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Background: Avian influenza (AI) is a public health challenge because of ongoing spread and pandemic potential. Non-pharmaceutical measures are important to prevent the spread of AI and to contain a pandemic. The effectiveness of such measures is largely dependent on the behaviour of the population. Risk perception is a central element in changing behaviour. This study aimed to investigate perceived vulnerability, severity and precautionary behaviour related to AI in the Netherlands during seven consecutive surveys in 2006 - 2007 as well as possible trends in risk perception and self-reported precautionary behaviours.Methods: Seven web-based surveys were conducted including 3,840 respondents over a one-year period. Time trends were analyzed with linear regression analyses. Multivariate analysis was used to study determinants of precautionary behaviour.Results: While infection with AI was considered a very severe health problem with mean score of 4.57 (scale 1 - 5); perceived vulnerability was much lower, with a mean score of 1.69. While perceived severity remained high, perceived vulnerability decreased slightly during a one-year period covering part of 2006 and 2007. Almost half of the respondents (46%) reported taking one or more preventive measures, with 36% reporting to have stayed away from (wild) birds or poultry. In multivariate logistic regression analysis the following factors were significantly associated with taking preventive measures: time of the survey, higher age, lower level of education, non-Dutch ethnicity, vaccinated against influenza, higher perceived severity, higher perceived vulnerability, higher self efficacy, lower level of knowledge, more information about AI, and thinking more about AI. Self efficacy was a stronger predictor of precautionary behaviour for those who never or seldom think about AI (OR 2.3, 95% CI 1.9 - 2.7), compared to those who think about AI more often (OR 1.5, 95% CI 1.2 - 1.9).Conclusions: The fact that perceived severity of AI appears to be high and remains so over time offers a good point of departure for more specific risk communications to promote precautionary actions. Such communications should aim at improving knowledge about the disease and preventive actions, and focus on perceived personal vulnerability and self efficacy in taking preventive measures. [ABSTRACT FROM AUTHOR]

Objective: To determine the relationship between the need for care and the use of care in the youth care system at neighbourhood level and the relationship with population characteristics, with consideration of the decentralisation of youth care., Design: Descriptive, retrospective study., Method: Data on youth care use, indicators of need for care and population characteristics were gathered from monitors and the records of the municipality, institutions and health insurance companies. Data were grouped on a neighbourhood level (n = 49). For the analyses we used univariate and multivariate regression. We used these to distinguish between neighbourhoods with large and small gaps between youth care use and need for youth care. Differences between these neighbourhoods were analysed with t-tests., Results: A multivariate model showed that the percentage of youths with emotional problems and behavioural problems and the percentage of parents with self-reported need for care were not predictors of youth care use at a neighbourhood level. About two thirds of the variance in youth care use between neighbourhoods could be explained by the population characteristics of a neighbourhood, particularly the percentage of youths originally from non-western countries, the percentage of youths with a low level of education or special training and the percentage of people who received income support. The number of 12-18-year-olds in a neighbourhood was a predictor of youth mental health care, and the percentage of youths in a single-parent family was a predictor of out-patient youth and parenting support. Neighbourhoods with a large gap between the need for and use of youth care were socially more disadvantaged than neighbourhoods with a smaller gap., Conclusion: Population characteristics explain the rate of use of youth care better than the need for youth care in a neighbourhood as measured by municipal monitors. The possible gap between the use of and need for youth care on an individual level in neighbourhoods with many characteristics of disadvantage is an important focus point for future neighbourhood teams.

Unlabelled: Hepatitis B virus (HBV) infections are an important health problem in Turkish migrants in the Netherlands. This study describes the effectiveness of a culturally tailored internet intervention promoting HBV screening in Turkish migrants., Methods: Turkish migrants, aged 16-40 years old, could participate in an online intervention offering either: (i) behaviourally plus culturally tailored (BCT) information; (ii) behaviourally tailored (BT) information or (iii) generic information (GI). Subsequently, free HBV screening was offered., Results: Out of 10.069 invited persons, 1512 (15%) logged in on the website and 623 people were tested. Screening uptake was 44% in the BCT group, 46% in the GI group and 44% in group BT. The BCT group showed favourable intervention effects for scores on determinants of screening when compared with baseline scores and BT., Conclusion: Although BCT did show favourable intervention effects for several determinants addressed in the intervention, we were not able to demonstrate the added value of BCT on screening uptake., Trial Registration: The Netherlands National Trial Register NTR 2394., (© The Author (2013). Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background & Aims: Migrants born in countries where hepatitis B is endemic are a risk group for chronic hepatitis B virus (HBV) infection. Treatment options have improved, but due to the asymptomatic nature of chronic HBV infection, the majority of patients remain unidentified., Methods: In 2009, a campaign targeting the Chinese community was held in the city of Rotterdam, The Netherlands. The campaign combined disease awareness activities with free HBV testing at outreach locations. Chronically HBV infected patients were referred to specialist care based on a referral guideline. Before and after the campaign, knowledge of chronic hepatitis B was measured through questionnaires in a convenience sample of the target population (n=285 and n=277)., Results: In a period of 3 months, 13 outreach activities took place and 1090 Chinese migrants were tested for HBV. Forty-nine percent had serological signs of a past or recent HBV infection and 8.5% (n=92) were chronically infected. Thirty-eight percent (n=35) of chronically infected patients were referred for evaluation by a specialist and of these, 15 started antiviral treatment within 1 year of follow-up. Before the campaign, 55% answered correctly to 6 or more out of 10 knowledge items. Knowledge was positively associated with educational level. After the campaign, an increase in knowledge was observed in participants with low levels of education., Conclusions: Chinese migrants could be reached with an outreach campaign, and on-site testing was well accepted. A high prevalence of chronic HBV infection was found and referral to specialist care and initiation of treatment was successful., (Copyright © 2012 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

This article describes the development of ROsafe, an intervention to promote sexually transmitted infection (STI) testing at vocational schools in the Netherlands. Using the planning model of intervention mapping (IM), an educational intervention was designed that consisted of two lessons, an Internet site, and sexual health services at the school sites. IM is a stepwise approach for theory- and evidence-based development and implementation of interventions. It includes six steps: needs assessment, specification of the objectives in matrices, selection of theoretical methods and practical strategies, program design, implementation planning, and evaluation. The processes and outcomes that are performed during Steps 1 to 4 of IM are presented, that is, literature review and qualitative and quantitative research in needs assessment, leading to the definition of the desired behavioral outcomes and objectives. The matrix of change objectives for STI-testing behavior is presented, and then the development of theory into program is described, using examples from the program. Finally, the planning for implementation and evaluation is discussed. The educational intervention used methods that were derived from the social cognitive theory, the elaboration likelihood model, the persuasive communication matrix, and theories about risk communication. Strategies included short movies, discussion, knowledge quiz, and an interactive behavioral self-test through the Internet.

Background: Adolescents are a risk group for acquiring sexually transmitted infections (STIs). In the Netherlands, senior vocational school students are particular at risk. However, STI test rates among adolescents are low and interventions that promote testing are scarce. To enhance voluntary STI testing, an intervention was designed and evaluated in senior vocational schools. The intervention combined classroom health education with sexual health services at the school site. The purpose of this study was to assess the combined and single effects on STI testing of health education and school-based sexual health services., Methods: In a cluster-randomized study the intervention was evaluated in 24 schools, using three experimental conditions: 1) health education, 2) sexual health services; 3) both components; and a control group. STI testing was assessed by self reported behavior and registrations at regional sexual health services. Follow-up measurements were performed at 1, 3, and 6-9 months. Of 1302 students present at baseline, 739 (57%) completed at least 1 follow-up measurement, of these students 472 (64%) were sexually experienced, and considered to be susceptible for the intervention. Multi-level analyses were conducted. To perform analyses according to the principle of intention-to-treat, missing observations at follow-up on the outcome measure were imputed with multiple imputation techniques. Results were compared with the complete cases analysis., Results: Sexually experienced students that received the combined intervention of health education and sexual health services reported more STI testing (29%) than students in the control group (4%) (OR = 4.3, p < 0.05). Test rates in the group that received education or sexual health services only were 5.7% and 19.9%, not reaching statistical significance in multilevel analyses. Female students were more often tested then male students: 21.5% versus 5.4%. The STI-prevalence in the study group was low with 1.4%., Conclusions: Despite a low dose of intervention that was received by the students and a high attrition, we were able to show an intervention effect among sexually experienced students on STI testing. This study confirmed our hypothesis that offering health education to vocational students in combination with sexual health services at school sites is more effective in enhancing STI testing than offering services or education only.

Worldwide, adolescents are at risk for sexually transmitted infections (STI). In The Netherlands, test rates among young heterosexual people are low and knowledge on the behavioral determinants of testing is scarce. In this study, we investigated STI testing in more detail with two independent samples of 16-25 year old vocational school students (n = 756/n = 1302). The aim of this study was to examine risk perceptions in relation to STI testing among lower educated adolescents in order to inform the development of an intervention promoting STI testing. We compared multiple measures of risk perception, fear of testing, self-efficacy for testing, and risk knowledge between groups of adolescents engaging and not engaging in risk behavior. The results show that at least half of the participating students with sexual experience underestimated their susceptibility for STI and showed an optimistic bias. Students with sexual experience also considered STI very severe but lacked self-efficacy for testing. This combination can yield a defensive reaction to the threat of STI that, in turn, results in the underestimation of personal risks. However, self-efficacy did not mediate the relationship between intention to test and perceived relative risk. In conclusion, our findings show underestimation of personal risks by vocational school students, a high perceived severity of STI and low self-efficacy for testing. A low level of knowledge regarding sexual risks and symptoms of STI might have contributed to low risk perceptions. Self-efficacy did not change the relation of intention-to-test to perceived risk.

Background: Research into risk perception and behavioural responses in case of emerging infectious diseases is still relatively new. The aim of this study was to examine perceptions and behaviours of the general public during the early phase of the Influenza A (H1N1) pandemic in the Netherlands., Methods: Two cross-sectional and one follow-up online survey (survey 1, 30 April-4 May; survey 2, 15-19 June; survey 3, 11-20 August 2009). Adults aged 18 years and above participating in a representative Internet panel were invited (survey 1, n = 456; survey 2, n = 478; follow-up survey 3, n = 934). Main outcome measures were 1) time trends in risk perception, feelings of anxiety, and behavioural responses (survey 1-3) and 2) factors associated with taking preventive measures and strong intention to comply with government-advised preventive measures in the future (survey 3)., Results: Between May and August 2009, the level of knowledge regarding Influenza A (H1N1) increased, while perceived severity of the new flu, perceived self-efficacy, and intention to comply with preventive measures decreased. The perceived reliability of information from the government decreased from May to August (62% versus 45%). Feelings of anxiety decreased from May to June, and remained stable afterwards. From June to August 2009, perceived vulnerability increased and more respondents took preventive measures (14% versus 38%). Taking preventive measures was associated with no children in the household, high anxiety, high self-efficacy, more agreement with statements on avoidance, and paying much attention to media information regarding Influenza A (H1N1). Having a strong intention to comply with government-advised preventive measures in the future was associated with higher age, high perceived severity, high anxiety, high perceived efficacy of measures, high self-efficacy, and finding governmental information to be reliable., Conclusions: Decreasing trends over time in perceived severity and anxiety are consistent with the reality: the clinical picture of influenza turned out to be mild in course of time. Although (inter)national health authorities initially overestimated the case fatality rate, the public stayed calm and remained to have a relatively high intention to comply with preventive measures.

Background: Adolescents are at risk for acquiring sexually transmitted infections (STIs). However, test rates among adolescents in the Netherlands are low and effective interventions that encourage STI testing are scarce. Adolescents who attend vocational schools are particularly at risk for STI. The purpose of this study is to inform the development of motivational health promotion messages by identifying the psychosocial correlates of STI testing intention among adolescents with sexual experience attending vocational schools., Methods: This study was conducted among 501 students attending vocational schools aged 16 to 25 years (mean 18.3 years ± 2.1). Data were collected via a web-based survey exploring relationships, sexual behavior and STI testing behavior. Items measuring the psychosocial correlates of testing were derived from Fishbein's Integrative Model. Data were subjected to multiple regression analyses., Results: Students reported substantial sexual risk behavior and low intention to participate in STI testing. The model explained 39% of intention to engage in STI testing. The most important predictor was attitude. Perceived norms, perceived susceptibility and test site characteristics were also significant predictors., Conclusions: The present study provides important and relevant empirical input for the development of health promotion interventions aimed at motivating adolescents at vocational schools in the Netherlands to participate in STI testing. Health promotion interventions developed for this group should aim to change attitudes, address social norms and increase personal risk perception for STI while also promoting the accessibility of testing facilities.

Background: Chronic hepatitis B virus infection (HBV) is an important health problem in the Turkish community in the Netherlands, and promotion of screening for HBV in this risk group is necessary. An individually tailored intervention and a culturally tailored intervention have been developed to promote screening in first generation 16-40 year old Turkish immigrants. This paper describes the design of the randomized controlled trial, which will be used to evaluate the effectiveness of the two tailored internet interventions as compared to generic online information on HBV, and to assess the added value of tailoring on socio-cultural factors., Methods/design: A cluster randomized controlled trial design, in which we invite all Rotterdam registered inhabitants born in Turkey, aged 16-40 (n = 10,000), to visit the intervention website is used. A cluster includes all persons living at one house address. The clusters are randomly assigned to either group A, B or C. On the website, persons eligible for testing will be selected through a series of exclusion questions and will then continue in the randomly assigned intervention group. Group A will receive generic information on HBV. Group B will receive individually tailored information related to social-cognitive determinants of screening. Group C will receive culturally tailored information which, next to social-cognitive factors, addresses cultural factors related to screening. Subsequently, participants may obtain a laboratory form, with which they can be tested free of charge at local health centres. The main outcome of the study is the percentage of eligible persons tested for HBV through to participation in one of the three groups. Measurements of the outcome behaviour and its determinants will be at baseline and five weeks post-intervention., Discussion: This trial will provide information on the effectiveness of a culturally tailored internet intervention promoting HBV-screening in first generation Turkish immigrants in the Netherlands, aged 16-40. The results will contribute to the evidence base for culturally tailored (internet) interventions in ethnic minority populations. An effective intervention will lead to a reduction of the morbidity and mortality due to HBV in this population. This may not only benefit patients, but also help reduce health inequalities in western countries., Trial Registration: The Netherlands National Trial Register NTR 2394.

Background: Hepatitis B virus infection is an important health problem in the Turkish community in the Netherlands. To prevent transmission and progression of the disease in this community, increased screening is necessary. This study aimed to determine 1) the levels of awareness and knowledge regarding hepatitis B, comparing these in tested and non-tested Turkish-Dutch in Rotterdam; 2) the self-reported hepatitis B test status in this population, and how this is related to demographic characteristics, knowledge and awareness., Methods: We conducted a postal survey amongst first and second generation migrants, aged 16 - 40 years., Results: The response rate was 30.2% (n = 355 respondents). Levels of awareness and knowledge regarding hepatitis B were low, as the majority of respondents (73%) never thought about the disease and 58% of the respondents scored 5 or less out of ten knowledge items. Weighted analysis of self-reports showed a test rate of 15%, and a vaccination rate of 3%. Regression analysis showed that having been tested for hepatitis B was related to being married and higher levels of awareness and knowledge., Conclusions: This study shows low levels of hepatitis B awareness and knowledge in the Turkish community in Rotterdam. Self-reported test rates are lower in people who are not currently married, and in those who have low levels of awareness and knowledge. Especially, knowledge about the consequences of hepatitis B, such as liver cancer, was lacking. Therefore, a health promotion intervention should foremost raise awareness, and increase knowledge on the seriousness of this disease.

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.

Objective: To gain insight into how the Dutch general public viewed the risk during the course of the recent pandemic, into how many and which people took precautionary measures, and into the extent to which people trust the information provided by the government., Design: Online survey, cross-sectional (the first two measurements) and follow-up investigations (the last two measurements)., Method: Between 10 and 17 November 2009, 754 people completed the online questionnaire. Earlier survey rounds were held in May (n = 572), June (n = 620) and August (n = 934)., Results: In November 2009, 38% of respondents considered the Mexican flu a serious disease and 36% viewed themselves as vulnerable to this flu. Feelings of anxiety had decreased versus earlier survey rounds. Of the respondents, 73% took precautionary measures against the disease. This concerned mainly hygiene measures, which were most frequently taken by people who were anxious, found hygiene measures effective, paid considerable attention to the media information on flu, and found information from the government reliable and those without children living at home. More than fifty percent (58%) of respondents indicated that they would be willing to have the vaccination if they would be eligible for this. Of the other 315 respondents, 40% indicated that they feared serious side effects, 35% that they doubted the effectiveness of the vaccine and 33% that they considered the vaccine to be insufficiently tested. Almost half of the respondents had read the information leaflet 'Fight the flu', which was sent to every home in the country. One third had seen the television campaign. Governmental institutions, notably the Ministry of Health, Welfare and Sport and the National Institute for Public Health and the Environment, were the most important sources of information and more than half of the respondents trusted this information., Conclusion: During the course of the 2009 influenza A (H1N1) pandemic, anxiety among the Dutch general public decreased progressively, while people increasingly considered themselves more vulnerable to the flu. The public therefore had a realistic view of the situation. Three quarters of the general public had taken precautionary measures against the flu. More than fifty percent would be willing to have the vaccination if they would be eligible for this. The most important reason for not wanting the vaccination was fear of serious side effects and doubts about the effectiveness of the vaccine. This is a point of attention for the development of public information campaigns about vaccinations in the future.

Background: Hepatitis B is an important health problem in the Turkish community in the Netherlands. Increased voluntary screening is necessary in this community, to detect individuals eligible for treatment and to prevent further transmission of the disease., Methods: We investigated socio-cultural determinants associated with hepatitis B screening in male and female, first and second generation Turkish migrants, by means of Focus Group Discussions., Results: Socio-cultural themes related to hepatitis B screening were identified; these were social norm, social support, sensitivity regarding sexuality, reputation, responsiveness to authority, religious responsibility, cleanliness and religious doctrine regarding health and disease, and the perceived efficacy of Dutch health care services. Motivating factors were the (religious) responsibility for one's health, the perceived obligation when being invited for screening, and social support to get tested for hepatitis B. Perceived barriers were the association of hepatitis B screening with STDs or sexual activity, the perception of low control over one's health, and the perceived low efficacy of the Dutch health care services. Reputation could act as either a motivator or barrier., Conclusion: This study identified relevant socio-cultural themes related to hepatitis B screening, which may serve to customize interventions aimed at the promotion of voluntary hepatitis B screening in the Turkish-Dutch population in the Netherlands.

Background: There is currently a trend towards unsafe unprotected anal intercourse (UAI) among men who have sex with men. We evaluated a short individual counselling session on reducing UAI among gay and bisexual men., Methods: A quasi-experimental design was used to evaluate the counselling session. This session was conducted during consulting hours at four municipal health clinics during a Hepatitis B vaccination campaign. These clinics offered free vaccination to high-risk groups, such as gay and bisexual men.All gay and bisexual men attending health clinics in four cities in the Netherlands were asked to participate. Each participant in the intervention group received a fifteen-minute individual counselling based on the Theory of Planned Behaviour and Motivational Interviewing. Changes in UAI were measured over a 5-months period, using self-administered questionnaires. UAI was measured separately for receptive and insertive intercourse in steady and casual partners. These measures were combined in an index-score (range 0-8)., Results: While UAI in the counselling group remained stable, it increased in the controls by 66% from 0.41 to 0.68. The results show that the intervention had a protective effect on sexual behaviour with steady partners. Intervention effects were strongest within steady relationships, especially for men whose steady-relationship status changed during the study. The intervention was well accepted among the target group., Conclusion: The fifteen-minute individually tailored counselling session was not only well accepted but also had a protective effect on risk behaviour after a follow-up of six months.

Objectives: The prevalence of viral hepatitis varies worldwide. Although the prevalence of hepatitis A virus (HAV) and hepatitis B virus (HBV) infection is generally low in Western countries, pockets of higher prevalence may exist in areas with large immigrant populations. The aim of this study was to obtain further information on the prevalence of viral hepatitis in a multi-ethnic area in the Netherlands., Methods: We conducted a community-based study in a multi-ethnic neighborhood in the city of Rotterdam, the Netherlands, including both native Dutch and migrant participants, who were tested for serological markers of hepatitis A, hepatitis B, and hepatitis C infection., Results: Markers for hepatitis A infection were present in 68% of participants. The prevalence of hepatitis B core antibodies (anti-HBc), a marker for previous or current infection, was 20% (58/284). Prevalence of hepatitis A and B varied by age group and ethnicity. Two respondents (0.7%) had chronic HBV infection. The prevalence of hepatitis C was 1.1% (3/271). High levels of isolated anti-HBc were found., Conclusions: We found a high prevalence of (previous) viral hepatitis infections. This confirms previous observations in ethnic subgroups from a national general population study and illustrates the high burden of viral hepatitis in areas with large immigrant populations.