Analysing tax-benefit reforms in the Netherlands using structural models and natural experiments.

We combine the strengths of structural models and natural experiments in an analysis of tax-benefit reforms in the Netherlands. We first estimate structural discrete-choice models for labour supply. Next, we simulate key past reforms and compare the predictions of the structural model with the outcomes of quasi-experimental studies. The structural model predicts the treatment effects well. The structural model then allows us to conduct counterfactual policy analysis. Policies targeted at working mothers with young children generate the largest labour supply responses but generate little additional government revenue. Introducing a flat tax, basic income or joint taxation is not effective.

Effects of a theory-based audio HIV/AIDS intervention for illiterate rural females in Amhara, Ethiopia.

In Ethiopia the level of illiteracy in rural areas is very high. In this study, we investigated the effects of an audio HIV/AIDS prevention intervention targeted at rural illiterate females. In the intervention we used social-oriented presentation formats, such as discussion between similar females and role-play. In a pretest and posttest experimental study with an intervention group (n = 210) and control group (n = 210), we investigated the effects on HIV/AIDS knowledge and social cognitions. The intervention led to significant and relevant increases in HIV/AIDS knowledge, self-efficacy, perceived vulnerability to HIV/AIDS infection, response efficacy of condoms and condom use intention. In the intervention group, self-efficacy at posttest was the main determinant of condom use intention, with also a significant contribution of vulnerability. We conclude that audio HIV/AIDS prevention interventions can play an important role in empowering rural illiterate females in the prevention of HIV/AIDS.

Correlates of sexual faithfulness among low-literate rural males in the Amhara Region of Ethiopia.

HIV is a major threat to the people of the rural Amhara Region, northwest Ethiopia. To date, numerous studies have focused on condom use for HIV prevention. Using the theory of planned behaviour, this study investigates the psychosocial determinants of intended sexual faithfulness among rural males in the Amhara Region. In February 2008, we conducted a cross-sectional study with 100 males, with an age range of 20-50 years (mean age 38 years), in Dejen Woreda. The participants were illiterate or had a low level of literacy and all were rural farmers. Consequently, 10 literate male data collectors were recruited from the same community to assist in collecting data by means of a structured questionnaire. In the analysis of social cognitions as determinants of sexual faithfulness, attitude to faithfulness emerged as the best predictor of intended faithfulness, with significant contributions from self-efficacy and social norm for faithfulness. Thus, balanced and comprehensive HIV interventions focusing on attitudes, self-efficacy and social norms pertaining to faithfulness, sexual abstinence and condom use are needed to halt the spread of HIV among low-literate males in rural Amhara.

Patient use and compliance with medical advice delivered by a web-based triage system in primary care.

We studied a web-based triage system which was accessible to the general public in the Netherlands. In a retrospective analysis we investigated the type of complaints that were submitted and the kind of advice provided. Over a period of 15 months, 13,133 different people began using the web-based triage system and 3812 patients went right through the triage process to the end. The most frequent complaints were common cold symptoms, such as cough and a sore throat (22%), itch problems (13%), urinary complaints (12%), diarrhoea (10%), headache (8%) and lower back pain (8%). Most commonly, the system generated the advice to contact a doctor (85%) and in 15% of the cases the system provided fully automated, problem-tailored, self-care advice. A total of 192 patients participated in a prospective study and completed an online survey immediately after the delivery of advice. A follow-up questionnaire on actual compliance was completed by 35 patients. Among these, 20 (57%) had actually complied with the advice provided by the system. A regression analysis revealed that intention to comply was strongly related to actual compliance. In turn, intention to comply was strongly related to attitude towards the advice (P < 0.001). Web-based triage can contribute to a more efficient primary care system, because it facilitates the gatekeeper function.

Reaching the hearts and minds of illiterate women in the Amhara highland of Ethiopia: Development and pre-testing of oral HIV/AIDS prevention messages.

In the style of radio programmes, we developed three episodes of audio HIV prevention education for illiterate women in Ethiopia. We used social-oriented presentation formats, such as discussion between women on HIV prevention, and expert-oriented presentation formats, such as an interview with a male doctor. The aim of this study was to assess the relation between evaluation of presentation formats and overall liking of episodes, which is important for persuasive effects. Thirty women from rural Amhara listened to the episodes and, after listening, female data collectors interviewed the women on evaluation of presentation formats, overall liking of episodes, identification with the characters and convincingness. Evaluation of social-oriented presentation formats was strongly related to overall liking of episodes, but evaluation of expert-oriented presentation formats was not. This relation was mediated through convincingness and not through identification. We conclude that social-oriented presentation formats make messages more convincing and, consequently, improve overall liking and persuasive impact.

Increasing the use of e-consultation in primary care: results of an online survey among non-users of e-consultation.

OBJECTIVE: To identify factors that can enhance the use of e-consultation in primary care. We investigated the barriers, demands and motivations regarding e-consultation among patients with no e-consultation experience (non-users). METHODS: We used an online survey to gather data. Via online banners on 26 different websites of patient organizations we recruited primary care patients with chronic complaints, an important target group for e-consultation. A regression analysis was performed to identify the main drivers for e-consultation use among patients with no e-consultation experience. RESULTS: In total, 1706 patients started to fill out the survey. Of these patients 90% had no prior e-consultation experience. The most prominent reasons for non-use of e-consultation use were: not being aware of the existence of the service, the preference to see a doctor and e-consultation not being provided by a GP. Patients were motivated to use e-consultation, because e-consultation makes it possible to contact a GP at any time and because it enabled patients to ask additional questions after a visit to the doctor. The use of a Web-based triage application for computer-generated advice was popular among patients desiring to determine the need to see a doctor and for purposes of self-care. The patients' motivations to use e-consultation strongly depended on demands being satisfied such as getting a quick response. When looking at socio-demographic and health-related characteristics it turned out that certain patient groups - the elderly, the less-educated individuals, the chronic medication users and the frequent GP visitors - were more motivated than other patient groups to use e-consultation services, but were also more demanding. The less-educated patients, for example, more strongly demanded instructions regarding e-consultation use than the highly educated patients. CONCLUSION: In order to foster the use of e-consultation in primary care both GPs and non-users must be informed about the possibilities and consequences of e-consultation through tailored education and instruction. We must also take into account patient profiles and their specific demands regarding e-consultation. Special attention should be paid to patients who can benefit the most from e-consultation while also facing the greatest chance of being excluded from the service. As health care continues to evolve towards a more patient-centred approach, we expect that patient expectations and demands will be a major force in driving the adoption of e-consultation.

HIV-prevention knowledge among illiterate and low-literate women in rural Amhara, Ethiopia.

More than 85% of Ethiopia's population lives in rural areas and literacy levels in the country are relatively low. Despite this, little is known about levels of knowledge in regard to HIV/AIDS and condom use among illiterate and low-literate rural individuals. We conducted a cross-sectional study among 200 illiterate to semi-literate women, ages 13 to 24, from two rural communities in the Amhara region of northwestern Ethiopia. Nearly all the women had heard about HIV and AIDS. Among the illiterate individuals (n = 54), 24% did not know that HIV was the cause of AIDS and 48% did not know that HIV could be transmitted by sexual intercourse without a condom with an HIV-infected person. Among the same group, 59% did not know what a condom is. Literacy had a strong positive association with knowledge of HIV transmission and condoms. Thus, due to a generally higher level of literacy (grade 5-8 attainment), very young women (ages 13-20) had better knowledge of HIV transmission and condoms than did women ages 21-24 who by comparison were less literate. Given poor knowledge of HIV transmission and condoms among illiterate and low-literate women in Amhara, targeted HIV-prevention interventions are needed in this region.

Evaluation of internet-based technology for supporting self-care: problems encountered by patients and caregivers when using self-care applications.

BACKGROUND: Prior studies have shown that many patients are interested in Internet-based technology that enables them to control their own care. As a result, innovative eHealth services are evolving rapidly, including self-assessment tools and secure patient-caregiver email communication. It is interesting to explore how these technologies can be used for supporting self-care. OBJECTIVE: The aim of this study was to determine user-centered criteria for successful application of Internet-based technology used in primary care for supporting self-care. METHODS: We conducted scenario-based tests combined with in-depth interviews among 14 caregivers and 14 patients/consumers to describe the use of various self-care applications and the accompanying user problems. We focused on the user-friendliness of the applications, the quality of care provided by the applications, and the implementation of the applications in practice. RESULTS: Problems with the user-friendliness of the self-care applications concerned inadequate navigation structures and search options and lack of feedback features. Patients want to retrieve health information with as little effort as possible; however, the navigation and search functionalities of the applications appeared incapable of handling patients' health complaints efficiently. Among caregivers, the lack of feedback and documentation possibilities caused inconvenience. Caregivers wanted to know how patients acted on their advice, but the applications did not offer an adequate feedback feature. Quality of care problems were mainly related to insufficient tailoring of information to patients' needs and to efficiency problems. Patients expected personalized advice to control their state of health, but the applications failed to deliver this. Language (semantics) also appeared as an obstacle to providing appropriate and useful self-care advice. Caregivers doubted the reliability of the computer-generated information and the efficiency and effectiveness of secure email consultation. Legal or ethical issues with respect to possible misuse of email consultation also caused concerns. Implementation problems were mainly experienced by caregivers due to unclear policy on email consultation and the lack of training for email consultations. CONCLUSIONS: Patients' and caregivers' expectations did not correspond with their experiences of the use of the Internet-based applications for self-care. Patients thought that the applications would support them in solving their health problems. Caregivers were more reserved about the applications because of medico-legal concerns about misuse. However, the applications failed to support self-care because eHealth is more than just a technological intervention. The design of the applications should include a way of thinking about how to deliver health care with the aid of technology. The most powerful application for self-care was secure email consultation, combined with a suitable triage mechanism to empower patients' self-awareness. Future research should focus on the effectiveness of such Web-based triage mechanisms for medical complaints and on the development of interactive features to enhance patients' self-care.

Gender power imbalance and differential psychosocial correlates of intended condom use among male and female adolescents from Venda, South Africa.

OBJECTIVES: In South Africa, a gender power imbalance exists which may prevent women from negotiating safe sexual encounters. In this study we tested which constructs from Protection Motivation Theory (PMT) and the Theory of Planned Behavior (TPB) under these circumstances were most related to condom use intention. We hypothesized that in a situation of gender power imbalance self-efficacy would be a more salient correlate of intended condom use for females, while for males attitude to condoms and subjective norm would be more important. DESIGN: This study employed a cross-sectional questionnaire design. METHOD: Male participants (N=94) and female participants (N=101) from Venda, South Africa completed standard, multi-item, reliable measures of TPB constructs (condom-related attitude, subjective norm, perceived behavioural control, intention) and PMT constructs (vulnerability, severity, fear, response-efficacy, self-efficacy) and reported their past condom use behaviour. RESULTS: Regression analysis indicated that among males attitude to condoms and subjective norm were significantly related to intended condom use. Among females attitude and self-efficacy were significantly related to intended condom use. CONCLUSION: The findings indicate that in a situation of gender power imbalance psychosocial correlates of intended condom use differ for males and females. Gender-specific analysis of determinants of condom use may be more appropriate in a situation of gender power imbalance.

Effects of pictures and textual arguments in sun protection public service announcements.

BACKGROUND: The effect of public service announcements aimed at promoting primary prevention of skin cancer may be limited by superficial cognitive processing. The use of both pictures and textual arguments in sun protection public service announcements were evaluated for their potentially beneficial effects on judgment, cognitive processing and persuasiveness. METHODS: In a 2 x 2 factorial experimental design individuals were shown public service announcements that advocated the advantages of sun protection measures in different versions in which a picture was present or not present and a textual argument was present or not present. The 159 participants were randomly assigned to one of four conditions. In each condition, participants were shown 12 different public service announcements designed according to the condition. Participants judged each public service announcement on attractiveness, credibility, clarity of communication and the required amount of reflection. After the judgment task, they completed a questionnaire to assess knowledge, perceived advantages and disadvantages of sun protection and intended use of sun protection measures. RESULTS: Pictures enhanced attractiveness, but diminished comprehension. Textual arguments enhanced attractiveness, credibility and comprehension. Pictures as well as textual arguments increased knowledge of sun protection measures. CONCLUSION: Pictures and textual arguments in public service announcements positively influence the individual's perception of the advantages of sun protection methods and the advantages of their adoption.

Psychosocial correlates of HIV protection motivation among black adolescents in Venda, South Africa.

We assessed the usefulness of the theory of planned behavior (TPB) and protection motivation theory (PMT) to predict intended condom use among 201 adolescents from Venda, South Africa. Results indicated that both the TPB and the PMT could significantly predict intended condom use, although the level of explained variance was limited. Hierarchical regression analysis indicated that there was considerable overlap between the TPB and the PMT in predicting condom use intention. In the regression analysis that used both the TPB and the PMT variables subjective norms and response efficacy were positively related to intended condom use. The results indicated that both the TPB and the PMT were valuable in explaining intended condom use among African adolescents. The TPB made clear that the social environment is an important contextual factor, whereas the PMT made clear that response efficacy is positively related to condom use intention. The results of this study indicated that social cognition models have some value in the analysis of condom use intention of African adolescents, but the role of other factors like myths about condoms should be further examined.