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AIMS: To examine the effects of processes of change (POC) on forward stage movement directly, indirectly through decisional balance and temptation, and total effects as a test of the key hypothesis of the Transtheoretical Model (TTM). DESIGN: Prospective cohort study. SETTING: United Kingdom. PARTICIPANTS: A total of 1160 adolescents aged 13-14 years who were current or former smokers at baseline. MEASUREMENTS: Stage was assessed with the standard algorithm three times, once every 3 months. On each occasion the POC, decisional balance and temptation were measured with the standard questionnaires. Path analysis was used to examine the direct, indirectly mediated and total contribution of POC and the other constructs to stage movement 3 months later. FINDINGS: Four of the 24 analyses showed evidence that the theoretically appropriate POC predicted stage transition, with statistically significant total effects. Effect sizes were small. When the POC were summarized to experiential and behavioural process means, one transition from pre-contemplation was predicted by experiential processes and, contrary to the TTM, one transition predicted by behavioural processes. There was slightly more evidence that decisional balance (attitudes towards smoking) and temptation (ability to resist the urge to smoke) was associated with stage transition. CONCLUSIONS: POC use was not associated generally with stage transition and evidence that effects, if missed, must be modest, giving no support to the central tenet of the TTM.

Objective There is evidence from laboratory studies that anxiety scores are elevated by completing questionnaires about health problems for the first time. This limits interpretation of the common finding that people receiving risk information from screening programs show elevated anxiety (as assessed by questionnaire) in the short-term, which subsides over time. We examine the extent to which postal questionnaire studies are affected by this potential measurement artifact. Study Design and Setting Participants were 964 patients at high risk of undiagnosed diabetes, registered at five general practices. A two-group randomized experimental design was used, with the experimental group (n = 484) receiving an initial questionnaire concerning screening for diabetes, and the control group (n = 480) not receiving this questionnaire. Outcomes were assessed by an identical questionnaire 3 months later. Results There were no significant differences in questionnaire scores at three months between the two groups on any of the outcome measures, including anxiety, symptoms, perceptions of diabetes severity, and perceived diabetes risk. Conclusion These results suggest that the problems associated with the use of anxiety questionnaires that are found in laboratory studies do not occur in postal studies: the observed changes in anxiety after receiving screening results are therefore unlikely to be artifactual.

Tobacco smoking continues to be a major public health problem. Few smokers present themselves for treatment, and it is important to offer a range of interventions that appeal to different individual needs and preferences. Computer-tailored feedback can fill the gap between generic self-help and intensive clinical therapy. Using focus groups, we investigated smokers’ perceptions of generic self-help materials and computer-generated individually tailored feedback reports. Participants recognized the generic nature of self-help material and welcomed the concept of personal support, but were concerned about some aspects of the material. Findings supported the continuation of the development and delivery of computer-tailored feedback, but more research is warranted to optimize the content and style of the feedback for individual perceptions and expectations. Tobacco smoking continues to be a major public health problem. Clinical services to help smokers to quit are available in the United Kingdom through the National Health Service, but are taken up by few (Bauld, Chesterman, Judge, Pound, & Coleman, 2003). Because so few people present themselves for treatment to existing services, there is an urgent need to develop and deliver costeffective interventions to the larger population, rather than to the dependent smokers who seek specialized help (Lichtenstein & Glasgow, 1992), and it is important to offer a range of interventions that appeal to different individual needs and preferences (Resnicow, Royce, Vaughan, Orlandi, & Smith, 1997). Developments in technology have made it possible to generate printed selfhelp material replicating individual counseling, filling the gap between generic self-help, intended for everyone, and intensive clinical therapy. With the use of computers, these customized health messages, derived from an individual assess

Smoking remains the leading preventable cause of disease and death. A proliferation of health information is available to educate and aid in smoking cessation, a disparity between reading levels of patients and reading estimates of health promotion literature exists. The aim of the study was to adapt computer-tailored feedback reports to different levels of readability, and to meet the needs of smokers from all social backgrounds. Focus groups were used to explore the perception of the adaptations. Results confirmed the importance of producing health promotion literature at an appropriate level of reading. However, it is essential that materials offer information and support using language that can be understood by smokers of all reading levels without being patronizing. © 2009 Wiley Periodicals, Inc.

Objective: To evaluate an innovative invitation designed to facilitate informed choices for undergoing screening for type 2 diabetes. Methods: Four hundred and seventeen people aged 40‐69 years (sex: F 53%/M 47%), without known diabetes, recruited from street locations. Participants were randomised to receive one of two hypothetical invitations for screening for type 2 diabetes; one based on General Medical Council guidelines and combined with a decisional balance sheet, the other a brief traditional invitation. Informed choice was assessed immediately after the invitation and 3 weeks later using measures of knowledge, attitudes and intentions. Results: Twoweeksafter receiptoftheinvitation,theproportionofinformedchoices wassignificantlyhigheramongparticipants whoreceivedthe informed choice invitation compared with those who received the traditional invitation (42.9% versus 11.2%; difference = 31.7%, 95% CI: 22.5‐ 40.5%; p < 0.001). Mean knowledge scores were significantly higher after the receipt of the invitation designed to facilitate informed choices than after thetraditional invitation (5.49versus 3.90; t(405) = 10.106, p < 0.001). Intentionsto participate inscreeningwere unaffected byreceipt ofthe informed choice invitation. Conclusion: Compared with a traditional invitation, receipt of the invitation designed to facilitate informed choices increased the proportion of informed choices about type 2 diabetes screening attendance. Practice implications: : Although the new invitation was associated with better knowledge of screening it had no differential effect on intention and its effect on attendance still requires evaluation. # 2008 Elsevier Ireland Ltd. All rights reserved.

Aims Self-help smoking cessation interventions for pregnant smokers are of importance due to their potential to be wide-reaching, low-cost and their appeal to pregnant smokers who are interested in quitting smoking. To date, however, there has been no systematic assessment of their efficacy.This systematic review aimed to assess the efficacy of self-help interventions for pregnant smokers and to investigate whether self-help material intensity, type or delivery are associated with cessation.Methods The literature was searched for randomized and quasi-randomized controlled trials of self-help smoking cessation interventions for pregnant smokers without significant cessation counselling. Fifteen trials met the inclusion criteria and relevant data were extracted independently. Results The primary metaanalysis pooled 12 trials comparing usual care (median quit rate 4.9%) with self-help (median quit rate 13.2%) and yielded a pooled odds ratio (OR) of 1.83 [95% confidence interval (CI) 1.23‐2.73], indicating that self-help interventions on average nearly double the odds of quitting compared with standard care. However, a further meta-analysis failed to find evidence that intervention materials of greater intensity increase quitting significantly over materials of lesser intensity (pooled OR = 1.25, 95% CI 0.81‐1.94). There was insufficient evidence to determine whether the tailoring of materials or levels of one-to-one contact were related to intervention efficacy. Conclusions Self-help interventions appear to be more effective than standard care although, due mainly to a lack of trials, it is unclear whether more sophisticated and intensive approaches increase intervention effectiveness.

Environmental agencies increasingly use flagship species (those popular, relatively large, charismatic animals) as tools to trigger concern for the species and motivate community members to conserv...

Objective: To explain inconsistent results in previous attempts to determine whether, when presented with health risk information, people focus primarily on information about their own risk status or on a comparison with others. Design: A randomized between-groups experiment in which participants were presented with hypothetical cardiac risk information. We examined whether affective responses were primarily sensitive to the relative difference between personal and comparison risk, rather than the absolute difference. Main Outcome Measures: Participants’ negative affective response to the risk information. Results: When relative differences were held constant, participants’ responses were independently influenced by both personal risk and comparative standing, effects that were greatly attenuated when absolute differences were held constant. When maintaining constant absolute differences, personal and comparison risk information appeared to interact. Conclusion: Previous studies tended to maintain constant absolute risk differences and so may have underestimated the impact of personal risk information. Participants’ responses were sensitive to the way the risk difference was constructed. Basing experimental design decisions on assumptions about the information participants will respond to can lead to misinterpretations of the basis of risk judgments.

The health action process approach (HAPA) is attracting increasing interest from researchers who want to predict, explain, and change health-related behaviors. The main aim of this commentary is to examine the causal structure of the continuum version of the HAPA (HAPA-C), and, in particular, to consider the implications of this structure for the claim that the theory helps to bridge the intention–behavior gap. The article discusses, in turn, mediators of the intention–behavior relationship, additional proximal determinants of behavior, moderators of the intention–behavior relationship and implications for intervention. The commentary may contribute to a better understanding of the HAPA-C and to its further development. L’Approche des Processus d’Action en faveur de la Sante (HAPA) suscite de plus en plus d’interet de la part des chercheurs qui souhaitent predire, expliquer et modifier les comportements relatifs a la sante. L’objet de ce commentaire est l’examen de la structure causale de la version continuum de l’HAPA (HAPA-C) et, en particulier, de prendre en consideration les implications de cette structure dans la pretention de la theorie a combler le fosse intention–comportement. L’article aborde successivement les mediateurs de la relation intention–comportement, les determinants immediats additionnels de la conduite, les moderateurs de la relation intention–comportement et les retombees pour les interventions. Ce commentaire peut contribuer a une meilleure comprehension de l’HAPA-C et a son futur developpement.

Summary Background Declining physical activity is associated with a rising burden of global disease. Efforts to reverse this trend have not been successful. We aimed to assess the efficacy of a facilitated behavioural intervention to increase the physical activity of sedentary individuals at familial risk of diabetes. Methods We enrolled 365 sedentary adults who had a parental history of type 2 diabetes. They were recruited from either diabetes or family history registers at 20 general practice clinics in the UK. Eligible participants were randomly assigned to one of two intervention groups, or to a comparison group. All participants were posted a brief advice leaflet. One intervention group was offered a 1-year behaviour-change programme, to be delivered by trained facilitators in participants' homes, and the other the same programme by telephone. The programme was designed to alter behavioural determinants, as defined by the theory of planned behaviour, and to teach behaviour-change strategies. The principal outcome at 1 year was daytime physical activity, which was objectively measured as a ratio to resting energy expenditure. Analysis was by intention to treat. This study is registered as ISRCTN61323766. Findings Of 365 patients, we analysed primary endpoints for 321 (88%) for whom we had data after 1 year of follow-up. At 1 year, the physical-activity ratio of participants who received the intervention, by either delivery route, did not differ from the ratio in those who were given a brief advice leaflet. The mean difference in daytime physical-activity ratio, adjusted for baseline, was −0·04 (95% CI −0·16 to 0·08). The physical-activity ratio did not differ between participants who were delivered the intervention face-to-face or by telephone (mean difference −0·05; 95% CI −0·19 to 0·10). Interpretation A facilitated theory-based behavioural intervention was no more effective than an advice leaflet for promotion of physical activity in an at-risk group; therefore health-care providers should remain cautious about commissioning behavioural programmes into individual preventive health-care services.

Maintaining a healthy balance between human prosperity and environmental integrity is at the core of the principles of Ecological Sustainable Development. Resource-protection policies are frequently implemented so as to regulate the balance between resource access and use, however, they can inadvertently compromise the ability of resource users to adapt and be resilient. Resource users who are especially dependent on a resource are more seriously compromised. But how do we define and measure resource dependency? And how do we assess its ability to influence social resilience? In this study, a conceptual model of resource dependency is developed in terms of: (i) occupational attachment, (ii) attachment to place, (iii) employability, (iv) family attitude to change, (v) business size, (vi) business approach, (vii) financial situation, (viii) level of specialisation, (ix) time spent harvesting, and (x) interest in and knowledge of the environment. The model of resource dependency and its effect on social resilience are (quantitatively and qualitatively) tested and explored using the commercial fishing industry in North Queensland, Australia. Results show that occupational attachment and employability were important influences as were business size and approach. Results can be used to identify vulnerability to institutional change and guide policy development processes.

Two studies aiming to identify the nature and extent of problems that people have when completing theory of planned behaviour (TPB) questionnaires, using a cognitive interviewing approach are reported. Both studies required participants to `think aloud' as they completed TPB questionnaires about: (a) increasing physical activity (six general public participants); and (b) binge drinking (13 students). Most people had no identifiable problems with the majority of questions. However, there were problems common to both studies, relating to information retrieval and to participants answering different questions from those intended by researchers. Questions about normative influence were particularly problematic. The standard procedure for developing TPB questionnaires may systematically produce problematic questions. Suggestions are made for improving this procedure.

Objective To evaluate the effectiveness of individually tailored smoking cessation advice letters as an adjunct to telephone counselling and generic self-help materials. Design Randomized controlled trial. Setting The UK Quitline. Participants A total of 1508 current smokers and recent ex-smokers. Interventions The control group received usual care (telephone counselling and an information pack sent through the post). The intervention group received in addition a computer-generated individually tailored advice letter. Main outcome measures All outcomes were assessed at 6-month follow-up.The primary outcome measure was self-reported prolonged abstinence for at least 3 months. Secondary outcomes were self-reported prolonged abstinence for at least 1 month and 7-day and 24-hour point-prevalence abstinence. Results For the sample as a whole, quit rates did not differ significantly between the two conditions.However,amongthemajority(n = 1164)whoweresmokersatbaseline,quitrateswereconsistentlyhigher in the intervention group: prolonged abstinence for 3 months, 12.2% versus 9.0% [odds ratio (OR) = 1.40, 95% confidenceinterval(CI) = 0.96‐2.04,P = 0.080);prolongedabstinencefor1 month,16.4%versus11.3%(OR = 1.53, 95% CI = 1.09‐2.15, P = 0.013); 7-day point-prevalence abstinence, 18.9% versus 12.7% (OR = 1.59, 95% CI = 1.15‐2.19, P = 0.004); 24-hour point-prevalence abstinence, 20.9% versus 15.4% (OR = 1.45, 95% CI = 1.07‐ 1.96,P = 0.015).Conclusions Theresultsforthesmokersareencouraginginshowingasmallbutusefuleffectof the tailored letter on quit rate. Versions of the tailoring program could be used on the web and in general practices, pharmacies and primary care trusts.

In response to a sharp decline in recreational fishing participation in Queensland, Australia, I sought to identify constraints experienced by fishers in Queensland and understand how demographic variables, fishing participation variables, and fishing motivations influence the amount and type of constraints experienced. In a survey of Queensland recreational fishers, 70% reported experiencing constraints-predominantly lack of time, crowding, unavailability of facilities, and costs associated with fishing. Fishers with higher incomes, fishers with higher centrality of fishing to lifestyle, fishers who placed higher importance on motivations related to catching fish and relaxation, and fishers who were male were more likely to experience constraints. With the exception of gender, variables found to have a significant effect on the presence of constraints also had a significant influence on the types of constraints experienced. Results provide insight into factors affecting recreational fishing part...

Artificial reefs are used to enhance recreational fishing and diving opportunities in the marine environment. Until recently, demand for artificial reefs in the Great Barrier Reef Marine Park (GBRMP) has been low due to the high value placed on the natural ecosystem of the Great Barrier Reef (GBR) and the abundance of fishing and diving opportunities it provides. In the GBRMP, where there are multiple stakeholder groups with diverse and often conflicting values and opinions, the deployment of artificial reefs will be a complex and controversial social issue. We review the available socio-economic literature regarding the deployment, use, and management of artificial reefs, and aim to identify and understand potential socio-economic issues and information gaps surrounding deployment of artificial reefs in the GBRMP. We also outline a strategy to guide decision-making and maximize the socio-economic value of artificial reefs should they be deployed in the GBRMP.

Objectives: To adapt a tailored short message service (SMS) text message smoking cessation intervention (MiQuit) for use without active health professional endorsement in routine antenatal care settings, to estimate ‘real-world’ uptake and test the feasibility of its use. Design: Single-site service evaluation. Setting: A Nottinghamshire (UK) antenatal clinic. Participants: Pregnant women accessing the antenatal clinic (N=1750) over 6 months. Intervention: A single-sheet A5 leaflet provided in the women's maternity notes folder describing the MiQuit text service. Similar materials were left on clinic desks and noticeboards. Outcome measures: MiQuit activation requests and system interactions were logged for two time frames: 6 months (strict) and 8 months (extended). Local hospital data were used to estimate the denominator of pregnant smokers exposed to the materials. Results: During the strict and extended time frames, 13 and 25 activation requests were received, representing 3% (95% CI 2% to 5%) and 4% (95% CI 3% to 6%) of estimated smokers, respectively. Only 11 (44%) of the 25 requesting activation sent a correctly formatted initiation text. Of those activating MiQuit, and invited to complete tailoring questions (used to tailor support), 6 (67%) completed all 12 questions by text or website and 5 (56%) texted a quit date to the system. Of the 11 activating MiQuit, 5 (45%, 95% CI 21% to 72%) stopped the programme prematurely. Conclusions: A low-intensity, cheap cessation intervention promoted at very low cost, resulted in a small but potentially impactful uptake rate by pregnant smokers.

BACKGROUND: The prevention of type 2 diabetes is recognised as a health care priority. Lifestyle change has proven effective at reducing the risk of type 2 diabetes, but limitations in the current evidence have been identified in: the promotion of physical activity; availability of interventions that are suitable for commissioning and implementation; availability of evidence-based interventions using new technologies; and physical activity promotion among ethnic minorities. We aim to investigate whether a structured education programme with differing levels of ongoing support, including text-messaging, can increase physical activity over a 4 year period in a multi-ethnic population at high risk of diabetes. METHODS/DESIGN: A multi-centre randomised controlled trial, with follow-up at 12 and 48 months. The primary outcome is change in ambulatory activity at 48 months. Secondary outcomes include changes to markers of metabolic, cardiovascular, anthropometric and psychological health along with cost-effectiveness. Participants aged 40-74 years for White European, or 25-74 years for South Asians, with an HbA1c value of between 6.0 and < 6.4% (42 and 47 mmol/mol) or with a previously recorded plasma glucose level or HbA1c value within the high risk (prediabetes) range within the last five years, are invited to take part in the trial. Participants are identified through primary care, using an automated diabetes risk score within their practice database, or from a database of previous research participants. Participants are randomly assigned to either: 1) the control group who receive a detailed advice leaflet; 2) the Walking Away group, who receive the same leaflet and attend a 3 hour structured education programme with annual maintenance sessions delivered in groups; or 3) the Walking Away Plus group, who receive the leaflet, attend the structured education programme with annual maintenance sessions, plus receive follow-on support through highly-tailored text-messaging and telephone calls to help to aid pedometer use and behaviour change. DISCUSSION: This study will provide new evidence for the long-term effectiveness of a structured education programme focused on physical activity, conducted within routine care in a multi-ethnic population in the UK. It will also investigate the impact of different levels of ongoing support and the cost-effectiveness of each intervention. TRIAL REGISTRATION: ISRCTN83465245 Trial registration date: 14/06/2012.

BackgroundMost people who quit smoking successfully for a short period will return to smoking again in 12 months. A previous exploratory meta-analysis indicated that self-help booklets may be effective for smoking relapse prevention in unaided quitters.ObjectivesThis study aimed to evaluate the effectiveness of a set of self-help educational booklets to prevent smoking relapse in people who had stopped smoking with the aid of behavioural support.DesignThis is an open, randomised controlled trial and qualitative process evaluation. Trial participants were randomly allocated to one of two groups, using a simple randomisation process without attempts to stratify by participant characteristics. The participant allocation was ‘concealed’ because the recruitment of quitters occurred before the random allocation.SettingShort-term quitters were recruited from NHS Stop Smoking Clinics, and self-help educational materials were posted to study participants at home.ParticipantsA total of 1407 carbon monoxide (CO)-validated quitters at 4 weeks after quit date in NHS Stop Smoking Clinics. The trial excluded pregnant women and quitters who were not able to read the educational materials in English.InterventionsParticipants in the experimental group (n = 703) received a set of eight revisedForever Freebooklets, and participants in the control group (n = 704) received a single leaflet that is currently given to NHS patients.Main outcome measuresFollow-up telephone interviews were conducted 3 and 12 months after quit date. The primary outcome was prolonged, CO-verified abstinence from months 4 to 12 during which time no more than five cigarettes were smoked. The secondary outcomes included self-reported abstinence during the previous 7 days at 3 and 12 months, CO-verified abstinence at 12 months, costs (NHS and NHS and participant medication costs perspectives) and quality-adjusted life-years. Logistic regression analyses were conducted to investigate effect-modifying variables. A simultaneous qualitative process evaluation was conducted to help interpret the trial results.ResultsData from 1404 participants were used for the final analysis, after excluding three participants who died before the 12-month follow-up. The proportion with prolonged abstinence from months 4 to 12 after quit date was 36.9% in the intervention group and 38.6% in the control group. There was no statistically significant difference between the groups (odds ratio 0.93, 95% confidence interval 0.75 to 1.15;p = 0.509). There were no statistically significant differences between the groups in secondary smoking outcomes. People who reported knowing risky situations for relapse and using strategies to handle urges to smoke were less likely to relapse. However, there were no differences between the groups in the proportion of participants who reported that they knew any more about coping skills, and no differences in reported use of strategies to cope with urges to smoke between the trial groups. The qualitative study found that some quitters considered self-help booklets unhelpful for smoking relapse prevention, although positive feedback by participants was common.ConclusionsAmong quitters who had stopped smoking with the aid of intensive behavioural support, there was no significant difference in the likelihood of smoking relapse between those who subsequently received a set of eight revisedForever Freebooklets and those who received a single leaflet. Although many people had suboptimal strategies to prevent relapse and most relapsed, theForever Freebooklets proved an ineffective medium for teaching them the skills to prevent relapse. Further research should focus on interventions that may increase the use of coping skills when required.Trial registrationCurrent Controlled Trials ISRCTN36980856.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 19, No. 59. See the NIHR Journals Library website for further project information.

Background There is increasing interest in brief and very brief behaviour change interventions for physical activity as they are potentially scalable to the population level. However, few very brief interventions (VBIs) have been published, and evidence is lacking about their feasibility, acceptability and which ‘active ingredients’ (behaviour change techniques) would maximise their effectiveness. The aim of this research was to identify and develop promising VBIs for physical activity and test their feasibility and acceptability in the context of preventive health checks in primary care. Methods The process included two stages, guided by four criteria: effectiveness, feasibility, acceptability, and cost. In Stage 1, we used an iterative approach informed by systematic reviews, a scoping review of BCTs, team discussion, stakeholder consultation, a qualitative study, and cost estimation to guide the development of promising VBIs. In Stage 2, a feasibility study assessed the feasibility and acceptability of the short-listed VBIs, using tape-recordings and interviews with practitioners (n = 4) and patients (n = 68), to decide which VBIs merited further evaluation in a pilot trial. Results Four VBIs were short-listed: Motivational intervention; Action Planning intervention; Pedometer intervention; and Physical Activity Diary intervention. All were deliverable in around five minutes and were feasible and acceptable to participants and practitioners. Based on the results of interviews with practitioners and patients, techniques from the VBIs were combined into three new VBIs for further evaluation in a pilot trial. Conclusions Using a two-stage approach, in which we considered the practicability of VBIs (acceptability, feasibility and cost) alongside potential efficacy from the outset, we developed a short-list of four promising VBIs for physical activity and demonstrated that they were acceptable and feasible as part of a preventive health check in primary care. Trial registration Current Controlled Trials ISRCTN02863077. Registered 5 October 2012. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-1703-8) contains supplementary material, which is available to authorized users.

Background Observational studies have shown that attentional bias for smoking-related cues is associated with increased craving and relapse. Laboratory experiments have shown that manipulating attentional bias may change craving. Interventions to reduce attentional bias could reduce relapse in smokers seeking to quit. We report a clinical trial of attentional retraining in treatment-seeking smokers. Methods This was a double-blind randomised controlled trial that took place in UK smoking cessation clinics. Smokers interested in quitting were randomised to five weekly sessions of attentional retraining (N = 60) or placebo training (N = 58) using a modified visual probe task from one week prior to quit day. Both groups received 21 mg nicotine patches (from quit day onwards) and behavioural support. Primary outcomes included change in attentional bias reaction times four weeks after quit day on the visual probe task and craving measured weekly using the Mood and Physical Symptoms Scale. Secondary outcomes were changes in withdrawal symptoms, time to first lapse and prolonged abstinence. Results No attentional bias towards smoking cues was found in the sample at baseline (mean difference = 3 ms, 95% CI = −2, 9). Post-training bias was not significantly lower in the retraining group compared with the placebo group (mean difference = −9 ms, 95% CI = −20, 2). There was no difference between groups in change in craving (p = 0.89) and prolonged abstinence at four weeks (risk ratio = 1.00, 95% CI = 0.70, 1.43). Conclusions Taken with one other trial, there appears to be no effect from clinic-based attentional retraining using the visual probe task. Attentional retraining conducted out of clinic may prove more effective. Clinical trial registration UK Clinical Trials ISRCTN 54375405.

Background Web-based interventions for physical activity offer several advantages over face-to-face, print-and telephone-based interventions and are scalable and potentially cost-effective. Recent reviews of web-based interventions in adults show that they have positive but small effects on physical activity but identify a number of limitations including a reliance on self-report measures of outcome. This trial used an objective measure of physical activity to assess the effectiveness of three minimal contact interventions: 1) A multi-component web-based intervention incorporating objective monitoring and graphical feedback of physical activity; 2) A version of the first intervention that consisted only of objective monitoring plus web-based graphical feedback; and 3) Self-monitoring of physical activity using a paper diary. Methods/design Get Moving is an individually randomised controlled trial with allocation of 488 participants to one of three interventions or to a no-intervention control group. Participants are physically inactive working adults aged 18–65 years. They attended a baseline assessment session at which anthropometric, biological and questionnaire measures were taken and they completed a treadmill exercise test. They then wore a combined movement and heart rate monitor for six days and nights before being randomised to one of the four trial arms. The baseline measures were repeated at the follow-up assessment which took place approximately 12 weeks post-randomisation, conducted by staff blind to group allocation. Participants wore the movement and heart rate monitor for six days and nights before this. The co-primary outcomes are: physical activity energy expenditure measured using individually calibrated combined heart-rate and movement data; and cardiorespiratory fitness measured using a sub-maximal treadmill exercise test. Discussion Strengths of the trial include the use of an objective measure of physical activity, a measure of cardiorespiratory fitness, relatively large sample size and the use of robust methods of randomisation, allocation concealment and blinding to outcome assessment. Get Moving will contribute to the evidence base on minimal contact interventions for increasing physical activity. The interventions could be implemented in other settings such as primary care. Trial registration ISRCTN31844443. Registered 18 June 2010.

Aims: Most people who quit smoking for a short term will return to smoking again in 12 months. We tested whether self-help booklets can reduce relapse in short-term quitters after receiving behavioural and pharmacological cessation treatment. Design: A parallel-arm, pragmatic individually randomized controlled trial. Setting: Smoking cessation clinics in England. Participants People who stopped smoking for 4 weeks after receiving cessation treatment in stop smoking clinics. Intervention: Participants in the experimental group (n = 703) were mailed eight booklets, each of which taught readers how to resist urges to smoke. Participants in the control group (n = 704) received a leaflet currently used in practice. Measurements: The primary outcome was prolonged, carbon monoxide-verified abstinence from months 4 to 12. The secondary outcomes included 7-day self#x02010;reported abstinence at 3 and 12 months. Mixed-effects logistic regression was used to estimate treatment effects and to investigate possible effect modifying variables. Findings: There were no statistically significant differences between the groups in prolonged abstinence from months 4 to 12 (36.9% versus 38.6%; odds ratio 0.93, 95% confidence interval 0.75–1.16; P = 0.524). In addition, there were no significant differences between the groups in any secondary outcomes. However, people who reported knowing risky situations for relapse and using strategies to handle urges to smoke were less likely to relapse. Conclusions: In people who stop smoking successfully with behavioural support, a comprehensive self-help educational programme to teach people skills to identify and respond to high-risk situations for return to smoking did not reduce relapse.

Background Smoking in pregnancy is a public health problem. Self-help smoking cessation support can help pregnant women to stop smoking, but the effects of delivering this kind of support via SMS text message are not known. A previous randomised controlled trial (RCT) demonstrated the feasibility and acceptability of providing such support to pregnant smokers using an automated, tailored text message intervention called MiQuit. This larger RCT will estimate key parameters for and will test the feasibility of delivering a major trial run within UK National Health Service settings aimed at providing definitive evidence on the utility of MiQuit for helping pregnant smokers to stop. Methods & Design A multi-centre, parallel group RCT. Participants are being identified in 16 English antenatal care settings and must be >16 years old, pregnant, < 25 weeks gestation, smoke >1 daily cigarette, have smoked >5 daily cigarettes before pregnancy, and able to understand texts in English. After consenting and collection of baseline data, participants are randomised to control or intervention groups in a 1:1 ratio; randomisation is stratified by trial site and gestation and employs computer generated pseudo-random code using random permuted blocks of randomly varying size, created by the Nottingham Clinical Trials Unit and held on a secure server. All participants receive a National Health Service (NHS) leaflet aimed at helping them to stop smoking. Intervention group women also receive the 12 week MiQuit intervention programme of tailored, supportive, interactive text message, self-help cessation support. Women are followed up by telephone 4 weeks after randomisation and at 36 weeks gestation. The study aims to recruit 400 women and although, for this kind of trial, formal sample size estimation for between-group comparisons is not appropriate, with this sample we will be able to estimate trial centres’ recruitment rates to within +/-1% (margin of error = half width of 95% confidence interval); individual trial groups’ ascertainment of rates for smoking outcomes between 4 weeks after randomisation until approximately 36 weeks gestation to within +/-4% and, across both groups, the combined cessation rate at 36 weeks +/-3%. Discussion Pilot trial completion will provide data to facilitate planning for a definitive trial investigating whether MiQuit works for smoking cessation in pregnancy. Trial registration ClinicalTrials.gov NCT02043509. Registered 14 January 2014

A number of psychosocial theories have been developed to predict, explain, and change health behaviors. In this article, six widely used theories are discussed in turn and then compared. They include four continuum theories (the health belief model; protection motivation theory; the theory of planned behavior; and social cognitive theory), one stage theory (the transtheoretical model), and one theory that has both stage and continuum versions (the health action process approach). Common criticisms of these theories are briefly addressed.

Patients diagnosed with von Hippel-Lindau disease (vHL) require life-long surveillance for this multi-system disease. It is therefore important to assess the comprehensiveness of screening provision, as well as identify what type of screening service is most likely to encourage regular patient attendance. This descriptive study reports on two types of screening service: single appointment One Stop (OS) clinics and multiple appointment Ad Hoc (AH) clinics. One hundred and seventeen vHL patients from eight regional genetics centres were approached to take part. Seventy-two (61.5%) returning a completed study questionnaire: fifty-four (75%) were screened at OS clinics and eighteen (25%) at AH clinics. Comprehensiveness of screening, attendance rates, patient ratings of quality of care and levels of psychological morbidity were compared between the two types of service. While levels of disease severity were similar in patients screened at OS and AH clinics, those seen at OS clinics were screened for twice as many site-specific vHL manifestations compared to those seen at AH clinics (P < 0.0001). More patients at OS clinics regularly attended their screening appointments compared to those at AH clinics (P = 0.0045). There was no difference in the quality of care reported by patients attending the two types of screening service and few problems were reported. Twenty-nine percent of respondents were categorised as clinically anxious and 13% as clinically depressed. These findings suggest that an optimum vHL screening service is one based on OS clinics offering regular comprehensive surveillance and psychological support.

Maintaining the performance of exercises recommended by rehabilitation specialists and recovering after lapses in the performance of exercises constitute a process of behavior change. Usually, researchers assume that the same cognitions may help individuals to maintain their activity and to recover from relapse. Self-efficacy, which can be defined as beliefs about one’s ability to perform a specific action (Bandura, 1997), is associated with a patient’s adherence during and after rehabilitation programs (Carlson et al., 2001; Guillot, Kilpatrick, Hebert, & Hollander, 2004; McAuley, Pena, & Jerome, 2001). In this study, we investigated whether specific beliefs predict the performance of exercises recommended by rehabilitation specialists, by examining whether patients maintained their activity levels or relapsed to their less active lifestyles.

This study sought to understand the demographic and commitment variables that predict participation by recreational fishers in public consultation programs, and investigated differences in opinions and beliefs between participants and non-participants. In a survey of recreational fishers in Queensland, Australia, 28% of respondents reported participating in public consultation programs regarding issues affecting recreational fisheries. Participation in consultation programs was positively related to age, avidity, centrality (i.e., importance) of fishing to lifestyle, and membership in fisheries-related organizations. There was no effect of gender, income, or years of fishing experience on participation. Participants and non-participants differed significantly in their level of agreement with 12 of 20 belief statements about fisheries management, issues and threats facing recreational fisheries, and the effects of recreational fishing on fish populations. Participants and non-participants also differed in their level of approval of four of eight fishing regulations. Results suggest that recreational fishers who participate in public consultation programs may not be representative of the wider recreational fisher population.

Valid measures of how people view risks due to combinations of hazards are needed. 320 adult smokers responded to four vignettes in which hypothetical men were described as having high or low levels of (1) smoking and (2) either (a) blood cholesterol or (b) family history of CHD (coronary heart disease). Ratings of the risk of a heart attack were made using one of three different rating scales: (a) nine‐point, (b) 101‐point, and (c) unbounded. The nine‐point scale yielded a strong sub‐additive interaction, the 101‐point scale yielded a weak sub‐additive interaction, and the unbounded scale yielded a weak synergistic interaction. Although respondents preferred the nine‐point scale, evidence from this and other studies suggest that scales with nine points or fewer should not be used to assess perceptions of risks due to multiple hazards.

Aim To evaluate the effectiveness of repeated-contact proactive telephone counselling for smoking cessation in a UK setting. Design Randomized controlled trial. Setting The Quitline((R)), an established national telephone counselling service available throughout the UK. Participants and intervention A total of 1457 callers to the Quitline in 2000 and 2001 were allocated randomly to a Control group to receive usual care or to a Repeated Contact group to be offered five proactive calls in addition to usual care. Measurements Prolonged abstinence and 24-hour point-prevalent abstinence 6 and 12 months after recruitment, quit attempts and 24-hour periods of abstinence in non-quitters. Findings No significant differences were found between the Repeated Contact and Control groups on prolonged or point-prevalent abstinence. On an intention-to-treat basis, 9.5% of the Control group were abstinent for longer than 6 months at the 12-month follow-up, compared with 9.3% of the Repeated Contact group; 18.9% and 20.2%, respectively, were point-prevalent abstinent at the 6-month follow-up. Significantly more non-quitters in the Control group made a quit attempt in the first 6 months following recruitment than in the Repeated Contact group (62.6%/56.1%, P < 0.05). Conclusions Proactive telephone counselling did not significantly increase abstinence rates, and appeared to decrease quit attempts, in callers to the Quitline. A non-structured, client-led counselling protocol and insufficient pre-quit motivational counselling could account for the lack of effect.

AIMS: Identifying patients' beliefs about taking medication can inform interventions to support medication taking, and their evaluation. We set out to establish the range of these beliefs, and measure the frequency of commonly held beliefs and their correlation with intention to take medication and self-reported medication adherence. METHODS: An exploratory survey among Type 2 diabetic patients aged 40 years or older, registered in general practice, used a questionnaire measuring a range of plausible beliefs about taking and intention to take medication developed from interviews where belief elicitation was guided by the Theory of Planned Behaviour. The Medication Adherence Report Schedule was used as a self-report adherence measure. RESULTS: Questionnaires were returned by 121 (61.7%) people. The majority strongly agreed with statements about the benefits of taking medication. Negative beliefs that taking medication would 'cause unpleasant side effects' and 'lead to weight gain' were held by 32.8 [corrected] and 13.9% of people, respectively. Beliefs about benefit were strongly associated with intention to take medication regularly. Two beliefs were associated with reduced medication adherence: 'changes to my daily routine would make it more difficult to take my diabetes medicines regularly' (P < 0.001), and 'if I were to take my diabetes medicines regularly this would lead to my gaining weight' (P < 0.01) [corrected] CONCLUSIONS: Use of a theoretical model to elicit and identify common beliefs about taking medication regularly underscores the importance of exploring weight-gain concerns and how to keep taking tablets when routines change. Beliefs associated with intention and taking medication will inform intervention development, implementation and evaluation in randomized controlled studies.

Research has shown that cancer patients in general benefit from support group participation. However, few patients attend such groups. This study investigated differences between participants of a community cancer support group and a random selection of non-participants from the Cancer Registry. Data were collected through mail survey, and included variables identified through past research and variables derived from Leventhal's self-regulatory model of illness representations and the theory of planned behaviour. Sixty-three support group participants and 44 comparison sample respondents were recruited. Support group participants were more likely to be female, without a partner, younger, and to have more education and formal support than non-participants. They held more favourable views of support groups, believed that significant others were favourable towards participation, and perceived less difficulty in joining a group. They furthermore used more active, adaptive coping strategies and felt more control over their cancer, but were more distressed and anxious. Non-participants reported more support from a special person. A multivariate logistic regression analysis showed only psychosocial variables to be independent predictors of participation. As psychological variables are amenable to change, increase of appropriate support group participation should be possible, for instance by addressing patients' beliefs about support groups.

Standard theory of planned behavior (TPB) questions to elicit salient behavioral beliefs may elicit instrumental consequences of behavior, and overlook affective consequences. Two hundred thirteen English adults (35 to 75 years of age) completed a questionnaire that contained closed measures of TPB constructs, and open-ended questions that asked not only about advantages and disadvantages, but also what respondents would like or enjoy and dislike or hate about being more physically active. Beliefs elicited by affective questions were associated more strongly with a closed affective attitude scale. Beliefs elicited by instrumental questions were associated more strongly with a closed instrumental attitude scale. Closed measures of the standard TPB variables explained 48% of the variance in intention to increase physical activity, while affective attitude explained an additional 11% of the variance. Applications of the TPB should consider affective and not just instrumental determinants of behavior.

We investigated the willingness of saltwater anglers in Florida and Texas to substitute other types of fishing for the type of fishing they most preferred. Anglers were asked if there was a suitable substitute for their most preferred species and, if so, what species would provide them with the same satisfaction and enjoyment as their most preferred species at the same cost. Most anglers (86%) reported that other species would provide acceptable substitutes for their preferred species and were able to identify acceptable substitutes from a list of common saltwater species in Texas and Florida. Logistic regression was used to determine the effects of demographic and fishing participation variables on willingness to substitute. Willingness to substitute was positively related to years of education and negatively related to age and the importance placed on trophy-seeking experiences. Also, females were more willing to substitute than males. Results suggest that for some species substitution behavior...

Theory-based intervention programmes to support health-related behaviour change aim to increase health impact and improve understanding of mechanisms of behaviour change. However, the science of intervention development remains at an early stage. We present a causal modelling approach to developing complex interventions for evaluation in randomized trials. In this approach a generic model links behavioural determinants, causally through behaviour, to physiological and biochemical variables, and health outcomes. It is tailored to context, target population, behaviours and health outcomes. The development of a specific causal model based on theory and evidence is illustrated by the ProActive programme, supporting increased physical activity among individuals at risk of Type 2 diabetes. The model provides a rational guide to appropriate measures, intervention points and intervention techniques, and can be tested quantitatively. Causal modelling is critically compared to other approaches to intervention development and evaluation, and research directions are indicated.

Background: Innovative technologies that enable the collection of family history information and the assessment of breast cancer risk have a potential to enhance the quality of preventive care. We developed a computerized tool that supports stratification of breast cancer risk, genetic risk assessment in the clinical environment (GRACE). Methods: In a preliminary evaluation of the tool's impact, we randomized women with a family history of breast cancer ( n =72) to either use the GRACE tool or undergo risk counseling by a nurse specialist. Results: There was no statistically significant differences between the GRACE and nurse counselling groups in risk perceptions ( F =.03, P >.05) and cancer-related worries ( F =.80, P >.05). However, patients reported more positive attitudes toward working with the nurse. Conclusion: It was feasible to use GRACE in a Clinic. Additional research is required to identify solutions for providing emotional support in conjunction with the tool.

This article investigates determinants of satisfaction for recreational fishers and nonfishers boating in Australia's Great Barrier Reef Marine Park. Trip satisfaction was modeled as a function of subjective evaluations of various trip aspects. Satisfaction of fishers and nonfishers was related to evaluations of environment quality and weather quality. Satisfaction of fishers was also related to evaluations of fishing quality. There was no effect of evaluation of marine life quality, facilities quality, number of people encountered, number of vessels encountered, or number of wildlife encounters on satisfaction for either group. Results are consistent with the multiple-satisfactions concept of recreation satisfaction, and provide insights into the types of experiences sought by fishers and nonfishers in the Great Barrier Reef Marine Park.

The invited commentaries to Hobbis and Sutton (this issue) show that we achieved our aim of stimulating debate about the development of new approaches to health behaviour change. Diverse opinions were expressed, including discussion of the feasibility of integrating techniques used in Cognitive Behaviour Therapy (CBT) into interventions based on the Theory of Planned Behaviour (TPB), commenton the integration of the two models at a theoretical level and consideration of CBT as an alternative to the TPB in health behaviour change. While we felt that an apparent bias towards the TPB precluded acknowledgement of the potential benefits associated with utilizing techniques used in CBT, we were encouraged by the general recognition that further research linking these two approaches is warranted.

The Theory of Planned Behaviour (TPB) is increasingly being used to inform the development of interventions to promote health behaviour change. However, although the theory can be used to identify the determinants of particular health-related behaviours, it offers little guidance on how to change these determinants and hence how to promote behaviour change. There is evidence that Cognitive Behaviour Therapy (CBT) can be used to support health behaviour change. This article discusses the similarities and differences between the two approaches, and considers whether techniques used in CBT are applicable to interventions based on the TPB.

Variation in the levels of distress in women at increased risk of breast cancer has been reported, yet there is limited understanding of the factors that are associated with heightened distress in this population. This study took a theoretical approach using Leventhal's Self Regulatory Model (SRM) to understand variation in distress levels. The study examined the associations between perceptions of breast cancer and distress in women at increased risk of breast cancer, and a comparison sample with no experience of the disease in their social environment. Questionnaire data from 117 women at increased risk of breast cancer and 100 comparison women were analysed. Women at increased risk of breast cancer showed comparable levels of general distress but significantly higher levels of cancer specific distress than the comparison group. There were few differences in illness perceptions between the samples, although a number of cognitive perceptions of breast cancer were related to both general and cancer specif...

Genetic testing for cancer susceptibility (e.g. hereditary non-polyposis colorectal cancer) is available for some families with a history of colon cancer. Our aim was to investigate participants' anticipated emotional and behavioral reactions to genetic testing for colon cancer and whether gender or clinical risk influences these reactions. 437 asymptomatic participants with a colorectal cancer family history completed a questionnaire about anticipated emotions and actions, under different genetic testing scenarios. More women than men anticipated feeling worried, regretful, and angry if tested positive. People at lower-risk anticipated more surprise and disbelief than those at higher-risk. People anticipated feeling more guilt, regret and less relief if they were not tested than if they were. High-risk results were anticipated to increase depression and worry. Most people still wanted screening if at low risk, anticipated leading healthier lifestyles whatever the result, but would make more plans for the future if they were at high risk. Clinical implications are that as anticipated emotional effects of not being tested may be more severe than having a test, people choosing to forgo testing should feel able to reconsider their decision anytime. Most people did not anticipate strong emotional reactions but thought it would change their lifestyle and would like continued clinical surveillance whatever the result.

The authors wanted to know the extent to which anglers were willing to make substitution decisions when constrained, and identify explanatory variables for substitution decisions. Anglers were asked if there were other outdoor recreation activities that would provide them with the same satisfaction and enjoyment they received from fishing. About 51% said yes. The most frequently identified substitutes were hunting and golf for males and camping and swimming for females. Logistic regression was used to determine the effects of hypothesized demographic and fishing participation variables on the binary yes/no response variable. Willingness to substitute was negatively related to age, positively related to years of education, and was greater for males than females. Willingness to substitute was negatively related to the importance placed on fishing and the importance placed on challenge-oriented experiences, and positively related to overall satisfaction with the activity. Odds ratio multipliers revealed that...

Objectives: To examine the emotional and cognitive impact of personal and social comparison information about health risk. Methods: A total of 970 adults responded to vignettes describing risk presentation scenarios that varied in terms of having (a) a ‘real world’ analogue (cardiac event) versus no such analogue (a fictitious pancreatic disease) condition, (b) high versus low levels of personal risk, and (c) no comparison group information given, comparison group risk higher or lower than own risk. Results: For both the cardiac and pancreatic disease vignettes, respondents’ emotional responses and estimates of their own risk were influenced by both personal and social comparison risk information. The cardiac event vignettes produced larger effects than the pancreatic disease vignettes. Unfavourable social comparison information had no discernible impact, relative to not providing any social comparison information. Favourable social comparison information resulted in greater reassurance, less worry, and perceptions of lower susceptibility. Lower personal risk generally produced similar effects, relative to higher personal risk. Conclusions: In contrast to previous theory and research in this area, we found that both personal and (favourable) social comparison risk information have emotional and cognitive consequences. We hypothesize that the perceived clarity of the information may account for the different patterns of findings in the literature.

Some combinations of hazards yield disease rates greater than would be expected from the risk attributable to each hazard in isolation. However, perceptions are often more consistent with the combined risk being seen as less than the sum of the individual factors, raising concerns over the validity of some measures of risk perception. Here, 249 adults estimated the risk of cardiac events for four hypothetical men, described as having high or low levels of smoking and family history of heart disease. Three distinct measures were used. A 9-point scale produced a strong sub-additive interaction, a 101-point scale produced a weaker sub-additive interaction, and an unbounded scale produced no interaction. In this study, as in all previous research, scales with relatively few points (here a 9-point scale) yield sub-additive interactions. Given the consistency of results yielded by such scales, irrespective of context, it is concluded that these scales are not valid for perceptions of multiple risk factors. Copyright # 2004 John Wiley & Sons, Ltd.

Abstract. The aims of this study were to assess adolescents’ perceptions of the personal risks and prevalence of smoking, and to examine whether these perceptions were related and how they varied by gender, age and smoking status. A questionnaire survey was conducted among 3657 11-16 year olds from a sample of 138 secondary schools in England. The results showed a large false consensus effect: smokers gave higher estimates of the prevalence of smoking among their peers than non-smokers. The gap between smokers and non-smokers decreased between 11 and 16 but was still apparent among 15 and 16 year olds. Smokers of different ages showed little difference in their estimates of prevalence. Smokers were substantially less optimistic in their risk perceptions than non-smokers. Even the youngest smokers acknowledged that their risks were higher than non-smokers’. Smokers nevertheless showed unrealistic optimism. There was little evidence for the idea that the false consensus effect may contribute to unrealistic optimism. The findings raise the question of whether giving children accurate information about smoking prevalence would reduce their likelihood of taking up smoking. The demonstration of optimism bias in teenage smokers highlights the need for innovative education campaigns focused on the health risks of smoking.

Hypothetical scenarios were used to understand the effects of personal and situational variables on freshwater anglers' choices to keep or release caught fish. When personal and situational variables were included in a single model, the odds of an angler choosing to release a caught fish were negatively related to importance placed on keeping fish and varied according to species preference, species caught, and whether the species caught was the angler's preferred species. Interactions between importance placed on catching a trophy fish and size of fish caught, and between species caught and whether the species caught was the angler's preferred species also influenced catch-and-release choice. Catch-and-release choice was not influenced by experience level, centrality of fishing to the angler's lifestyle, importance placed on number of fish caught, and importance placed on catching "something." Results were not entirely consistent with previous studies, suggesting that determinants of catch-and-release cho...

This prospective study examined whether the psychological impact of organized mammography screening is influenced by women's pre-existing experience with breast cancer and perceived susceptibility (PS) to the disease. From a target population of 16,886, a random sample of women with a normal screening finding and all women with a false positive or a benign biopsy finding were included (N=1942). Data were collected with postal questionnaires 1-month before screening invitation and 2 and 12 months after screening. Response rate was 63% at baseline; 86, and 80% of the baseline participants responded to the follow-ups. Psychological impact was measured as anxiety (STAI-S), depression (BDI), health-related concerns (IAS), and breast cancer-specific beliefs and concerns. Data was analyzed with repeated measures analyses of variance, with estimates of effect size based on Eta-squared. Women with breast cancer experience had higher risk perception already before screening invitation; after screening they were also more distressed. Women with high PS were more distressed than women with low PS also at pre-invitation. The distress was not alleviated by screening, but instead remained even after normal mammograms. Experience and PS did not influence responses to different screening findings. Of the finding groups, false positives experienced most adverse effects: their risk perception increased and they reported most post-screening breast cancer-specific concerns. Furthermore, they became more frequent in breast self-examination (BSE) despite a simultaneous decrease in BSE self-efficacy. Our findings suggest that women with high PS and women with false positive screening finding may need individualized counseling and follow-up as much as women with a family history of breast cancer. Besides medical risk factors, women's own perceptions of susceptibility should be discussed during the screening process. Copyright © 2003 John Wiley & Sons, Ltd.

This chapter presents a detailed causal analysis of the two leading theories of attitude-behaviour relations, the theory of reasoned action (TRA) and the theory of planned behaviour (TPB). It is noted that the direct path from perceived behavioural control to behaviour in the TPB is causally ambiguous. Focusing on the attitude-intention relationship, timeline and path diagrams are used to illustrate some of the hidden assumptions that underlie the way these theories are usually tested using standard multiple regression applied to nonexperimental data. Randomised experiments are recommended as the best solution to the serious problems arising from omitted causes.

BACKGROUND Computer decision support systems have been proposed as a suitable method to enable primary care practitioners to manage familial cancer and advise about other developments in clinical genetics. OBJECTIVE To investigate GPs' preferences, attitudes and intentions regarding the use of Genetic Risk Assessment on the Internet and Decision Support (GRAIDS) in clinical practice. METHODS GPs were recruited through a physician Internet portal for UK GPs (www.ukpractice.net). Electronic questionnaires assessed the respondents' current practice regarding family history taking and risk assessment, preferences about particular attributes of GRAIDS, intentions to use GRAIDS for familial cancer management and factors associated with these intentions. RESULTS Two hundred and sixty-eight GPs completed the electronic survey (adjusted response rate = 51.2%). Seventy-two GPs participated in a telephone survey of non-respondents (adjusted response rate = 63%). Ninety-two per cent of respondents in the electronic survey and 68% in the telephone survey stated that they would be either extremely or fairly likely to use GRAIDS. Intentions were associated with positive attitudes toward GRAIDS, beliefs that colleagues and patients would find the tool acceptable, perceived control and perceived confidence about conducting risk assessment and making appropriate decisions about patient management. Key attributes for the implementation of GRAIDS in practice were the authoritativeness of the guideline, easy user interface, the validity and reliability of risk estimation and specific advice about patient management. CONCLUSION GP users of the physician portal www.ukpractice.net value GRAIDS as an aid for the management of familial cancer in primary care. These Internet-literate GPs are likely to be early adopters of GRAIDS in clinical practice and could be important in promoting the use of such technology to support high quality advice about genetic issues in primary care.

Many women who have had breast or ovarian cancer who are undergoing tests for the presence of germline mutations in the genes will receive a result that is inconclusive. As this continuing uncertainty may have a detrimental effect on their psychological well-being and it is possible that such results will be misinterpreted as indicating that no mutation is present, studying their effect is important.Sixty-one women undergoing such tests completed questionnaires 2 weeks after their blood was taken and at 1 week and 6 months after receiving a preliminary "inconclusive" result, i.e., indicating that two thirds of the gene had been tested and no mutation had been found so far.Perceived likelihood of having a mutation and perceptions of cancer risk significantly decreased after receipt of the interim result. There were no changes in levels of psychological distress and worry about cancer, in intentions to have mammograms, to carry out breast self-examination, or to have prophylactic surgery.The continuing uncertainty does not seem to have increased distress; however, it is possible that the inconclusive result is being interpreted as a "good news" result, in view of the fact that perceptions of risk decrease after receipt of the result.