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OBJECTIVE: Optimizing a self-persuasion intervention app for adolescent HPV vaccination requires investigating its hypothesized mechanisms. Guided by the experimental medicine approach, we tested whether (a) self-persuasion intervention components (verbalize vaccination reasons, choose HPV topics) changed putative mechanisms (memory, autonomous motivation) and (b) measures of the putative mechanisms were associated with HPV vaccination. METHODS: These are secondary analyses from a randomized 2 (cognitive processing: verbalize reasons vs. listen) × 2 (choice: choose HPV topics vs. assigned) factorial trial (Tiro et al., 2016). Undecided parents (N = 161) with an unvaccinated child (11–17 years old) used the self-persuasion app, recalled reasons for vaccination (memory measure), and completed an autonomous motivation measure. Adolescent vaccination status was extracted from electronic medical records 12 months post-intervention. RESULTS: The verbalize component resulted in greater recall accuracy of vaccination reasons (p < .001); however, the choose topics component did not increase autonomous motivation scores (p = .74). For associations with HPV vaccination, recall accuracy was not associated (ps > .51), but autonomous motivation scores significantly predicted vaccination (ps < .03), except when controlling for baseline motivation (p = .22). CONCLUSION: The intervention app engages parents in reasons for vaccination; however, memory may not be a viable mechanism of vaccination. Although the intervention did not affect autonomous motivation, associations with vaccination status suggest it is a viable intervention target for HPV vaccination but alternative strategies to change it are needed. Future testing of a refined app should examine implementation strategies to optimize delivery in clinical or community settings.

People have much to gain from regular exercise, such as improved sleep, increased cognitive function, and reduced risk for cardiovascular disease, and these benefits may be particularly important for people experiencing deficits in these areas due to depressive symptoms (Kubesch et al., 2003; Lett et al., 2004; Rethorst et al., 2013). Moreover, regular exercise can be an effective treatment for depression (Babyak et al., 2000; Dunn et al., 2005; Mather et al., 2002; Mota-Pereira et al., 2011; Rethorst, Wipfli, & Landers, 2009). Despite the myriad benefits of regular exercise, adults with depressive symptoms have lower exercise levels than other adults (Patten, Williams, Lavorato, & Eliasziw, 2009; Roshaneai-Moghaddam, Katon, & Russo, 2009) and those with depressive symptoms who initiate a regular exercise regimen are more likely than others to discontinue it (DiMatteo, Lepper, & Croghan, 2000; Teixeira et al., 2004). Therefore, it is important to understand the reasons why people with depressive symptoms have difficulty initiating and maintaining regular exercise. Models of health behavior change, such as the Health Action Process Approach, Theory of Planned Behavior, and Social Cognitive Theory, emphasize the role of self-efficacy in successful behavior change (Ajzen, 1991; Bandura, 1997; Schwarzer, 1992). Self-efficacy is a person’s belief in his or her own ability to execute a specific behavior (Bandura, 1997), and it is central to behavior change because it guides what behaviors people choose to engage in and how people respond to obstacles and challenges in changing their behaviors (Bandura, 1997). Self-efficacy is known to be a predictor of successful initiation and maintenance of regular exercise (Rodgers, Hall, Blanchard, McAuley, & Munroe, 2002; Williams et al., 2008). Low self-efficacy may be one reason why people with depressive symptoms have difficulties initiating and maintaining regular exercise. People with depressive symptoms report lower self-efficacy than people without depressive symptoms across various behaviors (Bandura, 1998; Robinson-Smith, Johnston & Allen, 2000; Sacco et al., 2005). However, to date, it is unclear how depressive symptoms affect people’s self-efficacy while they attempt to initiate regular exercise. Self-efficacy beliefs are based on perceptions of ability to execute the relevant behavior, as well as perceptions of specific task demands and situational circumstances. Self-efficacy is theorized to stem from four sources: personal experience, vicarious experience, social persuasion (e.g., verbal encouragement), and physiological factors (e.g., arousal such as increased heart rate can lead to perceived inefficacy). Among these different sources, personal experience in executing the relevant behavior is the strongest source of self-efficacy perceptions (Bandura, 1997). Consistent with the proposition that personal experience is the strongest source of self-efficacy, exercise self-efficacy has been shown to significantly increase following participation in exercise. This has been observed after individual bouts of exercise (McAuley, 1995; McAuley et al., 2011) and long-term interventions for regular exercise (Marcus, Selby, Niaura, & Rossi, 1992; McAuley, 1995). This pattern of self-efficacy increases following the execution of exercise is consistent across the literature among healthy adults (Keller, Fleury, Gregor-Holt, & Thompson, 1999). In contrast, self-efficacy has been shown to decrease when individuals do not adhere to regular exercise, especially during the initiation of regular exercise as a new behavior (Parschau, Richert, Koring, Lippke, & Schwarzer, 2012). These findings all demonstrate that perceptions of self-efficacy are sensitive to whether people are successfully engaging in exercise or not. However, Bandura (1997) emphasized that it is not simply objective task execution that influences self-efficacy, but also the subjective perceptions and interpretations associated with the behavior. Subjective perceptions can be influenced by personal factors, such as differences in affective and cognitive processing. Depressive symptoms may be a personal factor that moderates the path between personal experience with exercise and self-efficacy. Depression is characterized by negative interpretations of experiences that are influenced by rumination, negative cognitions, and negative recall bias (Beck, 1991). The result of these negative interpretations is a tendency to minimize successes and exaggerate failures (Bandura, 1997). There is evidence to suggest that depressive symptoms influence self-efficacy to exercise regularly, but the evidence does not specifically address how this occurs. For example, older adults with depressive symptoms who enrolled in a 10-week progressive resistance-training program did not report increases in self-efficacy despite regular participation in exercise and objective gains in physical capability (Singh et al., 1997). This finding suggests the possibility that people with depressive symptoms have difficulties deriving self-efficacy from successfully performing exercise. This would be consistent with evidence that depressive symptoms are associated with a tendency to minimize successes (Bandura, 1997; Beck, 1991). Alternatively, Conroy and colleagues (2007) analyzed cross-sectional data one year after an exercise intervention in order to understand lapses (i.e., two weeks of failed adherence) during the initiation of a regular exercise regimen. They found that participants with high depressive symptoms were more likely than other participants to never return to regular exercise after a lapse to inactivity. This suggests that not exercising for two weeks was more detrimental to regular exercise behavior for participants with high depressive symptoms than those with low symptoms. One possible explanation is that participants with depressive symptoms may have experienced greater decreases in self-efficacy when they did not exercise regularly. This would be consistent with evidence that depressive symptoms can also be associated with a tendency to exaggerate failures (Bandura, 1997; Beck, 1991). However, this possibility was not directly examined. If depressive symptoms moderate the relation between exercise and self-efficacy, the moderation effect could be manifest in two different ways. First, depressive symptoms may dampen an increase in self-efficacy when people exercise (e.g., self-efficacy is lower for people with high depressive symptoms than those with low symptoms on days they exercise). Second, depressive symptoms may amplify a decrease in self-efficacy when people do not exercise (e.g., self-efficacy is lower for people with high depressive symptoms than those with low symptoms on days they do not exercise). Current evidence is unclear as to whether either or both effects occur for people with depressive symptoms (Singh et al., 1997; Conroy et al., 2007). Elucidating how these effects unfold on a daily basis would help specify why people with depressive symptoms have difficulties initiating regular exercise. Self-efficacy and exercise both have unique features that would benefit from daily examination over time. First, self-efficacy is not a static construct; it varies according to a person’s experiences (Shiffman et al., 2000). Second, the first days and weeks of initiating regular exercise are a sensitive period in both the formation of self-efficacy (Bandura, 1997) and establishing regular exercise (Dishman, Ickes, & Morgan, 1980), thus it is likely that exercise self-efficacy will be particularly sensitive to daily influences during this critical phase. Third, regular exercise is a health behavior that does not necessitate daily adherence, unlike other health behaviors such as smoking cessation or medication adherence. Indeed, public health guidelines for physical activity recommend activity on most but not all days of the week (USDHHS, 2008). Consequently, for people initiating regular exercise, there will routinely be days on which they exercise and days on which they do not. Distinguishing between experiences that occur on days of exercise and days of no exercise is relevant to understanding the daily psychological processes that occur during the initiation phase of regular exercise.

OBJECTIVE Self-persuasion-generating one's own arguments for engaging in a specific behavior-can be an effective strategy to promote health behavior change, yet the causal processes that explain why it is effective are not well-specified. We sought to elucidate specific causal components and a mediating process of self-persuasion in two health behavior domains: physical activity and smoking. METHODS In two experiments, participants were randomized to write or read arguments about regular exercise (Study 1: N = 76; college students) or smoking cessation (Study 2: N = 107; daily smokers). In Study 2, we also manipulated the argument content (matched vs. mismatched participants' own concerns about smoking) to isolate its effect from the effect of argument source (self vs. other). Study outcomes included participants' reports of argument ratings, attitudes, behavioral intentions (Studies 1 & 2), and cessation attempts at 1 month (Study 2). RESULTS In Study 1, self-generated arguments about exercise were evaluated more positively than other arguments (p = .01, d = .63), and this biased processing mediated the self-generated argument effect on attitudes toward exercise (β = .08, 95% CI = .01, .18). In Study 2, the findings suggested that biased processing occurs because self-generated argument content matches people's own health concerns and not because of the argument source (self vs. other). In addition, self-generated arguments indirectly led to greater behavior change intentions (Studies 1 & 2) and a greater likelihood of a smoking cessation attempt (Study 2). CONCLUSIONS The findings elucidate a causal component and a mediating process that explain why self-persuasion and related behavior change interventions, such as motivational interviewing, are effective. Findings also suggest that self-generated arguments may be an efficient way to deliver message interventions aimed at changing health behaviors.

OBJECTIVE Researchers who study physical activity often use outcome variables that have a lower bound of zero and are positively skewed (e.g., minutes of physical activity in a day). Researchers also often use statistical methods that assume the outcome is normally distributed or transform the outcome as an attempt to make it more normal, both of which can be problematic. In this article, the authors describe multilevel 2-part models that use a mixture of logistic regression-to predict whether a person was active-and gamma regression-to predict amount of activity if there was activity. METHOD The authors contrast the 2-part models to a linear multilevel model using data from a longitudinal study of physical activity (N = 113; 2,305 observations). The dependent variable was minutes of moderate-to-vigorous activity in a day and the predictor variables were day, satisfaction, and gender. RESULTS The 2-part models outperform the linear model and provide researchers critical information that is conceptually relevant, such as distinguishing between predictors of whether activity occurred and of how much activity occurred. CONCLUSIONS Two-part models represent a flexible and useful addition to the analysis repertoire of health researchers. To assist researchers in learning these methods, the online supplemental materials provide additional technical information as well as annotated computer code for estimating these models. (PsycINFO Database Record

Objectives: Even after acute coronary syndrome (ACS) is ruled out, observational studies have suggested that many patients with nonspecific chest pain have a high burden of cardiovascular risk factors (CRFs) and are at increased long-term risk of ischemic heart disease (IHD)-related mortality. The aim of this study was to evaluate the premise that evaluation in an observation unit for symptoms of possible ACS is a “teachable moment” with regard to modification of CRFs. Methods: The authors conducted a baseline face-to-face interview and a 3-month telephone interview of 83 adult patients with at least one modifiable CRF who presented with symptoms of possible ACS to an academic medical center. Existing questionnaires were adapted to measure Health Belief Model (HBM) constructs for IHD. Stage of change and self-reported CRF-related behaviors (diet, exercise, and smoking) were assessed using previously validated measures. The paired t-test or signed rank test was used to compare baseline and 3-month measures of health behavior within the analysis sample. Results: Of the 83 study patients, 45 and 40% reported having received clinician advice regarding diet and physical activity during the observation unit encounter, respectively; 69% of current smokers received advice to quit smoking. Patients reported lower susceptibility to IHD (13.3 vs. 14.0, p = 0.06) and greater perceived benefit of healthy lifestyles (27.5 vs. 26.4, p = 0.0003) at 3-month follow-up compared to baseline. Patients also reported greater readiness to change and improved self-reported behaviors at follow-up (vs. baseline): decreased intake of saturated fat (10.1% vs. 10.5% of total calories, p = 0.005), increased fruit and vegetable intake (4.0 servings/day vs. 3.6 servings/day, p = 0.01), and fewer cigarettes (13 vs. 18, p = 0.002). Conclusions: Observed changes in IHD health beliefs and CRF-related behaviors during follow-up support the idea that observation unit admission is a teachable moment. Patients with modifiable risk factors may benefit from systematic interventions to deliver CRF-related counseling during observation unit evaluation.

Background: Congruence between patients’ and providers’ preferred healthcare role orientations has been shown to be important for improved clinical outcomes and patient satisfaction. Thus, it is important to know how different patient and provider populations might vary in preferred role orientations. Objective: To measure the range of role orientation preferences among patients and providers in two different general medicine clinic populations. Methods: Role orientation preferences of patients (n = 319) and providers (n = 151) in six Veterans Administration (VA) primary care clinics and two university-based primary care clinics were measured in a cross sectional survey using the 9-item Patient-Practitioner Orientation Scale (PPOS) sharing subscale among patients and providers. Results: VA patients had lower mean PPOS scores (i.e. more provider-centered role preference) than the university clinic patients (31.2 vs 39.7, respectively; p< 0.001). The difference remained significant even after adjusting for age, sex, and education. VA and university clinic providers had similar mean PPOS scores (41.5 vs 42.6, respectively; p = 0.27). Greater differences were found in mean PPOS scores between VA patients and their providers (31.2 vs 41.5, respectively; p < 0.001) than university clinic patients and their providers (39.7 vs 42.6, respectively; p = 0.12). Conclusions: VA patients reported preferences for a more provider-centered role than university clinic patients and there was greater mean difference in preferred role orientations between VA patients and their providers than between university clinic patients and their providers. Differences in preferred role orientations by patients and providers should be considered when designing clinical initiatives and research to improve patient care.

We sought to determine whether different social, psychological, emotional, and physiological experiences associated with quitting smoking related to people’s satisfaction with cessation systematically, and whether the strength of the relations changes at different points during the cessation process and for different people (e.g., optimists). Using data from smokers enrolled in a cessation program, we used mixed models to assess the average longitudinal relation between people’s experiences and satisfaction measured at seven time points and whether the relations were moderated by key variables. Eight of nine experiences were related to people’s satisfaction (ps < 0.05) and the models accounted for 39–44% of the within-person variance in satisfaction. Current smoking behavior was more strongly related to people’s satisfaction during their early efforts to quit, whereas some experiences (e.g., feedback from others) had a stronger relation with satisfaction during people’s later efforts to quit or maintain abstinence (ps < 0.05). Individual differences in optimism and prior cessation experience moderated some of the relations (ps < 0.05). The findings mark the first evidence of factors that might influence how people determine their satisfaction with smoking cessation. The implications for tailoring interventions and potentially increasing the likelihood that people maintain abstinence are discussed.

In an academic setting, we tested competing predictions derived from two conceptual models about the effects of approach and avoidance referents (e.g., goals and role models) on student performance. One model suggests a main effect such that focusing on approach referents leads to better outcomes than focusing on avoidance referents, regardless of personality (e.g., A. J. Elliot & K. M. Sheldon, 1997). Another model suggests an interaction such that focusing on either approach or avoidance referents can lead to positive outcomes, but only when people are promotion focused or prevention focused, respectively (e.g., P. Lockwood, C. H. Jordan, & Z. Kunda, 2002). Findings supported the main effect model. The more prevention focused participants were, the more avoidance goals they generated, which led to poorer grades.

Using data from smokers (N = 591) who enrolled in an 8-week smoking cessation program and were then followed for 15 months, the authors tested the thesis that self-efficacy guides the decision to initiate smoking cessation but that satisfaction with the outcomes afforded by quitting guides the decision to maintain cessation. Measures of self-efficacy and satisfaction assessed at the end of the program, 2 months, and 9 months were used to predict quit status at 2, 9, and 15 months, respectively. At each point, participants were categorized as either initiators or maintainers on the basis of their pattern of cessation behavior. Across time, self-efficacy predicted future quit status for initiators, whereas satisfaction generally predicted future quit status for maintainers. Implications for models of behavior change and behavioral interventions are discussed.

Satisfaction with physical activity is known to be an important factor in physical activity maintenance, but the factors that influence satisfaction are not well understood. The purpose of this study was to elucidate how ongoing experiences with recently initiated physical activity are associated with satisfaction. Participants (n = 116) included insufficiently active volunteers who initiated a self-directed physical activity regimen and completed daily diaries about their experiences for 28 days. We used multilevel models to examine the associations between experiences with physical activity and satisfaction. Significant between-person effects demonstrated that people reporting higher average levels of positive experiences and lower levels of thinking about the negative aspects of exercise were more likely to report higher levels of satisfaction (ps