The regression trap: why regression analyses are not suitable for selecting determinants to target in behavior change interventions.

Objective: Regression analyses are commonly used for selecting determinants to target in behavior change interventions, but the aim of this article is to explain why regression analyses are not suitable for this purpose (i.e. the regression trap). Methods: This aim is achieved by providing (1) a theoretical rationale based on overlap among determinants; (2) a mathematical rationale based on the formulas that are used to calculate regression coefficients; and (3) examples based on real-world data. Results: First, the meaning of regression coefficients is commonly explained as expressing the association between a determinant and a target behavior 'holding all other predictors constant.' We explain that this often boils down to 'neglecting a part of the psyche.' Second, we demonstrate that the interpretation of regression coefficients is distorted by correlations between determinants. Third, the examples provided demonstrate the impact this has in practice. This results in interventions targeting determinants that are less relevant and, thereby, have less impact on behavior change. Conclusion: There are theoretical, mathematical, and practical reasons why regression analyses, and by extension multivariate analyses relying on correlations, are not suitable to select determinants to target in behavior change interventions. Instead, intervention developers should consider univariate distributions and bivariate association estimates simultaneously and there are freely accessible tools available to do so.

Increasing the transparency of systematic reviews: presenting a generalized registration form.

This paper presents a generalized registration form for systematic reviews that can be used when currently available forms are not adequate. The form is designed to be applicable across disciplines (i.e., psychology, economics, law, physics, or any other field) and across review types (i.e., scoping review, review of qualitative studies, meta-analysis, or any other type of review). That means that the reviewed records may include research reports as well as archive documents, case law, books, poems, etc. Items were selected and formulated to optimize broad applicability instead of specificity, forgoing some benefits afforded by a tighter focus. This PRISMA 2020 compliant form is a fallback for more specialized forms and can be used if no specialized form or registration platform is available. When accessing this form on the Open Science Framework website, users will therefore first be guided to specialized forms when they exist. In addition to this use case, the form can also serve as a starting point for creating registration forms that cater to specific fields or review types.

A lean method for selecting determinants when developing behavior change interventions.

When developing behavior change interventions in a systematic way, it is important to select determinants relevant to the target behavior. Data is needed to gain insight into the determinant structures (the relative strengths of associations between determinants and behavior) and their univariate distributions. This insight is crucial to select the most relevant determinants, but at the same time institutions tasked with behavior change (e.g. prevention organizations, municipal health services) often operate under prohibitive resource constraints, which also extend to how easily they can collect data from a sample. This paper introduces CIBERlite - an approach that furnishes the intervention developer with an idea of the relevance of a limited number of determinants using short measurements informed by theory. The first study (N = 401) in a series of three explores the convergent validity of short and full measurements of determinants derived from the Reasoned Action Approach. The short measurements are used in the main study (N = 415) that serves as a proof-of-concept for the CIBERlite plot, an efficient visualization combining data of determinant structures and their univariate distributions for eight behaviors. The unexpected patterns detected in the main study led to an expert estimation study (N = 45), which shows that individual experts have difficulty in predicting how people score on determinants. This stresses the importance of conducting determinant studies and CIBERlite is a valuable alternative to do so if resources are limited.

Acyclic behavior change diagrams: a tool to report and analyze interventions.

Background: Behavior change interventions have a vital role in enhancing human health and well-being. Nevertheless, concerns have been raised about suboptimal reporting of behavior change interventions, making analyses, replications, and intervention re-use hard or impossible to conduct. Objective: This paper introduces acyclic behavior change diagrams (ABCDs) to achieve more transparent development, evaluation, and reporting of behavior change interventions. ABCDs are a visual representation of the assumptions regarding causal-structural chains that underlie putative active ingredients of behavior change interventions. These causal-structural chains link the behavior change principles that are applied in an intervention to the (determinants of) behavior targeted in that intervention. Conclusions: ABCDs are helpful in making implicit assumptions explicit and help communicate assumptions with team members and other stakeholders. Moreover, we believe they make evaluation easier, and their machine-readability allows for ABCDs to be imported directly into (systematic review) databases with negligible costs while disclosing complete and accurate data. Finally, the ABCD approach fits well with other initiatives to gain a deeper understanding and synthesis of the literature on active intervention elements.

Preventing sexual violence in sport: Determinants of positive coach-bystander behavior.

Given their central role and position, coaches are instrumental in creating safe sport environments, especially in preventing sexual violence, but little is known about bystander behaviors, hampering the development of effective bystander programs in the context of sport. To identify determining characteristics of bystander behavior, 1,442 Belgian youth sport coaches completed an online questionnaire on bystander-related attitudes, norms, autonomy beliefs, and self-efficacy using two hypothetical scenarios of sexual violence in the sports club. Data were analyzed using confidence interval-based estimation of relevance (CIBER). A total of 127 coaches had witnessed sexual violence over the past year, most but not all intervened. Experiential attitude expectation, instrumental attitude evaluation, perceived referent behavior and approval, and subskill presence were positively associated with coaches' intention to intervene. Of the determinants of positive coach-bystander behavior, attitude and perceived norms proved key constituents for programs addressing sexual violence in youth sport. We conclude that interventions aiming at increasing positive affective consequences, reinforcing the sense of group membership, and strengthening the social norm of intervening in case of signs of sexual violence may be most influential to stimulate positive coach-bystander behavior.

The operationalization of self-identity in reasoned action models: a systematic review of self-identity operationalizations in three decades of research.

BACKGROUND: Self-identity has frequently been proposed as a useful addition to the Theory of Planned Behavior; yet Fishbein and Ajzen decided to not include self-identity when they published that theory's successor, the Reasoned Action Approach. One of their reasons for exclusion is the lack of clear conceptual independence, as manifested in self-identity operationalizations that often conflate the construct with attitudinal or normative measures. Therefore, establishing whether self-identity has added value in the Reasoned Action Approach first requires synthesis of the used operationalisations to develop an operationalization that captures self-identity but not attitude and perceived norm. METHOD: In this systematic review we identified 153 articles through the PsycINFO database and descendency approach using Google Scholar. In total, 342 of the operationalisations of self-identity were identified in studies operationalizing it as a potential Reasoned Action Approach extension. RESULTS AND CONCLUSIONS: After analyzing the full item pool to eliminate duplicates and items that did not measure selfidentity, (also) measured attitudes or norms, did not allow tailoring formulations to target, action, context and time, were not applicable to a wide variety of behaviors, or were ambiguous, seven prototypical items remained. These items lend themselves well for further psychometric study to establish the conceptual independence of self-identity from other Reasoned Action Approach constructs such as attitude and perceived norms.

Developing a new national MDMA policy: Results of a multi-decision multi-criterion decision analysis.

BACKGROUND: Ecstasy (3,4-methylenedioxymethamphetamine (MDMA)) has a relatively low harm and low dependence liability but is scheduled on List I of the Dutch Opium Act ('hard drugs'). Concerns surrounding increasing MDMA-related criminality coupled with the possibly inappropriate scheduling of MDMA initiated a debate to revise the current Dutch ecstasy policy. METHODS: An interdisciplinary group of 18 experts on health, social harms and drug criminality and law enforcement reformulated the science-based Dutch MDMA policy using multi-decision multi-criterion decision analysis (MD-MCDA). The experts collectively formulated policy instruments and rated their effects on 25 outcome criteria, including health, criminality, law enforcement and financial issues, thematically grouped in six clusters. RESULTS: The experts scored the effect of 22 policy instruments, each with between two and seven different mutually exclusive options, on 25 outcome criteria. The optimal policy model was defined by the set of 22 policy instrument options which gave the highest overall score on the 25 outcome criteria. Implementation of the optimal policy model, including regulated MDMA sales, decreases health harms, MDMA-related organised crime and environmental damage, as well as increases state revenues and quality of MDMA products and user information. This model was slightly modified to increase its political feasibility. Sensitivity analyses showed that the outcomes of the current MD-MCDA are robust and independent of variability in weight values. CONCLUSION: The present results provide a feasible and realistic set of policy instrument options to revise the legislation towards a rational MDMA policy that is likely to reduce both adverse (public) health risks and MDMA-related criminal burden.

Knowing how effective an intervention, treatment, or manipulation is and increasing replication rates: accuracy in parameter estimation as a partial solution to the replication crisis.

OBJECTIVE: Although basing conclusions on confidence intervals for effect size estimates is preferred over relying on null hypothesis significance testing alone, confidence intervals in psychology are typically very wide. One reason may be a lack of easily applicable methods for planning studies to achieve sufficiently tight confidence intervals. This paper presents tables and freely accessible tools to facilitate planning studies for the desired accuracy in parameter estimation for a common effect size (Cohen's d). In addition, the importance of such accuracy is demonstrated using data from the Reproducibility Project: Psychology (RPP). RESULTS: It is shown that the sampling distribution of Cohen's d is very wide unless sample sizes are considerably larger than what is common in psychology studies. This means that effect size estimates can vary substantially from sample to sample, even with perfect replications. The RPP replications' confidence intervals for Cohen's d have widths of around 1 standard deviation (95% confidence interval from 1.05 to 1.39). Therefore, point estimates obtained in replications are likely to vary substantially from the estimates from earlier studies. CONCLUSION: The implication is that researchers in psychology -and funders- will have to get used to conducting considerably larger studies if they are to build a strong evidence base.

Promoting ear plugs at music events: evaluation of the Celebrate Safe approach.

OBJECTIVE: The Celebrate Safe approach is a collaboration between public health organisations and music event/venue organisers to encourage health promotion interventions in nightlife settings and at music events. The purpose of this study was to evaluate the Celebrate Safe approach with regard to its impact on use of ear plugs among visitors of music events. DESIGN: A pre-registered cluster-randomised controlled trial conducted at music events throughout the Netherlands (k = 15). In the experimental condition, event organisers were asked to share an online pre-event message about ear plugs, clearly indicate where visitors could buy ear plugs, and sell ear plugs at busy locations on the premises. Visitors were encouraged to wear ear plugs by means of an 'ear check' at the beginning of the event.Study sample: Observations to assess whether event visitors wear ear plugs (N = 3836). RESULTS: A multilevel model, taking into account nesting of visitors within events, revealed that use of ear plugs at music events in the experimental condition was higher in comparison to events in the control condition (23% vs. 14%, OR = 1.9, 95%CI 1.2-3.0, p = 0.004). CONCLUSIONS: The Celebrate Safe approach has a positive impact on use of ear plugs among visitors of music events.

Sedentary Work in Desk-Dominated Environments: A Data-Driven Intervention Using Intervention Mapping.

BACKGROUND: Since desk-dominated work environments facilitate sedentary behavior, office workers sit for 66% of their working days and only 8% succeed in interrupting their prolonged periods of sitting within the first 55 minutes. Yet stretches of long and uninterrupted sitting increase the likelihood of several chronic metabolic and cardiovascular diseases. OBJECTIVE: We therefore developed a computer-based app designed to interrupt periods of prolonged sitting among office employees. METHODS: When developing the intervention, we applied the intervention mapping protocol. This approach for the systematic design of theory and evidence-based behavior change programs consists of 6 steps: creation of a logic model of the problem, creation of a logic model of change, program design, program production, design of an implementation plan, and development of an evaluation plan. RESULTS: Working through all 6 steps has resulted in an individually adaptable intervention to reduce sedentary behavior at work. The intervention, UPcomplish, consists of tailored, half-automatized motivational components delivered by a coach. To register sedentary behavior, the VitaBit (VitaBit Software International BV) toolkit, a wearable accelerometry-based monitoring device, is used. Among others, UPcomplish includes personalized goal setting, tailored suggestions to overcome hurdles, and weekly challenges. The VitaBit toolkit supports the participants to monitor their behavior in relation to self-set goals. CONCLUSIONS: Intervention mapping is a useful protocol not only for the systematic development of a comprehensive intervention to reduce sedentary behavior but also for planning program adherence, program implementation, and program maintenance. It facilitates obtaining the participation of relevant stakeholders at different ecological levels in the development process of the intervention and anticipating facilitators to and barriers of program implementation and maintenance. TRIAL REGISTRATION: Netherlands Trial Register NL7503; https://www.trialregister.nl/trial/7503.

Attitudes Underlying Reliance on Complementary and Alternative Medicine.

Objective: We aimed to map attitudes underlying complementary and alternative medicine (CAM) use, especially those involved in "dysfunctional CAM reliance," that is, forgoing biomedical treatment in a life-threatening situation in favor of alternative treatment. Analyses of modifiable determinants of CAM use were conducted at a sufficiently specific level to inform intervention development. Methods: We collected usable data on CAM-related attitudinal beliefs from 151 participants in Budapest with varying degrees of CAM use, which we analyzed using confidence interval-based estimation of relevance plots. Results: Although there were beliefs that the entire sample shared, there was a marked difference between the biomedical and CAM groups. These differences were beliefs concerning trust in various medical systems, the level of importance assigned to emotions in falling ill, and vitalism or Eastern concepts. Regarding CAM users in general, the most successful intervention targets are beliefs in vitalism on the one hand, and distrust in biomedicine on the other. In addressing dysfunctional CAM use specifically, the most significant beliefs pertain to "natural" cures and reliance on biomedical testing. Conclusions: Albeit much research has been carried out on the motivations behind CAM use, rarely do studies treat CAM users separately in order to scrutinize patterns of nonconventional medicine use and underlying cognition. This is the first study to begin pinpointing specific attitudes involved in dysfunctional CAM use to inform future intervention development. Such interventions would be essential for the prevention of incidents and mortality.

Incontinence in persons with fetal alcohol spectrum disorders: a polish cohort.

INTRODUCTION: Fetal alcohol spectrum disorders (FASD) is an important preventable public health concern, associated to a number of common pediatric problems such as incontinence. Little is known about the prevalence and presentation of incontinence in FASD, which hinders effective management. OBJECTIVE: The aim of the present study was to investigate incontinence among people with FASD. STUDY DESIGN: Parental questionnaires were sent to all eligible FASD participants. To enable comparing the observed prevalence with typically developing, non-prenatally alcohol-exposed individuals, two clinical control groups of patients undergoing immunotherapy for pollen allergy (GKA) and patients diagnosed with celiac disease (GKG) were selected. RESULTS: A total of 119 participants were included in the study (FAS: n = 24, partial fetal alcohol syndrome [pFAS]: n = 19, alcohol-related neurodevelopmental disorder [ARND]: n = 28, GKA: n = 34, and GKG: n = 14). Overall incontinence for FASD was estimated to be 24% (confidence interval [CI] ranges from 15 to 36); nocturnal enuresis (NE) was present in 10% (CI ranges from 4 to 19), daytime urinary incontinence (DUI) in 11% (CI ranges from 5 to 21), and fecal incontinence (FI) in 13% (CI ranges from 6 to 23). Symptoms of urgency were present for 52%, voiding postponement for 10%, and straining for 2%. These data are both consistent with higher prevalence in individuals with FASD and with similar prevalence (the CIs overlap). CONCLUSION: Children and adolescents with FAS, pFAS, ARND, GKA, and GKG are affected by incontinence. Highest rates were observed in pFAS and ARND. Persons with FAS were mostly affected by DUI, those with pFAS by NE, and those with ARND by FI.

Applying the Generalized Logistic Model in Single Case Designs: Modeling Treatment-Induced Shifts.

Many analytical approaches to single-case data assume either linear effects (regression-based methods) or instant effects (mean-based methods). Neither assumption is realistic; therefore, these approaches' assumptions are often violated. In this article, we propose modeling curvilinear effects to appropriately parametrize the characteristics of singe-case data. Specifically, we introduce the generalized logistic function as adequate function for this situation. The merits of the proposed procedure are demonstrated using data previously used in single case research that represent typical single case data. We provide the function with auxiliary graphical options to demonstrate the model parameters. The function is freely available in the R package "userfriendlyscience." The proposed procedure is a new way to analyze single case data, which may provide applied single case researchers with a new tool to better understand their data and avoid applying methods with violated assumptions.

Towards an assessment instrument for suffering in patients with psychiatric conditions: assessing cognitive validity.

BACKGROUND: Unbearable suffering is a key criterion in legally granting patients' euthanasia requests in Belgium yet a generally accepted definition of unbearable suffering remains elusive. The ability to understand and assess unbearable suffering is essential, particularly in patients with psychiatric conditions, as the underlying causes of these conditions are not always apparent. To enable research into when and why suffering experiences incite patients with psychiatric conditions to request euthanasia, and to help explore preventive and curative perspectives, the development of an assessment instrument is needed. AIMS: To improve the cognitive validity of a large initial item pool used to assess the nature and extent of suffering in patients with psychiatric conditions. METHOD: Cognitive validity was established via two rounds of cognitive interviews with patients with psychiatric conditions with (n = 9) and without (n = 5) euthanasia requests. RESULTS: During the first round of cognitive interviews, a variety of issues relating to content, form and language were reported and aspects that were missing were identified. During the second round, the items that had been amended were perceived as sufficiently easily to understand, sensitive to delicate nuances, comprehensive and easy to answer accurately. Neither research topic nor method were perceived as emotionally strenuous, but instead as positive, relevant, comforting and valuable. CONCLUSIONS: This research resulted in an item pool that covers the concept of suffering more adequately and comprehensively. Further research endeavours should examine potential differences in suffering experiences over time and in patients with psychiatric conditions with and without euthanasia requests. The appreciation patients demonstrated regarding their ability to speak extensively and openly about their suffering and wish to die further supports the need to allow patients to speak freely and honestly during consultations. DECLARATION OF INTERESTS: None.

Systematic literature review on which maternal alcohol behaviours are related to fetal alcohol spectrum disorders (FASD).

OBJECTIVES: Fetal alcohol spectrum disorders (FASD) is a worldwide problem. Maternal alcohol consumption is an important risk factor for FASD. It remains unknown which alcohol consumption patterns most strongly predict FASD. The objective of this study was to identify these. DESIGN: Systematic literature review. METHODS: We searched in PubMed, PsychINFO, PsycARTICLES, ERIC, CINAHL, Embase and MEDLINE up to August 2018. The query consisted of keywords and their synonyms related to FASD, pregnancy and behaviour. Studies were excluded when not published in English, were reviews or involved non-human subjects. Substantial heterogeneity precluded aggregation or meta-analysis of the data. Instead, data were qualitatively inspected. RESULTS: In total, 21 studies were eligible for further data analysis. All studies that measured both maternal alcohol drinking behaviours and FASD reported retrospective data on maternal drinking patterns, employing both continuous and categorical measures and exhibiting substantial heterogeneity in measures of alcohol consumption (eg, timing of exposure, quantification of alcohol measure and definition of a standard drink). Study quality improved over time and appeared higher for studies based on active case ascertainment, especially when conducted in schools and when behaviour was assessed through interviews. CONCLUSIONS: We aimed to identify specific maternal drinking behaviour(s) related to FASD. The state of the literature precludes such conclusions. Evidence-based preventive measures necessitate identifying which prenatal alcohol drinking behaviour(s) are most in need of intervention. Therefore, we formulate three recommendations for future research. First, future studies can optimise the value of the collected dataset through specifying measurements and reporting of maternal drinking behaviours and avoiding categorised measures (nominal or ordinal) whenever possible. Second, samples should not be selected based on FASD status, but instead, FASD status as well as maternal alcohol consumption should both be measured in a general population sample. Finally, we provide 10 reporting guidelines for FASD research.

Evolutionary learning processes as the foundation for behaviour change.

We argue that the active ingredients of behaviour change interventions, often called behaviour change methods (BCMs) or techniques (BCTs), can usefully be placed on a dimension of psychological aggregation. We introduce evolutionary learning processes (ELPs) as fundamental building blocks that are on a lower level of psychological aggregation than BCMs/BCTs. A better understanding of ELPs is useful to select the appropriate BCMs/BCTs to target determinants of behaviour, or vice versa, to identify potential determinants targeted by a given BCM/BCT, and to optimally translate them into practical applications. Using these insights during intervention development may increase the likelihood of developing effective interventions - both in terms of behaviour change as well as maintenance of behaviour change.

When unbearable suffering incites psychiatric patients to request euthanasia: qualitative study.

BackgroundThe concept of 'unbearable suffering' is central to legislation governing whether euthanasia requests may be granted, but remains insufficiently understood, especially in relation to psychiatric patients.AimsTo provide insights into the suffering experiences of psychiatric patients who have made a request for euthanasia.MethodTestimonials from 26 psychiatric patients who requested euthanasia were analysed using QualiCoder software.ResultsFive domains of suffering were identified: medical, intrapersonal, interpersonal, societal and existential. Hopelessness was confirmed to be an important contributor. The lengthy process of applying for euthanasia was a cause of suffering and added to experienced hopelessness, whereas encountering physicians who took requests seriously could offer new perspectives on treatment.ConclusionsThe development of measurement instruments to assess the nature and extent of suffering as experienced by psychiatric patients could help both patients and physicians to better navigate the complicated and sensitive process of evaluating requests in a humane and competent way. Some correlates of suffering (such as low income) indicate the need for a broad medical, societal and political debate on how to reduce the burden of financial and socioeconomic difficulties and inequalities in order to reduce patients' desire for euthanasia. Euthanasia should never be seen (or used) as a means of resolving societal failures.

Using Confidence Interval-Based Estimation of Relevance to Select Social-Cognitive Determinants for Behavior Change Interventions.

When developing an intervention aimed at behavior change, one of the crucial steps in the development process is to select the most relevant social-cognitive determinants. These determinants can be seen as the buttons one needs to push to establish behavior change. Insight into these determinants is needed to select behavior change methods (i.e., general behavior change techniques that are applied in an intervention) in the development process. Therefore, a study on determinants is often conducted as formative research in the intervention development process. Ideally, all relevant determinants identified in such a study are addressed by an intervention. However, when developing a behavior change intervention, there are limits in terms of, for example, resources available for intervention development and the amount of content that participants of an intervention can be exposed to. Hence, it is important to select those determinants that are most relevant to the target behavior as these determinants should be addressed in an intervention. The aim of the current paper is to introduce a novel approach to select the most relevant social-cognitive determinants and use them in intervention development. This approach is based on visualization of confidence intervals for the means and correlation coefficients for all determinants simultaneously. This visualization facilitates comparison, which is necessary when making selections. By means of a case study on the determinants of using a high dose of 3,4-methylenedioxymethamphetamine (commonly known as ecstasy), we illustrate this approach. We provide a freely available tool to facilitate the analyses needed in this approach.