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Implementation of health education programs is often inadequately considered or not considered at all in planning, developing and evaluating interventions. With the focus being predominantly on the adoption stage, little is known about the factors influencing the implementation and continuation stages of the diffusion process. This study contributes to the understanding of factors that promote or impede each stage of the diffusion process in the school setting using the sex education program Long Live Love (LLL) as an example. A survey integrating different diffusion-related concepts was completed by 130 teachers. Results showed that teacher curriculum-related beliefs were associated with all stages in the diffusion process. Although adoption of LLL was predominantly related to teacher curriculum-related beliefs, implementation completeness and fidelity and continued use of LLL were also enhanced by contextual factors, namely teacher training and interactive context variables (school policy, governing body support and student response), respectively. The results of this study can be used to optimize the adoption, implementation and continuation of school-based (sexual) health promotion programs.

Early coital debut is a risk factor for HIV. In this paper we investigate the predictors of young adolescents' transition to first intercourse using a social cognition theoretical framework. The analyses reported here were based on a longitudinal study of 2360 students in the schools allocated to the control arm of a cluster-randomized controlled trial to investigate the effect of a school-based HIV prevention programme among Grade 8 students in Cape Town. Structural equation modelling was performed with Mplus version 3.11. Of the 1440 students who were virgins at baseline, 1144 remained virgins 15 months later and 296 (20.6%) reported having had their first sexual intercourse. Transition to first sexual intercourse was more likely among males than females, among older students and among students with a lower socio-economic status. Transition to first sexual intercourse was significantly associated with intentions to have sexual intercourse, poor self-efficacy to negotiate delayed sex and intimate partner violence. The model predicted 35% of the variance in intentions and 16% of the variance in transition. These findings indicate some of the factors that influence young adolescent's transition to first intercourse and that need to be addressed when designing effective interventions. (Contains 3 tables and 1 figure.)

To enable improvements in school health promotion, this paper examines associations between the number of health-promotion issues addressed by primary school teachers in the Netherlands and factors thought to influence this behavior. The main factors studied are context characteristics and constructs of attitude, social influence, self-efficacy (SE) and perceived barriers. A total of 180 primary school teachers teaching 9- to 12-year olds (Grades 6, 7 and 8) participated in a cross-sectional survey. The results show that it is possible to differentiate between teachers addressing three or more health issues per year versus those who address fewer based on grade level (more health issues are addressed at higher grades), perceived disadvantages, SE and staff support. The latter seems to exert the greatest influence and may be one of the most promising focus points for improvements of school health promotion in the Netherlands. (Contains 5 tables and 1 figure.)

The aim of this study was to examine the fidelity and completeness of the implementation of a school-based healthful diet promotion programme called "Krachtvoer" (we use the Dutch title of the programme throughout this article. A possible translation is Power Food, but this does not reflect the play on words in the Dutch title), aimed at lower vocational training students aged 12-14 years. The teachers' and students' opinions of the programme were also assessed, as well as the association between these opinions and the level of implementation. Data were collected through structured teachers' monitoring reports, in-class observations and in-depth interviews with teachers. Further data were drawn from a student questionnaire included in a concurrent cluster-randomized baseline post-test experimental study evaluating the effects of the programme. The present study indicates that the teachers implemented the programme largely according to plan, that the teachers appreciated most parts of the programme and that the students who were exposed to the programme were more appreciative of their nutrition education lessons than students who followed the usual curriculum. However, programme elements that teachers did not like were often not implemented. We conclude that the Krachtvoer programme is a promising tool to encourage students in lower vocational training to adopt diets that are more healthful. The present study revealed the stronger and weaker parts of the programme and can thus guide programme improvement. (Contains 3 tables.)

This review examines the current state of knowledge on the effectiveness of HIV prevention interventions with respect to sexual behavior among the population of drug users. The review focuses specifically on the relation between intervention methods found to be effective and the underlying theory. Electronic searches were conducted and supplemented by publications gathered through other channels. The studies were reviewed for (1) study design, (2) evident use of theory in intervention development, (3) clear targeting of determinants, (4) description of the study or studies, and (5) evaluation of the behavioral goals and targeted determinants. For each study, a description is given of: (1) the size and nature of the sample; (2) the retention rate; (3) the study design; (4) the nature of the intervention programs, including theoretical methods, practical strategies and theoretical background; (4) the measures of variability. The results show that a limited number of interventions were effective in changing sexual risk behavior among drug users. More successful programs featured several of the following elements: use of multiple theories and methods, inclusion of peers and rehearsal of skills. Moreover, the community-level interventions showed the importance of sustainability. The most successful intervention methods were modeling, skill building and social support enhancement. These methods are generally derived from the Social-Cognitive Theory or the Diffusion of Innovations Theory. Future HIV/AIDS interventions should build on the strengths discussed. Evaluations of interventions should be designed to facilitate comparison, using standardized and specific behavioral outcomes as well as standardized and preferably long-term follow-up levels, and should also evaluate the impact of programs at a psychosocial level to examine whether or not the theoretical methods on which a program was based were actually effective in changing the psychosocial factors targeted and why. Keywords: HIV/AIDS prevention; Psychosocial interventions; Drug users; Sexual risk behavior; Review

AIDS education emphasizing personal responsibility toward AIDS-inducing behavior might enhance negative reactions to people with AIDS. This study, based on Weiner's attributional theory of motivation and emotion, addressed this dilemma by reporting data from a sample of 1,018 Dutch secondary school students. Results support the reasoning that emphasizing personal responsibility, and consequently personal controllability, increases negative reactions to people with AIDS. In addition to causal attributions, however, AIDS knowledge and attitudes toward homosexuality also related significantly to reactions to people with AIDS. To prevent negative reactions to people with AIDS, the subject of homosexuality should be dealt with before AIDS education is provided. AIDS education should address the impossibility of HIV infection by daily interactions, and the meaning and consequences of being seropositive. (J Sch Health. 1993;63(4):182-187), Since the beginning of the AIDS epidemic, Dutch policy toward AIDS education and prevention has been tailored at preventing the further spread of HIV, and at preventing discrimination against and [...]

Abstract Background This paper evaluates the effect of the World Starts With Me (WSWM), a comprehensive sex education programme in secondary schools in Uganda. The aim of the present study was to assess the effects of WSWM on socio-cognitive determinants of safe sex behaviour (delay; condom use and non-coercive sex). Methods A survey was conducted both before and immediately after the intervention among students in intervention (N = 853) and comparison (N = 1011) groups. A mixed model repeated measures analysis was performed to assess the effectiveness of the WSWM programme on the main socio-cognitive determinants of safe sex behaviour at post-test. A similar post-hoc comparison was made between schools based on completeness and fidelity of implementation of WSWM. Results Significant positive effects of WSMW were found on beliefs regarding what could or could not prevent pregnancy, the perceived social norm towards delaying sexual intercourse, and the intention to delay sexual intercourse. Furthermore, significant positive effects of WSWM were found on attitudes, self-efficacy and intention towards condom use and on self-efficacy in dealing with sexual violence (pressure and force for unwanted sex). A reversed effect of intervention was found on knowledge scores relating to non-causes of HIV (petting, fondling and deep kissing). A follow-up comparison between intervention schools based on completeness of the programme implementation revealed that almost all significant positive effects disappeared for those schools that only implemented up to 7 out of 14 lessons. Another follow-up analysis on the basis of implementation fidelity showed that schools with a "partial" fidelity score yielded more significant positive effects than schools with a "full" fidelity of implementation score. Conclusions The study showed an intervention effect on a number of socio-cognitive determinants. However, the effectiveness of WSWM could be improved by giving more systematic attention to the context in which such a programme is to be implemented. Implications for the systematic development and implementation of school-based safe sex interventions in Uganda will be discussed.

Abstract Background Cardiovascular risk factors are associated with physical fitness and, to a lesser extent, physical activity. Lifestyle interventions directed at enhancing physical fitness in order to decrease the risk of cardiovascular diseases should be extended. To enable the development of effective lifestyle interventions for people with cardiovascular risk factors, we investigated motivational, social-cognitive determinants derived from the Theory of Planned Behavior (TPB) and other relevant social psychological theories, next to physical activity and physical fitness. Methods In the cross-sectional Utrecht Police Lifestyle Intervention Fitness and Training (UP-LIFT) study, 1298 employees (aged 18 to 62) were asked to complete online questionnaires regarding social-cognitive variables and physical activity. Cardiovascular risk factors and physical fitness (peak VO2) were measured. Results For people with one or more cardiovascular risk factors (78.7% of the total population), social-cognitive variables accounted for 39% (p < .001) of the variance in the intention to engage in physical activity for 60 minutes every day. Important correlates of intention to engage in physical activity were attitude (beta = .225, p < .001), self-efficacy (beta = .271, p < .001), descriptive norm (beta = .172, p < .001) and barriers (beta = -.169, p < .01). Social-cognitive variables accounted for 52% (p < .001) of the variance in physical active behaviour (being physical active for 60 minutes every day). The intention to engage in physical activity (beta = .469, p < .001) and self-efficacy (beta = .243, p < .001) were, in turn, important correlates of physical active behavior. In addition to the prediction of intention to engage in physical activity and physical active behavior, we explored the impact of the intensity of physical activity. The intentsity of physical activity was only significantly related to physical active behavior (beta = .253, p < .01, R2 = .06, p < .001). An important goal of our study was to investigate the relationship between physical fitness, the intensity of physical activity and social-cognitive variables. Physical fitness (R2 = .23, p < .001) was positively associated with physical active behavior (beta = .180, p < .01), self-efficacy (beta = .180, p < .01) and the intensity of physical activity (beta = .238, p < .01). For people with one or more cardiovascular risk factors, 39.9% had positive intentions to engage in physical activity and were also physically active, and 10.5% had a low intentions but were physically active. 37.7% had low intentions and were physically inactive, and about 11.9% had high intentions but were physically inactive. Conclusions This study contributes to our ability to optimize cardiovascular risk profiles by demonstrating an important association between physical fitness and social-cognitive variables. Physical fitness can be predicted by physical active behavior as well as by self-efficacy and the intensity of physical activity, and the latter by physical active behavior. Physical active behavior can be predicted by intention, self-efficacy, descriptive norms and barriers. Intention to engage in physical activity by attitude, self-efficacy, descriptive norms and barriers. An important input for lifestyle changes for people with one or more cardiovascular risk factors was that for ca. 40% of the population the intention to engage in physical activity was in line with their actual physical active behavior.

Abstract Background This paper describes the results of an exploratory qualitative study on Muslim adolescents' views on sexuality in the Netherlands. Methods Data were gathered from an Internet forum on which 44 Muslim and 33 non-Muslim adolescents discussed sexuality as it relates to Islam. These discussions were subsequently analyzed for content using Nvivo 2.0. Results Our analysis revealed several issues that are relevant for the design of future sex education programs targeting Muslim youth. Apart from some expected outcomes regarding, for example, taboos on sexuality, sex outside marriage, abortion, homosexuality and conservative gender roles, our analyses showed that in cases of disputes 1) discussions were polarized, 2) opponents used the same Qur'anic passages to support their views, and 3) the authority of an Imam was questioned when his interpretation of Qur'anic passages was not in line with the views of participants. Conclusions Our findings show that current approaches to sex education among Muslim youth are likely to be unsuccessful given the rigidity of sexual norms in Muslim society. In addition, we also identified new barriers to sex education among Muslim youth (e.g. lack of respect for an Imam who opposes a youth's views on sexuality).

Abstract Background Little is known regarding which behavioural responses can be expected if an influenza pandemic were to occur. Methods A survey comprising questions based on risk perception theories, in particular PMT, was conducted with a Dutch sample. Results Although fear that an influenza pandemic may occur was high, participants do not feel well informed. General practitioners and local health authorities were considered trustworthy sources of information and the information considered most urgent pertained to which protective measures should be taken. Participants reported an intention to comply with recommendations regarding protective measures. However, response and self efficacy were low. Maladaptive behaviours can be expected. Increasing numbers of ill individuals and school closures are also expected to lead to a decreased work force. Participants indicated wanting antiviral drugs even if the supply were to be insufficient. Conclusions Messages regarding health protective behaviours from local health authorities should anticipate the balance between overreacting and underreacting. Also, when protective recommendations from health professionals conflict with company policies, it is unclear how employees will react.

Abstract Background Collaborations are important to health promotion in addressing multi-party problems. Interest in collaborative processes in health promotion is rising, but still lacks monitoring instruments. The authors developed the DIagnosis of Sustainable Collaboration (DISC) model to enable comprehensive monitoring of public health collaboratives. The model focuses on opportunities and impediments for collaborative change, based on evidence from interorganizational collaboration, organizational behavior and planned organizational change. To illustrate and assess the DISC-model, the 2003/2004 application of the model to the Dutch whole-school health promotion collaboration is described. Methods The study combined quantitative research, using a cross-sectional survey, with qualitative research using the personal interview methodology and document analysis. A DISC-based survey was sent to 55 stakeholders in whole-school health promotion in one Dutch region. The survey consisted of 22 scales with 3 to 8 items. Only scales with a reliability score of 0.60 were accepted. The analysis provided for comparisons between stakeholders from education, public service and public health. The survey was followed by approaching 14 stakeholders for a semi-structured DISC-based interview. As the interviews were timed after the survey, the interviews were used to clarify unexpected and unclear outcomes of the survey as well. Additionally, a DISC-based document analysis was conducted including minutes of meetings, project descriptions and correspondence with schools and municipalities. Results Response of the survey was 77% and of the interviews 86%. Significant differences between respondents of different domains were found for the following scales: organizational characteristics scale, the change strategies, network development, project management, willingness to commit and innovative actions and adaptations. The interviews provided a more specific picture of the state of the art of the studied collaboration regarding the DISC-constructs. Conclusion The DISC-model is more than just the sum of the different parameters provided in the literature on interorganizational collaboration, organization change, networking and setting-approaches. Monitoring a collaboration based on the DISC-model yields insight into windows of opportunity and current impediments for collaborative change. DISC-based monitoring is a promising strategy enabling project managers and social entrepreneurs to plan change management strategies systematically.

Abstract Background Ecstasy (MDMA, 3, 4-methylenodioxymethamphetamine) use is widespread in the Netherlands, with a lifetime prevalence of 4.3%, and two-thirds of dance party visitors being ecstasy users. However, research into Dutch ecstasy use patterns is lacking. In addition, recent studies suggest that ecstasy users cease their use automatically, which implies that interventions would do better to better focus on the promotion of harm reduction strategies than on inducing cessation. The current study addresses this process of ecstasy cessation. Methods 32 participants from the Dutch dance scene were interviewed, and the results were systematically analysed using NVivo. Results Most ecstasy users had started to use out of curiosity. During use, users applied a host of harm reduction strategies, albeit inconsistently and sometimes incorrectly. Most users appeared to cease ecstasy use automatically because of loss of interest or changing life circumstances (e.g. a new job or relationship). Conclusion It appears that cessation of ecstasy use is largely determined by environmental variables and not by health concerns. This supports the idea that health promotion resources are better spent in trying to promote consistent and correct application of harm reduction practices than in trying to induce cessation.