The Health Action Process Approach-Based Program's Effects on Influenza Vaccination Behavior

Theory-Based Social Media Intervention for Nonmedical Use of Prescription Opioids in Young Adults: Protocol for a Randomized Controlled Trial

BACKGROUND

The nonmedical use of prescription opioids (NMUPO) in young adults in the United States is concerning and is robustly influenced by many psychosocial factors. Given the advantages of flexibility, wide coverage, and real-time responses and assessment, using social media appears to be a promising and innovative approach to delivering psychosocial intervention to young adults. However, few theory-based social media interventions are available for NMUPO targeting this at-risk population.

OBJECTIVE

Guided by the information-motivation-behavioral skills model, the proposed research aims to address critical gaps by theoretically exploring psychosocial content associated with NMUPO among young adults via formative assessment. These findings will then be used to develop and evaluate the feasibility and preliminary efficacy of a peer-led social media intervention to reduce NMUPO among young adults.

METHODS

The proposed study will comprise serial research activities. First, formative research will be conducted through semistructured interviews among 30 young adults engaged in NMUPO. Qualitative data will be synthesized using a pragmatic approach for identifying psychosocial content associated with NMUPO. Second, qualitative findings will be used for developing a peer-led social media intervention to reduce NMUPO among young adults by integrating promising psychotherapy principles and incorporating them with well-trained recovery coaches. Third, the social media intervention will be evaluated through a 12-week randomized controlled trial among 70 young adults (n=35, 50% in the intervention group and control group) engaged in NMUPO via mixed methods, including pre- and postintervention surveys, social media paradata (eg, time-series reactions to posts) collection, and ecological momentary assessment during the intervention. The control group will not receive an intervention but will complete the pre- and postintervention surveys. The primary outcomes will be feasibility, usability, and acceptability, while the secondary outcomes will be psychosocial and behavioral measures, such as past-3-month NMUPO, intention, psychological distress, self-efficacy, resilience, and coping strategies.

RESULTS

The proposed study was funded in May 2024. Social media campaigns have received responses from a total of 379 individuals, with 24 (6.3%) identified as eligible. As of February 10, 2025, we have completed formative interviews with 8 eligible participants.

CONCLUSIONS

The proposed study will be one of the first efforts to develop and deliver a theory-based peer-led intervention on social media, incorporating empirical findings on the psychosocial mechanism of NMUPO. The findings of the proposed study will provide valuable insights into opioid risk reduction for young adults through an innovative approach. If the tested trial is found to be feasible, the proposed study will contribute to future scaled-up and fully powered psychosocial interventions among young adults and other key populations at risk for NMUPO.

TRIAL REGISTRATION

ClincialTrials.gov NCT06469749; https://clinicaltrials.gov/study/NCT06469749.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/65847.

Nudge theories and strategies influencing adult health behaviors and outcomes in COPD management: a systematic review

Objective

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease with high prevalence and mortality, and self-management is a key component for better outcomes of COPD. Recently, nudging has shown promising potential in COPD management. In the present study, we conducted a systematic review to collate the list of nudges and identified the variables that influence nudging.

Methods

We undertook a systematic review. We employed database searches and snowballing. Data from selected studies were extracted. The risk of bias was assessed using the Cochrane Effective Practice and Organization of Care risk of bias tool. The study is registered with PROSPERO, CRD42023427051.

Results

We retrieved 4,022 studies from database searches and 38 studies were included. By snowballing, 5 additional studies were obtained. Nudges were classified into four types: social influence, gamification, reminder, and feedback. Medication adherence, inhalation technique, physical activity, smoking cessation, vaccination administration, exercise capacity, self-efficacy, pulmonary function, clinical symptoms, and quality of life were analyzed as targeted health behaviors and outcomes. We found medication adherence was significantly improved by reminders via mobile applications or text materials, as well as feedback based on devices. Additionally, reminders through text materials greatly enhance inhalation techniques and vaccination in patients.

Conclusion

This review demonstrates nudging can improve the health behaviors of patients with COPD and shows great potential for certain outcomes, particularly medication adherence, inhalation techniques, and vaccination. Additionally, the delivery modes, the patient characteristics, and the durations and seasons of interventions may influence the successful nudge-based intervention.

Clinical trial registration

This review has been registered in the international Prospective Registry of Systematic Evaluation (PROSPERO) database (identifier number CRD42023427051).

How to Improve People's Intentions Regarding COVID-19 Vaccination in China: A Randomized Controlled Trial

BACKGROUND

The global COVID-19 pandemic has impaired the health and living conditions of millions of people. For governments to formulate policies promoting vaccination behavior, it is important to understand individuals' intentions to vaccinate. This study explores the effectiveness of a brief online intervention based on the Health Action Process Approach (HAPA) in improving individuals' COVID-19 vaccination intention, as well as considering the reasons for their unwillingness to get vaccinated.

METHOD

A total of 1,258 participants were assessed using a questionnaire to determine their phase of vaccination intention (pre-intention, intention, and action). Subsequently, focused on the underlying factors in the pre-intention phase (i.e., task self-efficacy, outcome expectation, and risk perception), a 7-day randomized controlled HAPA intervention (n intervention = 57, n control = 49) was conducted online for individuals who were not willing to get vaccinated. The measurement points included pre- (T1), post- (T2), and 30-day follow-up (T3).

RESULTS

The intervention may effectively improve participants' COVID-19 vaccination intentions; however, it had no impact on their planning and actions involved in taking the vaccine.

CONCLUSIONS

This study provides relevant reference data for government stakeholders to use in developing public awareness campaigns and policies to encourage COVID-19 vaccination.

A Mobile-Based Preventive Program for Young, Arabic-Speaking Asylum Seekers during the COVID-19 Pandemic in Germany: Design, Feasibility, and Implementation

BACKGROUND

A majority of individuals seeking asylum in Germany are living in collective housings and thus exposed to a higher risk of contagion during the COVID-19 pandemic.

OBJECTIVE

To test feasibility and efficacy of a culture-sensitive approach combining mobile app-based interventions and a face-to-face group intervention to improve knowledge about COVID-19 and promote vaccination readiness among collectively accommodated Arabic-speaking adolescents and young adults.

METHODS

We developed a mobile app that was composed of short video clips to explain the biological basis of COVID-19, demonstrate behavior to prevent transmission, and combat misconceptions and myths about vaccination. Explanations were given in a YouTube-like interview setting by a native Arabic-speaking physician. Elements of gamification (quizzes, rewards for solving test items) were also used. Consecutive videos and quizzes were presented over an intervention period of six weeks, the group intervention was scheduled as an add-on for half of participants in week 6. The manual of the group intervention was designed to provide actual behavior planning on the basis of the health action process approach. Sociodemographic information, mental health status, and knowledge about Covid-19 and available vaccines were assessed with questionnaire-based interviews at baseline and after six weeks. Interpreters assisted with the interviews in all cases.

RESULTS

Enrollment in the study proved to be very challenging as among other things, the housing facilities allowed contact with potentially eligible participants only during certain periods because of the pandemic situation. Also due to tightened contact restrictions, the face-to-face group interventions could not be held as planned. A total of 88 participants from 8 collective housing institutions were included in the study. 61 participants completed the full intake interview. Most participants had already been vaccinated at study enrollment (76.5%). They also yet claimed to comply with preventive measures to a very high extent (e.g., "always wearing masks" was indicated by 66% of participants), but practicing behavior that was not considered as effective against Covid-19 transmission was also frequently reported as a preventive measure (e.g., mouth rinsing). On the other hand, factual disease knowledge for COVID-19 was limited. Preoccupation with the information materials presented in the app steeply declined after study enrollment (e.g., 19% of participants watched the videos scheduled for week 3). Only 18 participants could be reached for the follow-up interview. Their COVID-19 disease knowledge did not shown to have increased after the intervention period (p=0.558).

CONCLUSIONS

The results indicate that vaccine uptake was high and seemed to be depending on organizational determinants for the target group. The current mobile app-based intervention demonstrated low feasibility, which might have been related to various obstacles faced during the delivery: Learning from mobile phone content based on short videos requires a basic understanding of biological and IT-aspects as well as sufficient literacy and a living situation enabling the practical application of the learned behavioral prevention strategies. Therefore, in case of future pandemics, transmission prevention in the specific target group should rely more on structural aspects instead on sophisticated psychological interventions.

CLINICALTRIAL

https://www.drks.de, identifier: DRKS00028825.

Development and Validation of the Outcome Expectancy Scale for COVID-19 Vaccination in the Adult General Population

Promotion of COVID-19 vaccination requires understanding its determinants, an important one of which is outcome expectancy. However, reliable and valid measurement tools are absent. This study thus developed and validated an Outcome Expectancy Scale for COVID-19 Vaccination (OES-COVID-19). An inductive approach was used for scale development; content validity of the items was then assessed by an independent evaluation expert panel. Iteratively, 17 scale items were created and validated in a population-based telephone survey conducted among 500 adults of the general population in Hong Kong, China, from August to September 2021. Using half of the sample (n = 249), exploratory factor analyses identified four factors of the OES-COVID-19, including (a) positive contribution to society, (b) functional benefits, (c) protective effect, and (d) negative impacts. Confirmatory factor analysis of these factors conducted on the second subsample (n = 251) was satisfactory. The OES-COVID-19 showed good psychometric properties in terms of internal consistency, absence of floor/ceiling effects, and concurrent validity. The newly created and validated OES-COVID-19 is deemed suitable for application. It may advance future studies related to COVID-19 vaccination behavior and intention, and potentially allows for comparisons across studies. Further validation with modifications across countries, populations, and phase of the pandemic are warranted.

Prosociality and Social Responsibility Were Associated With Intention of COVID-19 Vaccination Among University Students in China

BACKGROUND

Coronavirus disease 2019 (COVID-19) vaccination is expected to end the pandemic; a high coverage rate is required to meet this end. This study aimed to investigate the prevalence of behavioral intention of free/self-paid COVID-19 vaccination and its associations with prosociality and social responsibility among university students in China.

METHODS

An anonymous online cross-sectional survey was conducted among 6922 university students in five provinces in China during November 1-28, 2020. With informed consent, participants filled out an online survey link distributed to them via WeChat study groups. The response rate was 72.3%.

RESULTS

The prevalence of behavioral intentions of free COVID-19 vaccination was 78.1%, but it dropped to 57.7% if the COVID-19 vaccination involved self-payment (400 RMB; around 42 USD). After adjusting for background factors, prosociality (free vaccination: adjusted odds ratio [ORa] = 1.10, 95% CI: 1.09-1.12; self-paid vaccination: ORa = 1.08, 95% CI: 1.07-1.09) and social responsibility (free vaccination: ORa = 1.17, 95% CI: 1.14-1.19; self-paid vaccination: ORa = 1.13, 95% CI: 1.11-1.14) were positively associated with the two variables of COVID-19 vaccination intention.

CONCLUSION

The present study demonstrated the positive effects of prosociality and social responsibility on the intention of COVID-19 vaccination. Accordingly, modification of prosociality and social responsibility can potentially improve COVID-19 vaccination. Future longitudinal and intervention studies are warranted to confirm such associations across populations and countries.

Self-management interventions for people with chronic obstructive pulmonary disease

BACKGROUND

Self-management interventions help people with chronic obstructive pulmonary disease (COPD) to acquire and practise the skills they need to carry out disease-specific medical regimens, guide changes in health behaviour and provide emotional support to enable them to control their disease. Since the 2014 update of this review, several studies have been published.

OBJECTIVES

Primary objectives To evaluate the effectiveness of COPD self-management interventions compared to usual care in terms of health-related quality of life (HRQoL) and respiratory-related hospital admissions. To evaluate the safety of COPD self-management interventions compared to usual care in terms of respiratory-related mortality and all-cause mortality. Secondary objectives To evaluate the effectiveness of COPD self-management interventions compared to usual care in terms of other health outcomes and healthcare utilisation. To evaluate effective characteristics of COPD self-management interventions.

SEARCH METHODS

We searched the Cochrane Airways Trials Register, CENTRAL, MEDLINE, EMBASE, trials registries and the reference lists of included studies up until January 2020.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-randomised trials (CRTs) published since 1995. To be eligible for inclusion, self-management interventions had to include at least two intervention components and include an iterative process between participant and healthcare provider(s) in which goals were formulated and feedback was given on self-management actions by the participant.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, assessed trial quality and extracted data. We resolved disagreements by reaching consensus or by involving a third review author. We contacted study authors to obtain additional information and missing outcome data where possible. Primary outcomes were health-related quality of life (HRQoL), number of respiratory-related hospital admissions, respiratory-related mortality, and all-cause mortality. When appropriate, we pooled study results using random-effects modelling meta-analyses.

MAIN RESULTS

We included 27 studies involving 6008 participants with COPD. The follow-up time ranged from two-and-a-half to 24 months and the content of the interventions was diverse. Participants' mean age ranged from 57 to 74 years, and the proportion of male participants ranged from 33% to 98%. The post-bronchodilator forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) ratio of participants ranged from 33.6% to 57.0%. The FEV1/FVC ratio is a measure used to diagnose COPD and to determine the severity of the disease. Studies were conducted on four different continents (Europe (n = 15), North America (n = 8), Asia (n = 1), and Oceania (n = 4); with one study conducted in both Europe and Oceania). Self-management interventions likely improve HRQoL, as measured by the St. George's Respiratory Questionnaire (SGRQ) total score (lower score represents better HRQoL) with a mean difference (MD) from usual care of -2.86 points (95% confidence interval (CI) -4.87 to -0.85; 14 studies, 2778 participants; low-quality evidence). The pooled MD of -2.86 did not reach the SGRQ minimal clinically important difference (MCID) of four points. Self-management intervention participants were also at a slightly lower risk for at least one respiratory-related hospital admission (odds ratio (OR) 0.75, 95% CI 0.57 to 0.98; 15 studies, 3263 participants; very low-quality evidence). The number needed to treat to prevent one respiratory-related hospital admission over a mean of 9.75 months' follow-up was 15 (95% CI 8 to 399) for participants with high baseline risk and 26 (95% CI 15 to 677) for participants with low baseline risk. No differences were observed in respiratory-related mortality (risk difference (RD) 0.01, 95% CI -0.02 to 0.04; 8 studies, 1572 participants ; low-quality evidence) and all-cause mortality (RD -0.01, 95% CI -0.03 to 0.01; 24 studies, 5719 participants; low-quality evidence). We graded the evidence to be of 'moderate' to 'very low' quality according to GRADE. All studies had a substantial risk of bias, because of lack of blinding of participants and personnel to the interventions, which is inherently impossible in a self-management intervention. In addition, risk of bias was noticeably increased because of insufficient information regarding a) non-protocol interventions, and b) analyses to estimate the effect of adhering to interventions. Consequently, the highest GRADE evidence score that could be obtained by studies was 'moderate'.

AUTHORS' CONCLUSIONS

Self-management interventions for people with COPD are associated with improvements in HRQoL, as measured with the SGRQ, and a lower probability of respiratory-related hospital admissions. No excess respiratory-related and all-cause mortality risks were observed, which strengthens the view that COPD self-management interventions are unlikely to cause harm. By using stricter inclusion criteria, we decreased heterogeneity in studies, but also reduced the number of included studies and therefore our capacity to conduct subgroup analyses. Data were therefore still insufficient to reach clear conclusions about effective (intervention) characteristics of COPD self-management interventions. As tailoring of COPD self-management interventions to individuals is desirable, heterogeneity is and will likely remain present in self-management interventions. For future studies, we would urge using only COPD self-management interventions that include iterative interactions between participants and healthcare professionals who are competent using behavioural change techniques (BCTs) to elicit participants' motivation, confidence and competence to positively adapt their health behaviour(s) and develop skills to better manage their disease. In addition, to inform further subgroup and meta-regression analyses and to provide stronger conclusions regarding effective COPD self-management interventions, there is a need for more homogeneity in outcome measures. More attention should be paid to behavioural outcome measures and to providing more detailed, uniform and transparently reported data on self-management intervention components and BCTs. Assessment of outcomes over the long term is also recommended to capture changes in people's behaviour. Finally, information regarding non-protocol interventions as well as analyses to estimate the effect of adhering to interventions should be included to increase the quality of evidence.

Levels and factors derived from the Health Action Process Approach of behavioral intentions to take up COVID-19 vaccination: A random population-based study

Objectives

COVID-19 vaccination needs a high population coverage to achieve herd immunity. We investigated prevalence of three scenarios of intention of free COVID-19 vaccination involving: 1) 80% effectiveness and rare and mild side effects (Scenario 1), 2) 50% effectiveness and rare and mild side effect RMSE (Scenario 2), and 3) immediate vaccination (Scenario 3), and their associated factors derived from the pre-intentional motivational phase of the Health Action Process Approach (HAPA).

Methods

A random population-based telephone survey interviewed 450 Chinese adults in the general population (September 16–30, 2020). The four HAPA constructs included a) risk perception scale, b) overall scale/four subscales of positive outcome expectancy of COVID-19 vaccination, c) overall scale/three subscales of negative outcome expectancy of COVID-19 vaccination, and d) the overall scale/two subscales of self-efficacy of COVID-19 vaccination.

Results

The prevalence of intention of COVID-19 vaccination under Scenarios 1 to 3 was 38.0%, 11.1%, and 13.1%, respectively. Logistic regression analyses adjusted for background factors showed that 1) the associations between risk perception and the three scenarios of intention were non-significant; 2) the overall scale/four subscales of positive outcome expectancy were in general positively associated with two scenarios of intention (80% effectiveness and immediate vaccination); 3) the overall scale/three subscales of negative outcome expectancy were in general negatively associated with all three scenarios of intention; 4) the overall scale/two subscales of self-efficacy were only positively associated with the intention that involved 80% effectiveness. When all the four overall scales were entered into an adjusted model, positive and negative outcome expectancy, but not risk perception and self-efficacy, were independently associated with the three scenarios.

Conclusions

In this study population, the prevalence of intention of COVID-19 vaccination was very low and might not result in population protection. Health promotion should modify outcome expectancies to increase intention of COVID-19 vaccination.

Positive Association between Individualism and Vaccination Resistance against COVID-19 Vaccination among Chinese Adults: Mediations via Perceived Personal and Societal Benefits

Background: Vaccination resistance is the key hurdle against herd immunity as it limits the final vaccination coverage. This study investigated the prevalence and factors of COVID-19 vaccination resistance (i.e., those indicating definitely not taking up COVID-19 vaccination), including individualism, perceived personal benefits (PPB) and perceived societal benefits (PSB) of COVID-19 vaccination, and related mechanisms of the association. Methods: A random telephone survey interviewed 395 unvaccinated adults aged 18–75 not having scheduled for COVID-19 vaccination in May 2021 in Hong Kong, China (response rate = 56.8%). Results: The prevalence of vaccination resistance was 56.5%. Adjusted for background factors, individualism, PPB, and PSB were significantly associated with vaccination resistance. Path analysis showed that individualism exhibited a direct effect on vaccination resistance and a 3-step indirect effect (individualism → PSB → PPB→ vaccination resistance) that explained 46.8% of the total effect. The two 2-step indirect paths via PPB only and via PSB only were non-significant. Conclusion: High prevalence of vaccination resistance was observed. Individualism increased vaccination resistance via its direct and indirect effects. Health promotion may emphasize collective good to reduce the impact of individualism and promote PPB/PSB, which may reduce vaccination resistance directly and alleviate the impact of individualism on vaccination resistance indirectly.

Exploring mechanisms of a web-based values-tailored childhood vaccine promotion intervention trial: Effects on parental vaccination values, attitudes, and intentions

A recent childhood vaccine promotion intervention trial showed no effects on vaccination outcomes relative to usual care. The purpose of this paper was to test assumptions and theory-based relationships underlying hypothesised mechanisms for two vaccine promotion educational websites (one tailored to parental values, beliefs, and intentions; one untailored) compared with usual care. This is a secondary analysis of a three-arm randomized controlled trial. Parental vaccine values, hesitancy, attitudes, and intention to vaccinate surveys were administered at baseline (≤2 months) and at 4-6 and 10-12 months of age. Vaccination was assessed using electronic health records. Analyses included random coefficient models and risk differences with exact confidence limits. Parental vaccine values were mostly stable over time. Vaccine attitudes were generally positive, with no differences among study arms. Both tailored and untailored website arms showed similar increases in intention to vaccinate more than usual care. Positive changes in intentions were associated with lower rates of late vaccination. Although attitudes and intentions predicted vaccination behavior and the intervention increased intention to vaccinate all on time, the web-based education and values-tailored messaging approaches were not effective at increasing vaccination rates. Intentions are necessary but insufficient targets for vaccine promotion interventions.