Report of the Expert Panel on Awareness and Behavior Change to the Board of Directors, American Heart Association

A model of factors influencing COVID-19 vaccine acceptance: A synthesis of the theory of reasoned action, conspiracy theory belief, awareness, perceived usefulness, and perceived ease of use

The aim of this study is to investigate the key factors influencing the acceptance of COVID-19 vaccines and develop a model based on the theory of reasoned action, belief in conspiracy theory, awareness, perceived usefulness, and perceived ease of use. The authors created and distributed a self-administered online questionnaire using Google Forms. Data were collected from 351 respondents ranging in age from 19 to 30 years, studying at the graduate and postgraduate levels at various public universities in Bangladesh. The Partial Least Squares Structural Equation Modeling (PLS-SEM) method was used to analyze the data. The results indicate that belief in conspiracy theory undermines COVID-19 vaccine acceptance, thereby negatively impacting the individual attitudes, subjective norms, and acceptance. Individual awareness, on the other hand, has a strong positive influence on the COVID-19 vaccine acceptance. Furthermore, the perceived usefulness of vaccination and the perceived ease of obtaining the vaccine positively impact attitude and the acceptance of immunization. Individuals’ positive attitudes toward immunization and constructive subjective norms have a positive impact on vaccine acceptance. This study contributes to the literature by combining the theory of reasoned action with conspiracy theory, awareness, perceived usefulness, and perceived ease of use to understand vaccine acceptance behavior. Authorities should focus on campaigns that could reduce misinformation and conspiracy surrounding COVID-19 vaccination. The perceived usefulness of vaccination to prevent pandemics and continue normal education will lead to vaccination success. Furthermore, the ease with which people can obtain the vaccine and that it is free of cost will encourage students to get vaccinated to protect themselves, their families, and society.

Patient perspectives on health-related behavior change after transient ischemic attack or ischemic stroke

OBJECTIVE

Unhealthy lifestyle is common among patients with ischemic stroke or TIA. Hence, health-related behavior change may be an effective way to reduce stroke recurrence. However, this is often difficult to carry out successfully. We aimed to explore patients' perspectives on health-related behavior change, support in this change, and sustain healthy behavior.

METHODS

We conducted a descriptive qualitative study with in-depth, semistructured interviews in eighteen patients with recent TIA or ischemic stroke. Interviews addressed barriers, facilitators, knowledge, and support of health-related behavior change framed by the protection motivation theory. All interviews were transcribed and thematically analyzed.

RESULTS

Patients seem unable to adequately appraise their own health-related behavior. More than half of the patients were satisfied with their lifestyle and felt no urgency to change. Self-efficacy as coping factor was the most important determinant (both barrier and facilitator). Fear as threat factor was named as facilitator for health-related behavior change by half of the patients. Most of the patients did not need support or already received support in changing health behavior. Patients indicated knowledge, guidelines, and social support as most needed to support and preserve a healthy lifestyle.

CONCLUSION

This study suggests that patients with recent TIA or ischemic stroke often do not have a high intention to change health-related behavior. The results fit well within the framework of the protection motivation theory. As many patients seem unable to adequately appraise their health behaviors, interventions should focus on increasing knowledge of healthy behavior and improving self-efficacy and social support.

Mosquito-borne infectious disease, risk-perceptions, and personal protective behavior among U.S. international travelers

Vector-borne diseases account for a significant amount of the global infectious disease burden, including morbidity and mortality. In particular, mosquito-borne infectious diseases (MBIDs) have the greatest burden in number of cases, mortality, and disability-adjusted life years and their prevention and control is critical. However, prevention efforts are hindered by the absence of vaccines and failure of long-term mosquito vector control for these MBIDs. Thus, personal protective behaviors (PPBs) may offer the most promising and effective mode of prevention. This study examines the impact of awareness, perceived susceptibility, and perceived severity for five MBIDs (e.g., Malaria, Dengue, Zika, Chikungunya and West Nile) on the adoption of PPBs. Study participants (n = 1043) were recruited from a probability-based internet panel of adult United States residents with a history of traveling outside of the country in the past year. Data were collected in the U.S. between June 7, 2017 and June 12, 2017. Our findings show that awareness of Zika disease among respondents was consistently associated with adoption of all three PPBs. Respondents that reported high-perceived severity for all five MBIDs were also more likely to report adopting the PPBs of wearing covering clothing and use of mosquito repellent spray. Our findings indicate that U.S. travelers are largely more concerned about Zika, Chikungunya, and Dengue than Malaria and West Nile and that these concerns drive their adoption of the three recommended PPBs. This information should inform the development and design of future public health campaigns for behavior modification to prevent MBIDs.

Physical activity and awareness in breast screening attendees in Black Country, UK

This study aimed to determine the physical activity levels and awareness of the influence of physical activity and overweight/obesity on breast cancer risk among NHS breast screening programme (NHSBSP) attendees. One hundred and eighty-eight (white British = 95%; post-menopausal = 80%) attendees completed a demographic and anthropometric data questionnaire, International Physical Activity Questionnaire (IPAQ) and awareness of breast cancer risk factors questionnaire. IPAQ data were reported as continuous measures (MET-min · week(-1)) and as categorical variables (low, moderate and high activities). The highest median physical activity levels were reported in the domestic physical activity domain (756 MET-min · week(-1)). Most participants were categorized as 'moderately active' (45%), while 30% were classified in the 'high activity' and 25% as 'low activity' categories. Almost a third of participants (30%) reported no leisure-time physical activity and 83% reported no vigorous physical activity. There was high awareness of the effects of physical activity (75%) and obesity (80%) on breast cancer risk. No significant differences were found between physical activity categories and awareness that physical activity can reduce breast cancer risk (p > 0.05). However, compared with moderate and high activity categories, participants in the 'low activity' category were significantly more likely to respond that they thought they achieved recommended physical activity levels (p < 0.05). Participants who are unaware of their inadequate physical activity levels may have a less positive intention to increase physical activity levels. Practical strategies aimed to increase knowledge of the recommended physical activity guidelines and facilitate the achievement of these guidelines may be required for NHSBSP attendees.

Awareness and impact of New York City's graphic point-of-sale tobacco health warning signs

BACKGROUND

To increase knowledge of smoking-related health risks and provide smoking cessation information at the point of sale, in 2009, New York City required the posting of graphic point-of-sale tobacco health warnings in tobacco retailers. This study is the first to evaluate the impact of such a policy in the USA.

METHODS

Cross-sectional street-intercept surveys conducted among adult current smokers and recent quitters before and after signage implementation assessed the awareness and impact of the signs. Approximately 10 street-intercept surveys were conducted at each of 50 tobacco retailers in New York City before and after policy implementation. A total of 1007 adults who were either current smokers or recent quitters were surveyed about the awareness and impact of tobacco health warning signs. Multivariate risk ratios (RR) were calculated to estimate awareness and impact of the signs.

RESULTS

Most participants (86%) were current smokers, and the sample was 28% African-American, 32% Hispanic/Latino and 27% non-Hispanic white. Awareness of tobacco health warning signs more than doubled after the policy implementation (adjusted RR =2.01, 95% CI 1.74 to 2.33). Signage posting was associated with an 11% increase in the extent to which signs made respondents think about quitting smoking (adjusted RR =1.11, 95% CI 1.01 to 1.22).

CONCLUSIONS

A policy requiring tobacco retailers to display graphic health warning signs increased awareness of health risks of smoking and stimulated thoughts about quitting smoking. Additional research aimed at evaluating the effect of tobacco control measures in the retail environment is necessary to provide further rationale for implementing these changes.

Discrepancy between theoretical knowledge and real action in acute stroke: self-assessment as an important predictor of time to admission

BACKGROUND

Poor knowledge of stroke symptoms within the general population might be responsible for significant delay between symptom onset and hospital admission in most stroke patients.

METHODS

We prospectively evaluated whether theoretical knowledge about stroke influenced time to admission among 102 consecutive acute stroke patients using standardized questionnaires. We assessed in multiple logistic regression models the influence of theoretical knowledge (knowledge about stroke symptoms and knowledge about the appropriate actions to be taken in the case of a stroke) on the real actions taken in the acute situation. Predictors of a delayed hospital admission greater than 2 hours after stroke onset were determined. Models were adjusted for age, gender, level of education, stroke severity, previous history of stroke or transient ischemic attack (TIA), and being alone at symptom onset.

RESULTS

Patients arrived significantly later, if the patients themselves were the managers of the emergency situation [odds ratio (OR): 4.7; 95% confidence interval (CI): 1.5-140.8]. Symptom knowledge and action knowledge were not found to be significantly associated with shorter pre-hospital times, whereas the correct diagnosis of stroke by the manager (OR: 0.2; 95% CI: 0.1-0.4) and calling the emergency medical system (OR: 0.3; 95% CI: 0.1-0.7) independently led to a higher likelihood to arrive at a hospital within 2 hours.

CONCLUSION

Our study underscores that good theoretical knowledge about stroke does not imply appropriate management in the emergency situation. Educational efforts need to incorporate more practical aspects in order to translate theoretical knowledge into concrete action.

Delay of first treatment of mental and substance use disorders in Mexico

OBJECTIVES

We studied failure and delay in making initial treatment contact after the first onset of a mental or substance use disorder in Mexico as a first step to understanding barriers to providing effective treatment in Mexico.

METHODS

Data were from the Mexican National Comorbidity Survey (2001-2002), a representative, face-to-face household survey of urban residents aged 18 to 65 years. The age of onset for disorders was compared with the age of first professional treatment contact for each lifetime disorder (as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition).

RESULTS

Many people with lifetime disorders eventually made treatment contact, although the proportions varied for mood (69.9%), anxiety (53.2%), and substance use (22.1%) disorders. Delays were long: 10 years for substance use disorders, 14 years for mood disorders, and 30 years for anxiety disorders. Failure and delay in making initial treatment contact were associated with earlier ages of disorder onset and being in older cohorts.

CONCLUSIONS

Failure to make prompt initial treatment contact is an important reason explaining why there are unmet needs for mental health care in Mexico. Meeting these needs will likely require expansion and optimal allocation of resources as well as other interventions.

Ursachen einer verl�ngerten Pr�hospitalphase bei Stroke-Unit-Patienten

Since stroke has become a medical emergency because intravenous tissue plasminogen activator improves outcome after ischemic stroke within 3 h of symptom onset, the focus of acute stroke management lies on the prehospital phase. Having the worst median time of emergency department arrival after stroke onset according to nationwide statistics, we examined the factors influencing a late admission of 174 consecutive patients to our stroke unit and the effects of a public campaign over 5 months. The median time from symptom onset to arrival was 5.2 h; 36.4% of patients presented within 3 h at hospital. A high level of education, knowledge of the time window, direct contact with an emergency facility after stroke onset, high number of known symptoms, not living alone, and a stroke in the past were connected with an earlier presentation. The public campaign had a positive effect on median time of symptom onset to arrival from 12 h in July, 7.2 in August, 4.7 in October, 5.2 in November, and 3.2 in December 2002. This had a favorable effect on the number of thrombolysis.

Cardiopulmonary Resuscitation Programs Revisited: Results of a Community Study Among Older African Americans

Early cardiopulmonary resuscitation (CPR) performed by a layperson and prompt defibrillation in the field are critical links in the chain of survival of out-of-hospital sudden cardiac arrest. It has been suggested that minorities, women, and elderly persons are often left out of CPR training programs. To examine knowledge and attitudes toward CPR and automatic external defibrillation among African Americans, the author and colleagues conducted home interviews in a population sample of 425 older men and women in Miami-Dade County, FL. It was found that 25% of the participants did not know what CPR was. Only 18% of men and 28% of women had ever taken CPR classes. Mean age the time of CPR training was for men 36 years and for women 46 years. About 74% of all subjects did not know whom to contact for CPR training, and fewer than 5% knew about the American Heart Association Heartsaver Program (including automatic external defibrillation performed by laypersons). The majority of participants suggested churches or community organizations as organizers of CPR training. This study shows that there is a major need for improving knowledge and intensifying CPR training programs among older African Americans. Community organizations and churches may play a critical role in reaching this goal.

Delays in initial treatment contact after first onset of a mental disorder

OBJECTIVE

To examine nationally representative patterns and predictors of delays in contacting a professional after first onset of a mental disorder.

DATA SOURCES

The National Comorbidity Survey, a nationally representative survey of 8,098 respondents aged 15-54.

STUDY DESIGN

Cross-sectional survey.

DATA COLLECTION

Assessed lifetime DSM-III-R mental disorders using a modified version of the Composite International Diagnostic Interview (CIDI). Obtained reports on age at onset of disorders and age of first treatment contact with each of six types of professionals (general medical doctors, psychiatrists, other mental health specialists, religious professionals, human services professionals, and alternative treatment professionals). Used Kaplan-Meier (KM) curves to estimate cumulative lifetime probabilities of treatment contact after first onset of a mental disorder. Used survival analysis to study the predictors of delays in making treatment contact.

PRINCIPAL FINDINGS

The vast majority (80.1 percent) of people with a lifetime DSM-III-R disorder eventually make treatment contact, although delays average more than a decade. The duration of delay is related to less serious disorders, younger age at onset, and older age at interview. There is no evidence that delay in initial contact with a health care professional is increased by earlier contact with other non-health-care professionals.

CONCLUSIONS

Within the limits of recalling lifetime events, it appears that delays in initial treatment contact are an important component of the larger problem of unmet need for mental health care. Interventions are needed to decrease these delays.

Adequacy of treatment for serious mental illness in the United States

OBJECTIVES

The purpose of this study was to assess the prevalence and correlates of treatment for serious mental illness.

METHODS

Data were derived from the National Comorbidity Survey, a cross-sectional, nationally representative household survey assessing the presence and correlates of mental disorders and treatments. Crude and adjusted likelihoods of receiving treatment for serious mental illness in the previous 12 months were calculated.

RESULTS

Forty percent of respondents with serious mental illness had received treatment in the previous year. Of those receiving treatment, 38.9% received care that could be considered at least minimally adequate, resulting in 15.3% of all respondents with serious mental illness receiving minimally adequate treatment. Predictors of not receiving minimally adequate treatment included being a young adult or an African American, residing in the South, being diagnosed as having a psychotic disorder, and being treated in the general medical sector.

CONCLUSIONS

Inadequate treatment of serious mental illness is an enormous public health problem. Public policies and cost-effective interventions are needed to improve both access to treatment and quality of treatment.

Modeling emotion and behavior in animated personas to facilitate human behavior change: the case of the HEART-SENSE game

The goal of this research is to determine whether a computer based training game (HEART-SENSE) can improve recognition of heart attack symptoms and shift behavioral issues so as to reduce pre-hospitalization delay in seeking treatment. Since treatment delay correlates with adverse outcomes, this research could reduce myocardial infarction mortality and morbidity. In Phase I we created and evaluated a prototype virtual village in which users encounter and help convince synthetic personas to deal appropriately with a variety of heart attack scenarios and delay issues. Innovations made here are: (1) a design for a generic simulator package for promoting health behavior shifts, and (2) algorithms for animated pedagogical agents to reason about how their emotional state ties to patient condition and user progress. Initial results show that users of the game exhibit a significant shift in intention to call 9-1-1 and avoid delay, that multi-media versions of the game foster vividness and memory retention as well as a better understanding of both symptoms and of the need to manage time during a heart attack event. Also, results provide insight into areas where emotive pedagogical agents help and hinder user performance. Finally, we conclude with next steps that will help improve the game and the field of pedagogical agents and tools for simulated worlds for healthcare education and promotion.

A case-management program of medium intensity does not improve cardiovascular risk factor control in coronary artery disease patients: the Heartcare I trial

BACKGROUND

Case-management programs for secondary prevention of coronary artery disease that utilize extensive resources can reduce cardiovascular risk factors, but less intensive approaches have failed to show benefits. This randomized trial evaluated whether a medium intensity case-management program improves risk factor control in patients with coronary artery disease.

METHODS

We assigned 201 consecutive patients hospitalized for acute coronary events in the intensive care unit of University Hospital, Basel, Switzerland, to either a risk factor case-management program (n = 99) or care as usual (n = 102) using the patients' primary care physicians as the unit of randomization (cluster randomization). The case-management program consisted of an hour of counseling by a clinician during hospitalization and two short reminders by phone and mail 3 and 6 months later. Treatment decisions were left to patients and their primary care physicians.

RESULTS

After 9 and 18 months of follow-up, there were no significant differences in lipid values, blood pressure control, fasting blood glucose, body-mass index, or number of smokers between the two groups. However, significantly more patients in the intervention group than in the care as usual group achieved target cholesterol values after 18 months (48% versus 27%, P = 0.002 and remained significant after Bonferroni-Holms correction) but not after 9 months of follow-up (31% versus 27%, P >0.2).

CONCLUSION

This hospital-based case-management and outreach program, limited to counseling by a clinician, did not substantially improve cardiovascular risk factor control among patients hospitalized for coronary events.