kind of beliefs are associated with these models.

DESIGN

In a series of three studies (total N = 461), we asked participants to identify factors that are relevant for COVID-19 proliferation (Study 1a), rate the importance of factors (Study 1 b), and create a mental model of how these factors relate to virus spread by employing a validated tool for mental model elicitation (Study 2). Main outcome measures: inclusion and centrality of factors in mental models of COVID-19 infection spread.

RESULTS

Mitigation measures issued by government, adherence to measures, and virus characteristics were most strongly represented in participants' mental models. Participants who perceived measures as appropriate or who experienced more control and more worry over the spread of the virus created more complex models compared to participants who were less satisfied with measures or who felt lower control and less worry.

CONCLUSION

These findings suggest that people are able to create sensible mental models of virus transmission but may appreciate transparent communication to comprehend the bigger picture behind the governmental mitigation strategy.

Understanding a national increase in COVID-19 vaccination intention, the Netherlands, November 2020-March 2021

The intention to get the COVID-19 vaccine increased from 48% (November 2020) to 75% (March 2021) as national campaigning in the Netherlands commenced. Using a mixed method approach we identified six vaccination beliefs and two contextual factors informing this increase. Analysis of a national survey confirmed that shifting intentions were a function of shifting beliefs: people with stronger intention to vaccinate were most motivated by protecting others and reopening society; those reluctant were most concerned about side effects.

Discussing overweight in dogs during a regular consultation in general practice in the Netherlands

In previous studies, it has been demonstrated that, similar to general practitioners, veterinarians find it difficult to discuss overweight in dogs. This study aimed to provide insight in the barriers and motivators for veterinarians to discuss overweight in dogs and to compare the results with findings from human medicine. Sub‐hypotheses were postulated based on existing literature to investigate if lack of time, fear of offending clients, or lack of skills were potential barriers, and if feeling responsible and feeling compassion were potential motivators for veterinarians to discuss overweight in dogs. To this end, an online survey (n = 59) was conducted. Furthermore, 15 small animal clinicians working in general practice were interviewed by semi‐structured face‐to‐face interviews. Results from the online survey indicated that veterinarians find it sometimes difficult to discuss overweight in dogs. Veterinarians who responded to the online survey did not experience strong barriers but did make use of motivators (e.g. feeling responsible and feeling compassion) when discussing overweight in dogs. Interestingly, results from the semi‐structured face‐to‐face interviews showed that the responding veterinarians did experience strong barriers, as well as motivators, when discussing overweight in dogs with their clients. The most prominent barrier was customer dissatisfaction, whereas lack of time and lack of skills were also experienced. The most prominent motivator was feeling responsible for animal health and preventive veterinary medicine. These findings were strikingly similar to previous research on discussing childhood overweight by general practitioners. To improve treatment and prevention of overweight in dogs, veterinarians need more communication skills and should be more aware of the motivators that drive their self‐motivation. Improving awareness on overweight and its comorbidities should be a One Health issue.

Evaluating the Potential Benefit of a Combined Weight Loss Program in Dogs and Their Owners

Introduction: Little has been published on the psychological bond between the owner and the pet, and how this might influence shared habits that could lead to overweight and obesity. Another factor that could improve the effectiveness of a weight loss plan, is that the owner would see the dog as a weight loss partner and therefore this could increase the motivation to follow the assigned diet and exercise guidelines.

Objective: The aim of this research was to evaluate the potential mutual effects of weight loss programs for both dogs and dog owners.

Methods: Two studies were conducted: In the human-centered trial, 60 dog owners were enrolled, who signed up to receive dietary and exercise recommendations to lose weight themselves during an 8 week period, from which 29 were randomly assigned to also get recommendations for their dog. For the dog-centered trial, we selected 13 dog owners that wanted their dog to lose weight during a 6 week period, from which 7 were randomly assigned to also get recommendations for themselves. The average weight loss over the time period was recorded. A questionnaire was used to evaluate diet and exercise habits, as well as information about the relationship between the dog and owner.

Results: The average human weight loss was 2.6% in the owner+dog group (n = 29) and 2.3% in the owner only group (n = 31; p > 0.05). Forty percent (24/60) of the dogs in the human-centered trial were overweight. The overweight dogs in the owner+dog group (n = 12/29) lost 3.7% of their body weight, compared to 1.2% in the overweight dogs from the owner only group (n = 12/31; p > 0.05). In the dog-centered trial, the 7 dogs in the dog+owner group lost 8.0% of their body weight, vs. 8.3% in the six dogs in the dog only group (p > 0.05). The owners in the dog+owner group lost 2.5% of their body weight, compared to 0.5% in the dog only group (p > 0.05). In both trials owners' perceived responsibility for both their own and their dogs' weight significantly increased. In addition, habit strength regarding unhealthy feeding and exercise behaviors in relation to the dogs decreased, and self-efficacy in relation to providing the dog with healthy food and exercise increased.

Conclusion: Active weight loss in either dog owner or dog, seemed to lead to passive weight loss in the other, especially when some tools or guidelines were provided. These findings support mutual benefits of weight loss programs for dogs and dog owners, and support future weight loss programs to be a One Health approach.

When in Doubt, Follow the Crowd? Responsiveness to Social Proof Nudges in the Absence of Clear Preferences

Nudges have gained popularity as a behavioral change tool that aims to facilitate the selection of the sensible choice option by altering the way choice options are presented. Although nudges are designed to facilitate these choices without interfering with people’s prior preferences, both the relation between individuals’ prior preferences and nudge effectiveness, as well as the notion that nudges ‘facilitate’ decision-making have received little empirical scrutiny. Two studies examine the hypothesis that a social proof nudge is particularly effective when people have no clear prior preference, either because people are indifferent (in a color-categorization task; Study 1, N = 255) or because people experience a choice conflict (making shopping decisions about meat products; Study 2, N = 97). Both studies employed a social proof nudge to steer participants’ choices. The potential facilitating effect of the nudge was tested using a mouse-tracker paradigm that implicitly assessed experienced uncertainty during decision-making. Results showed that the nudge was effective in steering participants’ decisions; the facilitation effect (i.e., reduced uncertainty regarding the decision) was only observed for conflicting preferences, but not under indifference. A better understanding of when and how nudges can influence individuals’ behavior may help in deciding whether nudges are an appropriate policy tool for changing particular undesirable behavior.

The (bitter) sweet taste of nudge effectiveness: The role of habits in a portion size nudge, a proof of concept study

Seemingly insignificant daily practices, such as sugar usage in tea, can have a great accumulated impact on societal issues, such as obesity. That is why these behaviours are often the target of nudge interventions. However, when these behaviours are performed frequently they may turn into habits that are difficult to change. The aim of the current study was to investigate whether a portion size nudge has the potential to work in accordance with (instead of against) existing habits. Specifically, it was tested whether a portion size nudge would be more effective in reducing the amount of sugar added to tea, when people have a strong habit of adding a fixed amount of teaspoons of sugar to a cup of tea. The study (N = 123) had a mixed factorial design with teaspoon size (reduced size vs. control) as a within-subject factor, and habit disruption context condition (hot tea vs. cold tea) as a between-subjects factor. A paired t-test indicated that this nudge reduced sugar intake on average by 27% within subjects. When the context allowed for automatic enactment of the habit, the effectiveness of this nudge was moderated by habit strength. Surprisingly, the nudge effect was actually less pronounced when people had a strong habit. Implications for effective nudge interventions are discussed.

“Don’t Mind If I Do”: The Role of Behavioral Resistance in Self-Control’s Effects on Behavior

High self-control is known to be related to the performance of behaviors that have long-term benefits, such as healthy eating. Recently, studies have suggested that people with high self-control may perform goal-directed behaviors not by exerting effortful control but rather by employing smart, effortless strategies. The current paper investigates the crucial role of behavioral resistance in the relation between self-control and goal-directed behaviors: we propose that people with high self-control feel less resistance toward goal-directed behaviors compared to people with low self-control, and that this is associated with the increased frequency of performing these behaviors. Three cross-sectional studies were conducted in which participants reported on their level of self-control, behavioral resistance toward behaviors in the sustainability, healthy eating, exercise, and study/work domains, and their behavior in those domains. Findings consistently show that the relation between self-control and various behaviors is indeed partially mediated by behavioral resistance, although the study designs preclude establishing causal relations. It is implied that lower resistance makes it easier for people with higher self-control to perform the goal-directed behaviors, without requiring much effort. This notion yields an interesting, novel perspective on how people with high self-control manage to function so well.

Discussing overweight in children during a regular consultation in general practice: a qualitative study

Background

Overweight in children is a rising problem leading to serious consequences later in life. The Dutch guideline ‘Obesity’ for general practitioners recommends discussing obesity in children regardless of the reason of consultation and provides diagnostic and therapeutic tools. However, limited literature indicates that general practitioners experience barriers to discuss this topic. The aim of this study was to determine current perceived barriers of general practitioners in discussing overweight during a regular consultation in children aged 4 to 12 years and to what extent they discuss the topic. Furthermore, we attempt to get more insight in the specific needs and ideas for improvement among GPs.

Methods

A semi-structured in-depth interview study was conducted. Dutch general practitioners with a broad range of demographic characteristics were invited to participate. The transcripts were analysed using a modified version of the constant comparative method. Using this method, we identified perceived barriers of general practitioners.

Results

Ten general practitioners were included in the study. Four major themes were identified in the interviews: absence of physical or mental complaints related to overweight, internal barriers of the general practitioners, the child’s family background and logistics. Major barriers appeared to be a low consultation rate of these children, the sensitivity of the topic (e.g. fear for children’s or parents’ reactions and/or disturbance of the relation, influence on the self-esteem of the child, resistance in the parents), the absence of a long-standing relation between general practitioner and child or parent, the background of the child and lack of time or prioritizing.

Conclusion

Dutch general practitioners indicate to experience barriers and need tools for how to discuss children’s overweight during regular consultations within the limited time available. The low consultation rate among children aged 4 to 12 years due to lack of physical complaints is mentioned as a new and important barrier. Therefore, the prior focus might be raising awareness among parents concerning overweight in children aged 4 to 12 years and, thereby, stressing the potential supporting role of primary care professionals in tackling the overweight of their child.

Cueing healthier alternatives for take-away: a field experiment on the effects of (disclosing) three nudges on food choices

Background

The current field experiment demonstrates the effectiveness of nudging to promote healthy food choices.

Methods

Three types of nudges were implemented at a take-away food vendor: 1) an accessibility nudge that placed fruits at the front counter; 2) a salience nudge that presented healthy bread rolls to be more visually attractive; and 3) a social proof nudge that conveyed yoghurt as a popular choice. We additionally assessed whether nudging effects would remain robust when a disclosure message was included. The field experiment was conducted over a seven-week period. The measured outcome was the sales of the targeted healthy food products.

Results

The accessibility nudge significantly increased the sales of the fresh fruits. The impact of the salience nudge was limited presumably due to existing preferences or habits that typically facilitate bread purchases. As the sales of the yoghurt shakes remained consistently low over the seven-week period the impact of the social proof nudge remained unexamined. Critically, disclosing the purpose of the nudges did not interfere with effects.

Conclusions

Current findings suggest nudging as an effective strategy for healthy food promotion, and offer implications for topical debate regarding the ethics of nudges.

I'm still standing: A longitudinal study on the effect of a default nudge

OBJECTIVE

This study assessed the effect of a default nudge to reduce sedentary behaviour at work over time.

DESIGN AND MAIN OUTCOME MEASURES

A field study was conducted at a governmental organisation. In the present study, the default setting of sit-stand desks (SSDs) was changed from sitting to standing height during a two-week intervention. Stand-up working rates were calculated based on observations that were done prior to, during, two weeks after and two months after the intervention. Additionally, a pre-measure survey (n = 606) and post-measure survey (n = 354) were completed. Intention and social norms concerning stand-up working were compared for the 183 employees who completed both pre- and post-assessments (45.4% female, M_age = 44.21).

RESULTS

Stand-up working rates raised from 1.82% in the baseline to 13.13% during the intervention. After the nudge was removed the percentage was 10.01% after two weeks and 7.78% after two months. A multilevel analysis indicated a significant increase in both intention and social norms after the nudge intervention.

CONCLUSIONS

This study shows that a default nudge can increase stand-up working rates in offices with SSDs at least until two months after the nudge intervention.

The Hunger Games: Using hunger to promote healthy choices in self-control conflicts

The majority of existing research and conventional wisdom would advise against shopping on an empty stomach as hunger is assumed to encourage impulsive choices that typically lead to self-control failure (i.e., favouring short-term gratifications at the expense of long-term goals). Nonetheless, through two studies the current research aims to demonstrate that hungry consumers would not always be disadvantaged when encountering a self-control conflict involving a trade-off choice between a healthy vs. a more palatable but unhealthy choice. Particularly we posit that the choice outcome of the self-control conflict is dependent on contextual cues, such that hungry consumers with the tendency to make fast decisions could benefit from following a social proof heuristic promoting the healthy options. In Study 1, we indeed observed participants' self-reported hunger to be negatively associated with state self-control, but as most participants generally experienced low levels of hunger we did not observe apparent effects of hunger on food choice (DV), and correspondingly the potential influence of the social proof heuristic in moderating the choice outcome. However, in Study 2 where hunger was manipulated, we found hungry participants making significantly less healthy choices than satiated participants, but a social proof heuristic mitigated this effect (i.e., in the presence of social proof heuristic hungry participants made just as many healthy food choices as satiated participants; and hungry participants made more healthy choices in the social proof condition than in the no heuristic condition). These findings support our approach of providing contextual cues in the environment in order to work with, rather than against, the impulsivity triggered by hunger to promote successful self-control behaviours.

Turning Pain Into Cues for Goal-Directed Behavior: Implementation Intentions Reduce Escape-Avoidance Behavior on a Painful Task

Pain automatically elicits escape-avoidance behavior to avert bodily harm. In patients with chronic pain, long-term escape-avoidance behavior may increase the risk of chronic disability. The aim of the presents study was to examine whether implementation intentions reduce escape-avoidance behavior during painful tasks in healthy individuals. Implementation intentions are "if-then" self-statements associating situational cues with goal-directed behaviors. Seventy healthy participants performed a painful finger pressing task, preceded by either implementation intention instructions with pain or a nonpain cue as a cue for goal-directed behavior, or control instructions. Escape-avoidance behavior was operationalized as task duration and response rate. Inhibitory control was measured using the Stop Signal Task. The pain implementation intentions resulted in the longest task duration (P = .02), and thus less escape-avoidance behavior. Low inhibitory control was associated with shorter task duration (P = .03), and thus more escape-avoidance behavior. The nonpain implementation intentions resulted in the highest response rate, but only when inhibitory control was low (P = .04). Implementation intentions referring to pain or nonpain reduce escape-avoidance behavior on a painful task. It is worthwhile to examine whether individuals in pain and with low inhibitory control benefit from interventions that incorporate implementation intentions.

PERSPECTIVE

To our knowledge, this study is the first to show that forming implementation intentions reduces escape-avoidance behavior during pain and fosters nonpain goal pursuit. The use of implementation intentions is indicated to be an intervention that could be of use in patients with pain, particularly when inhibitory control is low.

Put a limit on it: The protective effects of scarcity heuristics when self-control is low

Low self-control is a state in which consumers are assumed to be vulnerable to making impulsive choices that hurt long-term goals. Rather than increasing self-control, the current research exploits the tendency for heuristic-based thinking in low self-control by employing scarcity heuristics to promote better consumption choices. Results indicate that consumers low in self-control especially benefited and selected more healthy choices when marketed as "scarce" (Study 1), and that a demand (vs supply) scarcity heuristic was most effective in promoting utilitarian products (Study 2) suggests low self-control involves both an enhanced reward orientation and increased tendency to conform to descriptive norms.

The role of pre-treatment proactive coping skills in successful weight management

OBJECTIVES

Proactive coping encompasses future-oriented self-regulatory skills that help people prepare for future difficulties before they occur, such as planning and monitoring. The aim of the present study was to examine the interplay between pre-treatment proactive coping skills and expected difficulties during weight loss in determining successful weight management.

METHOD

Obese and overweight Dutch adults (N=119) who enrolled in a weight management intervention reported their level of proactive coping skills and expected difficulties at the start of intervention. Two months later, weight loss was assessed via self-report.

RESULTS

The results show that the detrimental effects of a low level of proactive coping skills were compensated by the expectation that many difficulties would accompany the weight loss attempt. Also, pre-treatment proactive coping skills did not predict weight loss success above and beyond self-efficacy and socio-demographic factors (e.g., gender).

CONCLUSION

It is concluded that future-oriented self-regulatory skills and beliefs about impending difficulties at the start of intervention may have predictive value for subsequent success in weight management.

Bedtime procrastination: A self-regulation perspective on sleep insufficiency in the general population

Getting insufficient sleep has serious consequences in terms of mental and physical health. The current study is the first to approach insufficient sleep from a self-regulation perspective by investigating the phenomenon of bedtime procrastination: going to bed later than intended, without having external reasons for doing so. Data from a representative sample of Dutch adults (N = 2431) revealed that a large proportion of the general population experiences getting insufficient sleep and regularly goes to bed later than they would like to. Most importantly, a relationship between self-regulation and experienced insufficient sleep was found, which was mediated by bedtime procrastination.

Bedtime procrastination: introducing a new area of procrastination

Background: Procrastination is a prevalent and problematic phenomenon that has mostly been studied in the domain of academic behavior. The current study shows that procrastination may also lead to harmful outcomes in the area of health behavior, introducing bedtime procrastination as an important factor related to getting insufficient sleep and consequently affecting individual well-being. Bedtime procrastination is defined as failing to go to bed at the intended time, while no external circumstances prevent a person from doing so.

Methods: To empirically support the conceptual introduction of bedtime procrastination, an online survey study was conducted among a community sample (N = 177). The relationship between bedtime procrastination and individual difference variables related to self-regulation and general procrastination was assessed. Moreover, it was investigated whether bedtime procrastination was a predictor of self-reported sleep outcomes (experienced insufficient sleep, hours of sleep, fatigue during the day).

Results: Bedtime procrastination was negatively associated with self-regulation: people who scored lower on self-regulation variables reported more bedtime procrastination. Moreover, self-reported bedtime procrastination was related to general reports of insufficient sleep above and beyond demographics and self-regulation.

Conclusions: Introducing a novel domain in which procrastinators experience problems, bedtime procrastination appears to be a prevalent and relevant issue that is associated with getting insufficient sleep.

Effortless inhibition: habit mediates the relation between self-control and unhealthy snack consumption

In contrast to prevailing beliefs, recent research suggests that trait self-control promotes health behavior not because those high in self-control are more successful at resisting single temptations, but rather because they develop adaptive habits. The present paper presents a first empirical test of this novel suggestion by investigating the mediating role of habit in explaining the relation between self-control and unhealthy snacking behavior. Results showed that self-control was negatively associated with unhealthy snack consumption and unhealthy snacking habits. As hypothesized, the relation between self-control and unhealthy snack intake was mediated by habit strength. Self-control was not associated with fruit consumption or fruit consumption habits. These results provide the first evidence for the notion that high self-control may influence the formation of habits and in turn affect behavior. Moreover, results imply that self-control may be particularly influential in case of inhibiting unhealthy food intake rather than promoting healthy food intake.

Allured or alarmed: counteractive control responses to food temptations in the brain

Typically, it is believed that palatable, high caloric foods signal reward and trigger indulgent responses. However, Counteractive Control Theory suggests that, to the extent that people are concerned about their weight, a confrontation with palatable foods should also trigger 'alarm bell responses' which promote successful self-control. Our study is the first to investigate such counteractive control processes in the brain employing functional magnetic resonance imaging (fMRI) in a sample of successful self-regulators. Indeed, besides the traditional finding that foods elicit heightened attention as witnessed by greater activation of primary visual cortex, we found that viewing palatable foods elicited brain activation in areas associated with self-regulation. Crucially, brain activation in self-regulation areas was related to diet importance. Thus, our results are the first to show that food cues not only evoke hedonic brain responses; in successful self-regulators they also trigger alarm bell responses, which may reflect the neural processes underlying successful self-control.

Boosters, anyone? Exploring the added value of booster sessions in a self-management intervention

The current study explored the benefits of adding booster sessions to a validated and successful self-management intervention for type 2 diabetes patients (i.e. Beyond Good Intentions). Although the addition of booster sessions to self-management interventions is often recommended, it has not been empirically established to what extent booster sessions are in fact appreciated by participants. Participants in the current study (N = 129) followed the Beyond Good Intentions program and were offered a series of three booster sessions at 1, 3 and 5 months afterwards. Primary outcome variables included participants' attendance and evaluations of the booster phase. In addition, self-management behavior was assessed at baseline (T1), after the initial phase (T2) and after the booster phase (T3). Results showed that more than one-fourth of participants who completed the initial phase dropped out during the booster phase, and those who did complete both phases evaluated the booster phase significantly less positive as compared to the initial phase. With regard to the behavioral outcomes, we replicated previous findings showing positive effects on all measures during the initial phase. The booster phase, however, did not result in further improvements. It was concluded that the added value of booster sessions was, at best, questionable.

Are Self-Management Interventions Suitable for All? Comparing Obese Versus Nonobese Type 2 Diabetes Patients

Objective. The aim of the current study was to compare obese and nonobese type 2 diabetes patients at baseline and after participating in an existing self-management intervention (i.e., Beyond Good Intentions) on cognitive, self-care, and behavioral measures to examine whether both groups are equally prepared and able to adopt self-management approaches. Methods. A total of 94 type 2 diabetes patients were included, of whom 64 (59% male) completed the study. The final sample consisted of 27 obese (33% male) and 37 nonobese (78% male) patients. The intervention comprised one individual and four group sessions and aimed to improve self-management behavior by enhancing proactive coping skills (i.e., setting concrete goals, identifying barriers, coping with difficult situations, action planning, and progress evaluation). Cognitive (i.e., proactive coping, self-control, self-efficacy), self-care (i.e., adherence to lifestyle recommendations), and behavioral (i.e., diet, exercise) measures were assessed at baseline and after completing the intervention. Results. At baseline, obese patients reported to possess lower cognitive skills and lower adherence to lifestyle recommendations compared with nonobese patients. The intervention was effective in improving cognitive skills, self-care activities, as well as dietary and exercise behaviors. Improvements were equal for obese and nonobese patients. However, obese patients were more likely to drop out. Conclusions. Although obese type 2 diabetes patients were found to possess limited skills at baseline compared with nonobese patients, the self-management course proved to be equally effective for both groups.

"Instant success": turning temptations into cues for goal-directed behavior

Contrary to lay intuition, counteractive control theory posits that tempting food cues can help individuals to act in accordance with their long-term dieting goal. However, studies have shown that temptations trigger goal-directed behavior only in successful but not in unsuccessful self-regulators. The aim of the present study was to test whether it is possible to create facilitated temptation-goal associations in unsuccessful dieters using implementation intentions (e.g., "If I see or smell chocolate then I will follow my goal to diet") and whether this indeed stimulates more successful self-regulation. It was found that implementation intentions linking a temptation to a dieting goal lead to self-perceived improved resistance to (Study 1) as well as reduced consumption (Study 2) of tempting snacks compared to a control condition. Moreover, Study 2 revealed that the reduced snack consumption was indeed related to facilitated temptation-goal associations in participants who had formed implementation intentions.

Breaking Habits With Implementation Intentions: A Test of Underlying Processes

Implementation intentions specifying the replacement of a habitual response with an alternative response in a critical situation can overrule habits. In three experiments the cognitive effects of such counterhabitual implementation intentions were investigated. Results showed that implementation intentions eliminated the cognitive advantage of the habitual means in the “horse race” with the alternative response. That is, in the control condition, the habitual means was more accessible than the alternative means on encountering the critical situation, but this was no longer the case when implementation intentions were formulated. However, the cognitive advantage of the habitual means was not immediately replaced by an automatic activation of the alternative means. This suggests that formulating counterhabitual implementation intentions increases individuals’ flexibility to choose which behavior to perform in the critical situation but that actual behavior will depart from their habits only to the extent that individuals have strong alternative goal intentions.