Using the Health Belief Model to understand intention to vaccinate for Lyme disease in the United States.

AIMS: A growing number of Lyme disease (LD) cases in the U.S. are reported in states neighbouring those with high-incidence (>10 cases per 100,000 population) rates. Considering the evolving epidemiology, high-incidence counties in many of these "neighbouring states," and the forthcoming vaccines, understanding the drivers of vaccination intention is critical, particularly how drivers of intention in neighbouring states vary relative to regions currently classified as high incidence. This study uses the Health Belief Model (HBM) to determine the key drivers associated with vaccine intention for U.S. adults and caregivers of children residing in neighbouring states. METHODS AND RESULTS: Using an established panel with quotas for age, sex, race/ethnicity and urbanity, we surveyed 887 adults and 822 caregivers of children residing in U.S. neighbouring states. Survey items included measures of intention and HBM constructs, all of which were assessed using 5-point Likert scales. We subsequently used structural equation modelling to understand the influence of the HBM constructs on LD vaccine intention. Estimates from structural equation modelling show that the HBM constructs explain much of the variation in intention to vaccinate against LD. Intentions to vaccinate for both adults and caregivers are positively influenced by cues to action, perceived susceptibility of LD, and perceived benefits to vaccination. Both are also negatively influenced by perceived barriers to vaccination. The caregiver's intention to vaccinate is also positively influenced by the perceived severity of LD. CONCLUSION: The intention to vaccinate for respondents residing in LD neighbouring states is strongly influenced by recommendations from healthcare providers or the Centers for Disease Control and Prevention (CDC). As incidence rises in neighbouring states and the need to prevent disease becomes more overt, public health officials should strongly recognize the influence of healthcare providers and CDC recommendations on intention to vaccinate against LD.

Intention to vaccinate for Lyme disease using the Health Belief Model.

AIMS: Lyme disease (LD) cases in the United States are estimated to be approaching 500,000 annually. Protective measures, such as repellent use and wearing protective clothing are recommended by public health officials. However, no protective measure has been proven to be consistently effective, partly because they require consistent and persistent behaviour change. While safe and effective vaccines are in development, it is unclear what factors influence the intention to vaccinate against LD. This study uses the Health Belief Model (HBM) framework to determine key drivers associated with vaccine intention. The HBM is widely applied in public health research and uses the following constructs: perceived susceptibility and severity of disease, perceived benefits and barriers to disease prevention, and cues to action for disease prevention to predict health behaviours. To date, the HBM framework has not been applied to vaccination intention for LD. METHODS AND RESULTS: Data were collected from 874 adults and 834 caregivers of children residing in US states endemic to LD. Sampling adults and caregivers allows us to explore how the intention to vaccinate differs among those at-risk. Estimates from structural equation modelling (SEM) show that the HBM constructs explain much of the variation in intention to vaccinate against LD. Both adult and caregiver intentions to vaccinate are positively influenced by cues to action, perceived susceptibility of LD, and perceived benefits to vaccination. However, there is variation in the influence of constructs across the samples. Caregiver's intention to vaccinate is positively influenced by the perceived severity of LD and negatively influenced by safety concerns about the vaccine, whereas adult intention is negatively influenced by perceived barriers to vaccination. CONCLUSION: A strong relationship of cues to action on vaccine intention in samples of adults and caregivers suggests the importance of a recommendation from a healthcare provider or the Centers for Disease Control and Prevention (CDC).

Social norms and financial incentives to promote employees' healthy food choices: A randomized controlled trial.

OBJECTIVE: Population-level strategies to improve healthy food choices are needed for obesity prevention. We conducted a randomized controlled trial of 2672 employees at the Massachusetts General Hospital who were regular customers of the hospital cafeteria with all items labeled green (healthy), yellow (less healthy), or red (unhealthy) to determine if social norm (peer-comparison) feedback with or without financial incentives increased employees' healthy food choices. METHODS: Participants were randomized in 2012 to three arms: 1) monthly letter with social norm feedback about healthy food purchases, comparing employee to "all" and to "healthiest" customers (feedback-only); 2) monthly letter with social norm feedback plus small financial incentive for increasing green purchases (feedback-incentive); or 3) no contact (control). The main outcome was change in proportion of green-labeled purchases at the end of 3-month intervention. Post-hoc analyses examined linear trends. RESULTS: At baseline, the proportion of green-labeled purchases (50%) did not differ between arms. At the end of the 3-month intervention, the percentage increase in green-labeled purchases was larger in the feedback-incentive arm compared to control (2.2% vs. 0.1%, P=0.03), but the two intervention arms were not different. The rate of increase in green-labeled purchases was higher in both feedback-only (P=0.04) and feedback-incentive arms (P=0.004) compared to control. At the end of a 3-month wash-out, there were no differences between control and intervention arms. CONCLUSIONS: Social norms plus small financial incentives increased employees' healthy food choices over the short-term. Future research will be needed to assess the impact of this relatively low-cost intervention on employees' food choices and weight over the long-term. TRIAL REGISTRATION: Clinical Trials.gov: NCT01604499.

Put Your Imperfections Behind You: Temporal Landmarks Spur Goal Initiation When They Signal New Beginnings.

People often fail to muster the motivation needed to initiate goal pursuit. Across five laboratory experiments, we explored occasions when people naturally experience enhanced motivation to take actions that facilitate goal pursuit and why certain dates are more likely to spur goal initiation than others. We present causal evidence that emphasizing a temporal landmark denoting the beginning of a new time period increases people's intentions to initiate goal pursuit. In addition, we propose and show that people's strengthened motivation to begin pursuing their aspirations following such temporal landmarks originates in part from the psychological disassociation these landmarks induce from a person's past, imperfect self.

Communicating science-based recommendations with memorable and actionable guidelines.

For many domains of basic and applied science, a key set of scientific facts is well established and there is a need for public action in light of those facts. However, individual citizens do not consistently follow science-based recommendations, even when they accept the veracity of the advice. To address this challenge, science communicators need to develop a guideline that individuals can commit to memory easily and act on straightforwardly at moments of decision. We draw on research from psychology to discuss several characteristics that will enhance a guideline's memorability and actionability and illustrate using a case study from the US Department of Agriculture's communications based on nutrition science. We conclude by discussing the importance of careful research to test whether any given guideline is memorable and actionable by the intended target audience.

Traffic-light labels and choice architecture: promoting healthy food choices.

BACKGROUND: Preventing obesity requires maintenance of healthy eating behaviors over time. Food labels and strategies that increase visibility and convenience of healthy foods (choice architecture) promote healthier choices, but long-term effectiveness is unknown. PURPOSE: Assess effectiveness of traffic-light labeling and choice architecture cafeteria intervention over 24 months. DESIGN: Longitudinal pre-post cohort follow-up study between December 2009 and February 2012. Data were analyzed in 2012. SETTING/PARTICIPANTS: Large hospital cafeteria with a mean of 6511 transactions daily. Cafeteria sales were analyzed for (1) all cafeteria customers and (2) a longitudinal cohort of 2285 hospital employees who used the cafeteria regularly. INTERVENTION: After a 3-month baseline period, cafeteria items were labeled green (healthy); yellow (less healthy); or red (unhealthy) and rearranged to make healthy items more accessible. MAIN OUTCOME MEASURES: Proportion of cafeteria sales that were green or red during each 3-month period from baseline to 24 months. Changes in 12- and 24-month sales were compared to baseline for all transactions and transactions by the employee cohort. RESULTS: The proportion of sales of red items decreased from 24% at baseline to 20% at 24 months (p<0.001), and green sales increased from 41% to 46% (p<0.001). Red beverages decreased from 26% of beverage sales at baseline to 17% at 24 months (p<0.001); green beverages increased from 52% to 60% (p<0.001). Similar patterns were observed for the cohort of employees, with the largest change for red beverages (23%-14%, p<0.001). CONCLUSIONS: A traffic-light and choice architecture cafeteria intervention resulted in sustained healthier choices over 2 years, suggesting that food environment interventions can promote long-term changes in population eating behaviors.

A traffic light food labeling intervention increases consumer awareness of health and healthy choices at the point-of-purchase.

OBJECTIVE: We surveyed customers in a hospital cafeteria in Boston, Massachusetts before and after implementation of traffic light food labeling to determine the effect of labels on customers' awareness and purchase of healthy foods. METHODS: Cafeteria items were identified as red (unhealthy), yellow (less healthy), or green (healthy). Customers were interviewed before (N=166) and after (N=223) labeling was implemented. Each respondent was linked to cash register data to determine the proportion of red, yellow, and green items purchased. Data were collected from February-April 2010. We compared responses to survey questions and mean proportion of red, yellow, and green items per transaction between customers interviewed during baseline and customers interviewed during the intervention. Survey response rate was 60%. RESULTS: Comparing responses during labeling intervention to baseline, more respondents identified health/nutrition as an important factor in their purchase (61% vs. 46%, p=0.004) and reported looking at nutrition information (33% vs. 15%, p<0.001). Respondents who noticed labels during the intervention and reported that labels influenced their purchases were more likely to purchase healthier items than respondents who did not notice labels (p<0.001 for both). CONCLUSION: Traffic light food labels prompted individuals to consider their health and to make healthier choices at point-of-purchase.

Food choices of minority and low-income employees: a cafeteria intervention.

BACKGROUND: Effective strategies are needed to address obesity, particularly among minority and low-income individuals. PURPOSE: To test whether a two-phase point-of-purchase intervention improved food choices across racial, socioeconomic (job type) groups. DESIGN: A 9-month longitudinal study from 2009 to 2010 assessing person-level changes in purchases of healthy and unhealthy foods following sequentially introduced interventions. Data were analyzed in 2011. SETTING/PARTICIPANTS: Participants were 4642 employees of a large hospital in Boston MA who were regular cafeteria patrons. INTERVENTIONS: The first intervention was a traffic light-style color-coded labeling system encouraging patrons to purchase healthy items (labeled green) and avoid unhealthy items (labeled red). The second intervention manipulated "choice architecture" by physically rearranging certain cafeteria items, making green-labeled items more accessible and red-labeled items less accessible. MAIN OUTCOME MEASURES: Proportion of green- (or red-) labeled items purchased by an employee. Subanalyses tracked beverage purchases, including calories and price per beverage. RESULTS: Employees self-identified as white (73%); black (10%); Latino (7%); and Asian (10%). Compared to white employees, Latino and black employees purchased a higher percentage of red items at baseline (18%, 28%, and 33%, respectively, p<0.001) and a lower percentage of green (48%, 38%, and 33%, p<0.001). Labeling decreased all employees' red item purchases (-11.2%, 95% CI= -13.6%, -8.9%) and increased green purchases (6.6%, 95% CI=5.2%, 7.9%). Red beverage purchases decreased most (-23.8%, 95% CI= -28.1%, -19.6%). The choice architecture intervention further decreased red purchases after the labeling. Intervention effects were similar across all race/ethnicity and job types (p>0.05 for interaction between race or job type and intervention). Mean calories per beverage decreased similarly over the study period for all racial groups and job types, with no increase in per-beverage spending. CONCLUSIONS: Despite baseline differences in healthy food purchases, a simple color-coded labeling and choice architecture intervention improved food and beverage choices among employees from all racial and socioeconomic backgrounds.

A 2-phase labeling and choice architecture intervention to improve healthy food and beverage choices.

OBJECTIVES: We assessed whether a 2-phase labeling and choice architecture intervention would increase sales of healthy food and beverages in a large hospital cafeteria. METHODS: Phase 1 was a 3-month color-coded labeling intervention (red = unhealthy, yellow = less healthy, green = healthy). Phase 2 added a 3-month choice architecture intervention that increased the visibility and convenience of some green items. We compared relative changes in 3-month sales from baseline to phase 1 and from phase 1 to phase 2. RESULTS: At baseline (977,793 items, including 199,513 beverages), 24.9% of sales were red and 42.2% were green. Sales of red items decreased in both phases (P < .001), and green items increased in phase 1 (P < .001). The largest changes occurred among beverages. Red beverages decreased 16.5% during phase 1 (P < .001) and further decreased 11.4% in phase 2 (P < .001). Green beverages increased 9.6% in phase 1 (P < .001) and further increased 4.0% in phase 2 (P < .001). Bottled water increased 25.8% during phase 2 (P < .001) but did not increase at 2 on-site comparison cafeterias (P < .001). CONCLUSIONS: A color-coded labeling intervention improved sales of healthy items and was enhanced by a choice architecture intervention.

Inviting consumers to downsize fast-food portions significantly reduces calorie consumption.

Policies that mandate calorie labeling in fast-food and chain restaurants have had little or no observable impact on calorie consumption to date. In three field experiments, we tested an alternative approach: activating consumers' self-control by having servers ask customers if they wanted to downsize portions of three starchy side dishes at a Chinese fast-food restaurant. We consistently found that 14-33 percent of customers accepted the downsizing offer, and they did so whether or not they were given a nominal twenty-five-cent discount. Overall, those who accepted smaller portions did not compensate by ordering more calories in their entrées, and the total calories served to them were, on average, reduced by more than 200. We also found that accepting the downsizing offer did not change the amount of uneaten food left at the end of the meal, so the calorie savings during purchasing translated into calorie savings during consumption. Labeling the calorie content of food during one of the experiments had no measurable impact on ordering behavior. If anything, the downsizing offer was less effective in changing customers' ordering patterns with the calorie labeling present. These findings highlight the potential importance of portion-control interventions that specifically activate consumers' self-control.

Are they really that happy? Exploring scale recalibration in estimates of well-being.

OBJECTIVE: The authors addressed a lingering concern in research on hedonic adaptation to adverse circumstances. This research typically relies on self-report measures of well-being, which are subjective and depend on the standards that people use in making judgments. The authors employed a novel method to test for, and rule out, such scale recalibration in self-reports of well-being. DESIGN: The authors asked patients with chronic illness (either lung disease or diabetes) and nonpatients to evaluate quality of life (QoL) for the patients' disease. In addition, the authors also asked them to rank and rate the aversiveness of a diverse set of adverse circumstances, allowing examination of both the numerical ratings and ordering among items. MAIN OUTCOME MEASURES: The authors compared patients' and nonpatients' ratings and rankings for the patients' disease and other conditions. RESULTS AND CONCLUSION: The authors found that patients not only assigned higher numerical QoL ratings to their own disease than did nonpatients but also ranked it higher among the broad set of conditions. These results suggest that scale recalibration cannot account for discrepant QoL ratings between patients and nonpatients. More generally, this study presents a new approach for measuring well-being that is not subject to the problem of scale recalibration.

Functional imaging of decision conflict.

Decision conflict occurs when people feel uncertain as to which option to choose from a set of similarly attractive (or unattractive) options, with many studies demonstrating that this conflict can lead to suboptimal decision making. In this article, we investigate the neurobiological underpinnings of decision conflict, in particular, the involvement of the anterior cingulate cortex (ACC). Previous studies have implicated the ACC in conflict monitoring during perceptual tasks, but there is considerable controversy as to whether the ACC actually indexes conflict related to choice, or merely conflict related to selection of competing motor responses. In a functional magnetic resonance imaging study, we dissociate the decision and response phases of a decision task, and show that the ACC does indeed index conflict at the decision stage. Furthermore, we show that it does so for a complex decision task, one that requires the integration of beliefs and preferences and not just perceptual judgments.

Ignorance of hedonic adaptation to hemodialysis: a study using ecological momentary assessment.

Healthy people generally underestimate the self-reported well-being of people with disabilities and serious illnesses. The cause of this discrepancy is in dispute, and the present study provides evidence for 2 causes. First, healthy people fail to anticipate hedonic adaptation to poor health. Using an ecological momentary assessment measure of mood, the authors failed to find evidence that hemodialysis patients are less happy than healthy nonpatients are, suggesting that they have largely, if not completely, adapted to their condition. In a forecasting task, healthy people failed to anticipate this adaptation. Second, although controls understated their own mood in both an estimation task and a recall task, patients were quite accurate in both tasks. This relative negativity in controls' estimates of their own moods could also contribute to their underestimation of the moods and overall well-being of patients.

Effect of assessment method on the discrepancy between judgments of health disorders people have and do not have: a web study.

Three experiments on the World Wide Web asked subjects to rate the severity of common health disorders such as acne or arthritis. People who had a disorder ("Haves") tended to rate it as less severe than people who did not have it ("Not-haves"). Two explanations of this Have versus Not-have discrepancy were rejected. By one account, people change their reference point when they rate a disorder that they have. More precise reference points would, on this account, reduce the discrepancy, but, if anything, the discrepancy was larger. By another account, people who do not have the disorder focus on attributes that are most affected by it, and the discrepancy should decrease when people make ratings on several attributes. Again, if anything, the discrepancy increased when ratings were on separate attributes (combined by a weighted average). The discrepancy varied in size and direction across disorders. Subjects also thought that they would be less affected than others.