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Background: Depressive disorders are highly prevalent and disabling diseases. Epidemiological studies have shown that they often co-occur with addictive behaviors, which in part might be explained by common risk factors. Rumination might be such a risk factor. Comorbidity can have substantial adverse effects for those affected. Thus, combined treatment approaches are needed. These should not be restricted to individuals with clinical disorders. In light of an apparent treatment gap, new treatment approaches that provide widespread access to evidence-based treatments need to be explored. In recent years, e-health interventions received a lot of attention. With their potential to be widely disseminated, they might be suitable to provide population-based intervention approaches. Developing population-based interventions might present special challenges to intervention developers, for example, in terms of intervention design or the selection of samples to preliminary test interventions. This thesis explored the application of e-health interventions in the treatment and prevention of depressive symptoms and addictive behaviors. Its first aim was to provide an overview on publicly accessible evidence-based e-health interventions for the treatment and prevention of depressive symptoms (study 1). The second aim was to test the feasibility, acceptability and potential effectiveness of a newly developed computer-based expert system intervention simultaneously targeting hazardous alcohol consumption and depressive symptoms and to investigate the importance of the sample selection when preliminary testing interventions (study 2). The third aim was to further investigate rumination with its subfactors brooding and reflection as a common cause of depression and addictive behaviors and thus as a potential target for combined interventions by analyzing its associations with symptoms of pathological gambling (SPGs; study 3).
Methods: This thesis provides a summary of different working steps in the process of developing and testing a computer-based intervention for health care patients (HCPs) with comorbid hazardous alcohol consumption patterns and depressive symptoms. In study 1, a systematic literature search was conducted to identify evidence-based e-health interventions for depressive symptoms. Interventions were considered for further inspection if studies provided evidence for at least small intervention effects and if the interventions were accessible to at least selected groups of individuals. For study 2, 2773 consecutive HCPs were screened for hazardous drinking and depressive symptoms. Of the 41 HCPs who were offered to participate in the study, 27 (65.9%) consented. To investigate the importance of the sample selection when preliminary testing interventions, HCPs were compared to media recruited volunteers (MVs). Over a period of 6 months, study participants received 6 individualized counselling letters and weekly short messages. Pre-post data were analyzed for 30 participants (15 HCPs, 15 MVs). Intervention acceptability was assessed in post-intervention interviews conducted with 32 study participants. In study 3, cross-sectional data of 506 (80.4% male) individuals aged 14 to 64 years with a history of gambling problems were analyzed. Associations between the rumination subfactors and SPGs across different levels of problem gambling severity were investigated by means of sequential quantile regression.
Results: In study 1, 37 publicly accessible evidence-based e-health interventions for depressive symptoms were identified. Most interventions (81.1%) were available in English. For the German language area, only 3 interventions were identified. In study 2, HCPs and MVs reduced regular binge drinking (HCPs: p = 0.016; MVs: p = 0.031) and depressiveness (HCPs: p = 0.020; MVs: p < 0.001). MVs further reduced average daily consumption (p = 0.034). Both subsamples rated the intervention positive. Compared to HCPs, MVs rated the alcohol module more favorably (p = 0.012). Intervention usage was higher in MVs than in HCPs (p = 0.013). Study 3 showed that at the median, ruminative brooding was positively associated with the severity of problem gambling after controlling for covariates (p = 0.005). Along the distribution of problem gambling severity, findings did hold for all but the lowest severity level. Ruminative reflection was not associated with problem gambling severity at the median (p = 0.347).
Conclusions: E-health interventions show great potential in the treatment and prevention of depressive symptoms and addictive behaviors. However, more research is needed to clarify how to make the most of this potential. Important questions that remain to be answered include, for example, how to best provide e-health interventions to those in need or how to design interventions in order to maximize their reach and thus their public health impact. This thesis showed that 1) publicly accessible evidence-based e-health interventions for depressive symptoms were available. However, the supply in the German language area was low. 2) The computer-based expert system intervention targeting hazardous alcohol consumption and depressive symptoms was technically and logistically feasible, acceptable, and may have the potential to reduce hazardous drinking and depressive symptoms in different populations, including populations unselected in terms of their motivation to change. To avoid biased conclusions about the potential of interventions, intervention developers should preliminary test interventions on intended target populations. 3) Rumination might be important in the development and maintenance of addictive behaviors. With its relations to depression and addictive behaviors, it should be considered as a target for future combined interventions.
Background: Physical inactivity is one of the main risk factors for cardiovascular disease,
which remains a major cause of death in Germany and around the globe. Thus, investigating
prevalences, population trends, high-risk groups, and intervention effects of physical activity
(PA) and sedentary time (ST) is highly relevant to public health. To receive reliable data, a
key issue in research is to apply an appropriate study design including the carefully
considered use of assessments. Otherwise, bias to PA and ST data may be introduced. The
present thesis investigates three often overlooked issues related to the impact of measurement
on PA and ST research data. The first aim was to examine whether mere measurement alters
PA and ST over the course of twelve months (study 1). The second aim was to identify
potential socio-demographic and cardiometabolic moderators of the mere-measurement effect
(study 2). The third aim was to present design, protocol, and preliminary results of an interim
analysis of a randomized controlled trial (RCT) aiming to test whether a video demonstration
of PA intensity levels reduces the lack of agreement between self-reported and objectively
measured PA (study 3).
Methods: Studies 1 and 2 were based on data of a trial to test the feasibility of a brief tailored
letter intervention to increase PA and to reduce ST during leisure time. Among a sample of
subjects with no history of myocardial infarction, stroke, or vascular interventions, a number
of 175 individuals aged 40 to 65 years participated in the study. At baseline, participants
received standardized measurement of blood pressure and waist circumference, blood sample
taking, and seven-day accelerometry. At baseline and after one, six, and twelve months,
participants completed the International Physical Activity Questionnaire (IPAQ). A random
subsample received a brief tailored letter intervention at months one, three, and four. A
number of 153 participants were included in study 1 using all available data across 12 months.
Changes in PA and ST were analyzed using latent growth modeling. For study 2, baseline and
one-month follow-up data of 175 participants were used. Dependence of one-month changes
in PA and ST on socio-demographic and cardiometabolic variables was analyzed using linear
regression models. In study 3, individuals aged between 40 and 75 years were recruited at a
shopping mall in Greifswald, Germany. Participants received seven-day accelerometry and
were invited to the cardiovascular examination center of the University Medicine Greifswald.
After random allocation to experimental and control group, they completed the selfadministered
IPAQ – Short Form via tablet-computer. The experimental group additionally
received a video demonstration of PA intensity levels before answering the questionnaire. A number of 131 participants were analyzed to receive preliminary results of an interim analysis
in order to verify the presumptions made for the a priori power calculation and to decide on
early stopping of the study. The difference between the study groups in the agreement
between self-reported and accelerometer-based PA was analyzed using a two-sample t-test.
Results: In study 1, results revealed no change in leisure-time PA, an increase in transportrelated
PA (p = .023), and a tendency towards a reduction of ST (p = .060) between baseline
and one-month assessment. Further, ST decreased between six and twelve months (p = .037).
Time trends of the intervention group did not differ significantly from those of the
assessment-only group. Results of study 2 revealed that men increased transport-related PA
more than women (p = .031) and men with higher triglycerides increased transport-related PA
less than men with lower triglycerides (p = .043). Men with higher systolic blood pressure
reduced ST more than those with lower systolic blood pressure (p = .028). However, this
linear association ceased to exist at a level of approximately 145 mmHg. A similar
relationship was found for glycated hemoglobin and ST in men. In study 3, preliminary
results of the interim analysis revealed a lower formal mean difference in the video group (M
= 21.8 min/day, SD = 108.9) compared to the control group (M = 41.0 min/day, SD = 117.4,
t(129) = 0.97, p = .166). The p-value lay between the significance (p < .010) and futility (p >
.269) boundaries of the test simulations.
Conclusions: Results of the present thesis have three implications for considering the impact
of PA and ST assessments in cardiovascular research. First, mere-measurement effects within
a feasibility trial were found in transport-related PA and ST suggesting to interfere with
potential intervention effects. Thus, measurement effects should be considered when planning
studies and interventions and when interpreting outcomes. Second, male sex and more
favorable triglycerides levels in men were associated with a higher increase of transportrelated
PA whereas worse health in men was associated with a higher reduction of ST. Thus,
using the mere-measurement effect for prevention purposes may require researchers and
practitioners to tailor PA and ST intervention components to individuals’ health condition.
Third, the design and protocol of the RCT seems appropriate to test the effect of a novel video
on the gap between self-reported and accelerometer-based PA. Preliminary results point to the
efficacy of the video.
Trade of cattle between farms forms a complex trade network. We investigate partitions of this network for cattle trade in Germany. These partitions are groups of farms with similar properties and they are inferred directly from the trade pattern between farms. We make use of a rather new method known as stochastic block modeling (SBM) in order to divide the network into smaller units. SBM turns out to outperform the more established community detection method in the context of disease control in terms of trade restriction. Moreover, SBM is also superior to geographical based trade restrictions and could be a promising approach for disease control.
Abstract
Aims
To demonstrate the attitudes of general practitioners (GPs), nurses, persons with dementia, and caregiver towards suitable tasks and qualification needs for and the acceptance and impact of advanced nursing roles in German dementia primary care.
Design
Observational study using a questionnaire survey with 225 GPs, 232 nurses, 211 persons with dementia, and 197 caregivers, conducted between December 2017–August 2018.
Methods
A questionnaire was generated that includes specific assessment, prescription, and monitoring tasks of advanced nursing roles in dementia primary care as well as qualification requirements for and the acceptance and the impact of advanced nursing roles. Data were analysed using descriptive statistics. Group differences were assessed using the Fisher's exact test.
Results
Advanced nursing roles were highly appreciated across all groups. Assessment and monitoring tasks were rated as highly suitable, and prescription authorities as moderately suitable. Nurses felt less confident in assessment and monitoring, but more confident in prescribing as practitioners expected. Patients and caregivers would appreciate a takeover of tasks by nurses; nurses and practitioners preferred a delegation. A dementia‐specific qualification was rated as best suitable for advanced nursing roles, followed by ‘no specific qualification’ if medical tasks that only can be carried out by practitioners were delegated and an academic degree if tasks were substituted. Advanced nursing roles were rated as beneficial, strengthening the confidence in nursing care and improving the cooperation between professionals and the treatment. Practitioners assumed that advanced nursing roles would improve job satisfaction of nurses, which was not confirmed by nurses.
Conclusion
There is an extended consensus towards the enlargement of advanced nursing roles, represented by high endorsement, acceptance, and willingness to reorganize tasks.
Impact
Results debunk the common notion that German practitioners would be reluctant towards advanced nursing roles and a takeover of current practitioner tasks, supporting the implementation of advanced nursing roles in Germany.
Background: Sedentary behavior (SB) is a modifiable behavior with increasing prevalence worldwide. There is emerging evidence that time spend in SB and the manner in which SB is accumulated over time is associated with cardiovascular and cardiometabolic health. The requirement for SB data to be accurately measured is minimization, or at least accurate quantification of human-related sources of measurement errors such as accelerometer measurement reactivity (AMR). The present thesis was to examine SB and their associations with cardiovascular and cardiometabolic health, and to focus on challenges related to the assessment of SB. The first aim of the thesis was to identify patterns of SB describing how individuals accumulate their time spend in SB day-by-day over one week, and to examine how these patterns are associated with cardiorespiratory fitness as a marker for cardiovascular health (paper 1). The second aim of the thesis was to examine the multiple types of SB, and how this is associated with a clustered cardiometabolic risk score (CMRS; paper 2). The third aim of the thesis was to examine AMR and the reproducibility in SB and physical activity (PA) in two measurement periods, and to quantify AMR as a confounder for the estimation of the reproducibility of SB and PA data (paper 3).
Methods: The three papers were based on data of two different studies. For study 1, 1165 individuals aged 40 to 75 years were recruited in three different settings. Among these, 582 participated in a cardiovascular risk factor screening program including cardiopulmonary exercise testing. For the analyses of paper 1, 170 participants were eligible, agreed to wear an accelerometer, fulfilled the wearing regime, and completed the study period by wearing the accelerometer for seven consecutive days. Patterns in accelerometer data were classified based on time spent in SB per day applying growth mixture modeling. Model‐implied class‐specific peak oxygen uptake (VO2peak) means were compared using adjusted equality test of means (paper 1). The underlying study of paper 2 and 3 were based on data of a pilot study aiming to investigate the feasibility of a brief tailored letter intervention to increase PA and to reduce SB during leisure time. Among the individuals who agreed to be contacted again in study 1, a random sample of those aged between 40 and 65 years was drawn. Of those, 175 attended in a cardiovascular examination program. Assessment included giving blood sample, standardized measurement of blood pressure, waist circumference, body weight, and height at baseline, and after twelve months. Further, they agreed to complete a paper-pencil questionnaire on SB (Last 7-d Sedentary Behavior Questionnaire, SIT-Q-7d) and PA (International Physical Activity Questionnaire, IPAQ), and to receive seven-day accelerometery at baseline, and after 12 months. In addition, self-administered assessments were conducted at months one, three, four, and six after baseline. Only individuals of a random subsample (= intervention group) received up to three letters tailored to their self-reported SB and PA at months one, three, and four. For paper 2, associations between SBs and a clustered cardiometabolic risk score (CMRS) were analyzed using linear as well as quantile regression. To account for missing values at baseline, multiple imputations using chained equations were performed resulting in a total sample of 173 participants. Paper 3 comprised data of 136 individuals who participated at the baseline and twelve months assessments, and fulfilled the wearing regime. AMR was examined using latent growth modeling in each measurement period. Intraclass correlations (ICC) were calculated to examine the reproducibility of SB and PA data using two-level mixed-effects linear regression analyses.
Results: Results of paper 1 revealed four patterns of SB: 'High, stable', 'Low, increase', 'Low, decrease', and 'High, decrease'. Persons in the class 'High, stable' had significantly lower VO2peak values (M = 25.0 mL/kg/min, SD = 0.6) compared to persons in the class 'Low, increase' (M = 30.5 mL/kg/min, SD = 3.6; p = 0.001), in the class 'Low, decrease' (M = 30.1 mL/kg/min, SD = 5.0; p = 0.009), and in the class High, decrease' (M = 29.6 mL/kg/min, SD = 5.9; p = 0.032), respectively. No differences among the other classes were found. In paper 2, results revealed that the only factor positively associated with a CMRS in all regression models was watching television. Depending on the regression analysis approach used, other leisure-time SBs showed inconsistent (using a computer), or no associations (reading and socializing) with a CMRS. In paper 3, results revealed that time spent in SB increased (baseline: b = 2.3 min/d; after 12 months: b = 3.8 min/d), and time spent in light PA decreased (b = 2.0 min/day; b = 3.3 min/d). However, moderate-to-vigorous PA remained unchanged. Accelerometer wear time was reduced (b = 4.6 min/d) only at baseline. The ICC coefficients ranged from 0.42 (95% CI = 0.29 - 0.57) for accelerometer wear time to 0.70 (95% CI = 0.61 - 0.78) for moderate-to-vigorous PA. None of the regression models identified a reactivity indicator as a confounder for the reproducibility of SB and PA data.
Conclusions: The present thesis highlights SB in the field of cardiovascular and cardiometabolic research that have implications for future research. Individuals sit for different purposes and durations in multiple life domains, and the time spent in SB is accumulated in different patterns over time. Therefore, research should consider the fact that SB is embedded in an individual's daily life routine, hence might have differential effects on cardiovascular and cardiometabolic health. Further, methodological aspects have to be considered when dealing with SB. In order to detect how SB is 'independently' associated to an individual's health, an accurate measurement of SB is fundamental. Therefore, human-related sources of bias such as AMR should be taken into account when either planning studies or when interpreting data drawn from analysis of SB data.
Ziel der Arbeit war eine Analyse des Auftretens von Risikoclustern unter der Berücksichtigung der Risikoausprägung der Risikoverhaltensweisen Tabakrauchen, Alkoholkonsum, Übergewicht und geringe körperliche Aktivität in einer bevölkerungsrelevanten Stichprobe. Dafür wurde ausgehend von Literaturrecherchen ein Risikoscore entwickelt, anhand dessen Prävalenzdarstellungen sowie multinomiale logistische Regressionsanalysen für als besonders relevant erachtete Risikoscoreausprägungen erfolgten. Die Ergebnisse zeigten ein Dominieren von nicht und wenig riskanten Verhaltenskombinationen in der Gesamtbevölkerung sowie eine Häufung von Risikoverhaltensweisen bei Jüngeren und kürzer Ausgebildeten. Zudem bestand bei den Befragten mit geringerem Bildungsgrad eine hohe Varianz der Risikoverhaltenskombinationen. Als wichtigste Risikoverhaltenskombination mit erhöhter Risikoausprägung wurde das Vorliegen eines Bewegungsmangels kombiniert mit dem Konsum von Tabak festgestellt.