Exploring health perceptions and behavioural drivers of diet in those with familial risk of AMD: A COM-B Model Approach.

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Miguel Gedtal, Jayne V Woodside, Ruth Esther Hogg This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6761699/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Age-related macular degeneration (AMD) is the leading cause of sight loss in the UK. Those with a family history of AMD are at elevated risk; however, evidence suggests that AMD can be prevented or delayed through dietary modifications. This study aimed to explore the influences that encourage a healthy diet among adult children or siblings of AMD patients with the goal of designing a theory-based dietary intervention using the COM-B model. Methods Online and physical surveys with a battery of questionnaires were delivered. Participants completed a Mediterranean Diet (MedDiet) Score assessment (theoretical range 0–14), established instruments measuring dietary influences, and newly developed tools assessing AMD-specific perceptions. Correlations between MedDiet scores, dietary components (fruit, vegetable, and fish intake), and dietary influences were examined. Appropriate behavioural intervention types were identified based on the COM-B model domains associated with dietary behaviour. Results Overall, there were 63 valid respondents, the majority of which were female (57.1%; 36/63), Caucasian(90.2%;55/61)and were aged 46–65 years(90.5%; 57/63). The mean MedDiet score was 5.22 (SD = ± 2.22). The proportion who ate fruit (≥ 2 servings/day) was 65.1% (41/63); for those who ate vegetables (≥ 3 servings/week) it was 38.1% (24/63); for those who ate fish (≥ 3 servings/week) it was 15.9% (10/63). MedDiet adherence, fruit intake, and vegetable intake were positively associated with influences categorised under the reflective motivation domain of the COM-B model. This indicates that intervention strategies incorporating education, persuasion, incentivization, coercion, and/or modeling may be effective for promoting healthy dietary behaviours in this at-risk group. There was strong negativity around fish intake and and positive behavioural influences for fish intake were not identified. Conclusion This study identified potential behavioural intervention types to enhance Mediterranean diet adherence and increase fruit and vegetable intake among individuals with a familial risk of AMD. This information can now be used to design targeted interventions. Further qualitative research is recommended to identify potential facilitators to increasing fish intake and to triangulate these findings. Age-related macular degeneration Family history COM-B model Dietary influences Mediterranean diet Fruit Vegetables Fish Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Age-related macular degeneration (AMD) is a disease that spans the outer retina and choroid, which frequently progresses to central vision loss for one or both eyes. As we age waste products tend to build-up in the outer retina and the discrete deposits are called drusen. Drusen are hallmark features of AMD and are used to indicate severity of the disease, depending on their size, texture and position 1 , 2 . Currently, there is no cure for AMD; available treatments that contribute to the maintenance of sight are given lifelong. Such treatments are expensive, with intra-vitreal injection therapy costing the NHS £740-£816 per injection 1 , 3 . Preventing or delaying the onset of AMD is a worthy aim with the potential to prevent the substantial loss of quality of life experienced by those with late-stage AMD. While drusen are considered the hallmark of AMD, not all with drusen progress to the sight-threatening stages of AMD. Risk factors can be categorised as 1. Lifestyle, e.g., smoking, diet high in fat or low in certain nutrients; and 2. Individual factors, which are outside human control, e.g., age, genetics, and family history of AMD 4 . There is evidence that the progression of AMD can be slowed, or even prevented in the first place by a diet rich in vegetables, fruit and fish, such as the Mediterranean diet 5 – 9 . Hence, prevention or lowering the risk of AMD could involve modification of lifestyle factors, e.g., diet, among those with a family history of the disease. Indeed, one should consider providing advice to those at most risk of developing AMD in later life before the earliest stages of AMD appear. Current best practice guidelines in the UK advise a high intake of fruit, vegetables and fish among patients already with AMD 10 , 11 . Stevens et al. (2015) highlighted that some AMD patients may have poor motivation to eat vegetables and fruits 12 . The team subsequently designed an educational resource for AMD patients, which improved motivation scores for daily intake of vegetables and daily AREDS2 supplementation 13 . However, research which explores those who are AMD-free but are nonetheless at high risk of AMD is scarce; their motivations for lifestyle change and perceptions regarding health, AMD and diet are poorly understood. Determining factors associated with current dietary intake in this population could be used to design a behaviour modification study to effectively encourage behaviours that could lower their risk of AMD or delay onset. To achieve this, a behaviour change framework could be used to maximise the effect of such a study. Several behaviour change frameworks have been developed but one developed in the UK context by Michie et al 14 is the the Capability Opportunity and Motivation Behaviour (COM-B) model which dictates that a behaviour must be influenced by physical and mental capability; social and environmental/physical opportunity; and motivation which is either automatic or has been reflected upon (Fig. 1 ). Moreover, behaviour change intervention types have been associated across different categories of the COM-B model (Table 1 ), and each behaviour change intervention type has been associated with specific behaviour change techniques (BCTs) (Table 2 ). BCTs are the primary units that could be observed and replicated in a behaviour change modification study; BCTs, on their own, have the potential to cause behaviour change 15 . Thus, in this study, a battery of questionnaires was designed specifically for healthy offspring or siblings of AMD patients and was validated to determine the influences of diet and perceptions on food, health and AMD within this cohort. Ultimately, the aim is to identify the relevant behaviour change intervention types and, potentially, BCTs that could inform a future behaviour dietary modification study among those with a family history of AMD. Methods Preparing the survey Questionnaires that captured food and health perceptions were sourced from literature and were mostly developed and/or validated in the UK population to produce a battery of questionnaires. The survey consisted of eleven parts: (i) Food Choice Questionnaire (7-point scale Likert score from “Not at all important” to “Very important”) 16 , (ii) Mediterranean Diet Score (range = 0–14 score) 17 , 18 , (iii) Cooking skills [7-point Likert score from “Never/rarely do it”=0 to “7 (very good)”] 19 , (iv) Food skills [8-point Likert score from “Never/rarely do it”=0 to “7 (very good)”] 19 , (v) Social Norms/Theory of Planned Behaviour (5-point scale from “Strongly Disagree” to “Strongly Agree”) 20 , (vi) Participant Background, (vii) Cues to action questionnaire (5-point scale from “Strongly Disagree” to “Strongly Agree”) 21 (viii) Knowledge of Dietary Risk factors 1 , 10 , 22 – 24 , (ix) Knowledge of Lifestyle and Individual Risk Factors 1 , 10 , 22 – 24 , (x) Familial Case Background and (xi) Participant background. There were no validated instruments that captured knowledge of AMD; hence, they were created in this study. Note that a brief Mediterranean diet (MedDiet) questionnaire (which was previously validated in a UK population for indicating serum lutein and zeaxanthin carotenoids) was used 17 , 18 . The development and validation of these instruments have been detailed in the Appendix ( Appendix Sections 1–5; F8A-F8D; T5A-5D, T6 and T7 ). Ethical approval for this research was received from Queen’s University Belfast Research Ethics Committee. The Theoretical Domains Framework (TDF) are theoretical constructs that influence behaviour which can be captured by survey instruments. As each questionnaire captures specific constructs, the TDF ultimately aids in placing where in the COM-B model the captured construct is most relevant. Should a construct reveal a significant impact towards a specific dietary or food intake, the framework can be used to suggest the appropriate behaviour change intervention types 25 . In our study, questionnaires i,iii-v, and vii-ix were captured and mapped onto the COM-B model (Table 3 ). After the appropriate intervention types are identified, the appropriate BCTs could be determined as agreed upon in consensus by Michie et al. or as evidenced in the literature through the BCT Taxonomy v1 (Table 2 ) 26 . A similar process has been done previously in a UK population whereby specific behaviour change intervention types and therefore BCTs for dietary change were informed by the COM-B model 27 The figure is adapted from Alexander et al. (2014) 28 . B is for behaviour change technique. The green outer ring indicates the Capability, Opportunity and Motivation categories. The green inner ring indicates the subcategories of Capability which are i. Physical and ii. Psychological; for Opportunity, they are i. Social and ii. Physical; and for Motivation, they are i. Automatic and ii. Reflective. The yellow ring indicates the domains of the Theoretical Domains Framework. The domains under the category Capability, subcategories i. Physical and ii. Psychological have the sub-domains of Skills; Knowledge (Know); Behavioural Regulation (Beh Reg) and Memory, Attention and Decision Processes (Mem). The domains under the category Opportunity, sub-domains i. Social and ii. Physical are Social influences (Soc) and Environmental context and resources (Env). The category Motivation has the sub-domains i. Automatic and ii. Reflective which has the domains of Emotion (Em); Professional role and identity (Id); Beliefs about capabilities (Bel Cap); Goals, intentions and motivations (Goals); and Beliefs about consequences (Bel Cons). Table 1 Behaviour change intervention types under each subcategory of the Capability Opportunity and Motivation Behaviour (COM-B) model COM-B model CAPABILITY OPPORTUNITY MOTIVATION COM-B categories PHYSICAL PSYCHOLOGICAL PHYSICAL SOCIAL AUTOMATIC REFLECTIVE Intervention type Education (Ed) √ √ Persuasion (Pe) √ √ Incentivisation (In) √ √ Coercion (Co) √ √ Training (Tr) √ √ √ √ Restriction (Re) √ √ Environmental restructuring (Er) √ √ √ Modelling (Mo) √ √ Enablement (En) √ √ √ √ √ √ Adapted from Reidy et al. (2020) 28 . Ticked boxes indicate which part of the COM-B model a specific behaviour change intervention type can most appropriately be used. Table 2 Behaviour change intervention type (Education) and appropriate behaviour change techniques (BCTs) as suggested in the BCT Taxonomy App version 1 Intervention type Most frequently used BCTs Definition of BCT Education Information about social and environmental consequences Provide information (e.g. written, verbal, visual) about social and environmental consequences of performing the behaviour Information about health consequences Provide information (e.g. written, verbal, visual) about health consequences of performing the behaviour Feedback on behaviour Monitor and provide informative or evaluative feedback on performance of the behaviour (e.g. form, frequency, duration, intensity Feedback on outcome(s) of the behaviour Monitor and provide feedback on the outcome of performance of the behaviour Prompts/cues Introduce or define environmental or social stimulus with the purpose of prompting or cueing the behaviour. The prompt or cue would normally occur at the time or place of performance Self-monitoring of behaviour Establish a method for the person to monitor and record their behaviour(s) as part of a behaviour change strategy This table is a snapshot of the taxonomy based on the BCT Taxonomy App version 1. The suggested BCTs for all behaviour change intervention types and definitions for each BCT are also provided in the App. Table 3 Constructs regarding food and health perceptions captured by the questionnaires in the survey and where they map in the Capability Opportunity and Motivation Behaviour (COM-B) model COM-B model CAPABILITY OPPORTUNITY MOTIVATION COM-B categories PSYCHOLOGICAL PHYSICAL SOCIAL PHYSICAL AUTOMATIC REFLECTIVE Food Choice Questionnaire 16 † °Familiarity (Mem) † °Affordability (Env) † °Convenience (Env) † °Mood (Em) † °Sensory appeal (Em) † °Natural content (Bel Cons) † °Health (Bel Cons) † °Ethical concern (Bel Cons) † °Weight control (Bel Cons) † Cooking and Food Skills Questionnaire 19 † °Cooking skills (range = 0 to 49) and food skills confidence scores (range = 0 to 42) (Phys) † Social Norms/ Theory of Planned Behaviour 20 (adapted for fruit and veg intake) ‡ °Perceived social norms (Soc) ‡ Cues to Action Questionnaire 21 (adapted for age-related macular degeneration and dietary behaviour) ‡ ° Cues to action (Bel Cap) ‡ Knowledge Questionnaires for Diet and Demographics/ Lifestyle 1, 10 , 22 – 24 ‖ °Knowledge scores for diet (range=-1 to 3) and for lifestyle/individual (range= -2 to 5) (Know) ‖ Behaviour change intervention types Ed, En, Tr En, Tr Em, Er, Mo, Re En, Er, Re, Tr Co, En, Er,In, Mo, Pe, Tr Co, Ed, In, Mo, Pe Key: †=Already construct validated in the UK population; ‡=Requires validation. ‖=Only content validated by eye clinicians in the UK in this study. These are the predicted constructs according to the originating literature. Relevant sections in the Theoretical Domains Framework covered are 1. Memory, Attention and Decision Processes (Mem); 2. Environmental Context and Resources (Env); 3. Emotion (Em); 4. Beliefs about Consequences (Bel Cons); 5. Physical skills (Phys); 6. Social influences (Soc); 7. Beliefs about capabilities (Bel Cap); 8. Behaviour change intervention types: Knowledge 25 . Ed = Education; En = Enablement; Er = Environmental restructuring; Co = Coercion; In = Incentivisation; Mo = Modelling; Pe = Persuasion; Re = Restriction; Tr = Training. Pilot before the initial release The entire survey was prepared in Qualtrics and piloted online by relatives of AMD patients (n = 3), by researcher colleagues in CPH QUB (n = 5) and by adult laypersons (i.e., those outside the field of academia) who have no relatives with AMD (n = 5) (overall respondents = 13). The survey took ≤ 25 minutes to complete. Minor changes were undertaken following their comments. Recruitment strategy for initial release Non-random sampling methods (i.e., opportunistic, volunteer sampling and snowballing methods) were used as they were the most pragmatic means of recruitment. A link for the survey was also disseminated through relevant Facebook groups such as the Royal National Institute of Blind People and Macular Society, each of which was approached and permission sought from the group administrator before any post was made. Additionally, permission was asked from Macular Society support groups whether physical copies of the survey could be distributed in the group for relatives of AMD patients, as they may attend the meeting. Copies were also provided to AMD patients so they could pass them on to their relatives. To ensure anonymity, the researcher attending the Macular Society support group meeting did not have access to the attendance list. In addition, recruitment was through word of mouth. The physical and online surveys were self-paced, so potential participants were given time to read the Patient Information Form and provide consent. Responses in the physical survey were added to Qualtrics. Inclusion criteria were: i. be 18 years or older, ii. live in the UK, iii. have either a biological parent or biological sibling with AMD, iv. have no diagnosis of AMD. In the initial release, there was a sufficient sample of participants (n = 20) for validation and refinement of the instruments via exploratory factor analysis (EFA) (See Appendix Section 5; F8A-F8D ) but insufficient numbers for correlation analysis; hence, the survey was released in the second round through an accredited panel provider called Norstat (Norstat - Data to trust for decisions that matter) who identified those who self-reported as having a parent with AMD from their larger panel of potential participants. Secondary release (March-July 2024) There were several changes in the second live release of the survey in addition to recruitment via Norstat: potential participants (i.e., screened before displaying the participant information sheet) were pre-screened to reduce the chance of invalid responses; the questionnaire instruments that were validated previously which had the number of items reduced ( Appendix F8A-F8D .) were used; and, with the guidance from the ethics committee, the consent form was reduced to one statement. Following these changes, the participant burden was decreased (i.e., reduction of five minutes) on account of shortening the overall survey. Moreover, measures that screened ineligible or bot respondents (using Captcha, honeypot questions, repeated questions and an open-ended comment box 29 ) were used. Correlation method The method for correlation for multi-item factors followed those used by Michael Foley 30 (2020) and George Mount 31 (2020), whereby the MedDiet score, fruit, vegetables and fish variables were latentised and each survey instrument was tested whether they had a significantly associated correlation to the latentised MedDiet score, fruit, vegetables and fish variables. Standardisation was not necessary since items used in each questionnaire used identical scales. San-Cristobal et al. (2017) observed that the effect of food and health perceptions on the Mediterranean Diet score in a large international population (including the UK) was R 2 = 0.22 32 . The f 2 was calculated from the equation f 2 = R 2 / (1- R 2 ) as recommended in previous literature 33 . Hence, f 2 was 0.282. Using this effect size, the power was set at 0.8, alpha at 0.05, and the maximal number of predictors being two following concurrent validity. G*power calculated a total sample size of 38. Similarly, a minimum sample of 40 has been reported as sufficient to validly correlate a given model to the outcome of interest 34 ; the outcomes in this study’s case are the MedDiet score, fish intake, fruit intake and vegetable intake. The mice package (V.3.16.0) was used to impute the dataset 35 . The range of correlations across imputations was presented as minimum-maximum. The pooled p-values were acquired using the median-p-rule 36 . P-values < 0.05 were deemed significant. Results Screening of bots in the initial survey After running the initial survey between September to December 2022, over 400 responses were gathered, but many of the responses were from bots which could be checked and removed where appropriate by using a scoring mechanism (Captcha score) in the Qualtrics software. There was also a spike of responses between December 10th -12th 2022. This is highly suspicious of bot activity; hence, respondents from the spike period were also removed. Furthermore, online responses from outside UK which could be determined based on their IP address (a unique but anonymous ID of an internet-connected device) were removed, unless they stated in the survey that they were currently outside UK. In this case, it was assumed that participants were UK residents who were temporarily outside UK by the time they completed the survey. Responses that did not progress past the consent form were removed as there was little (if any) data provided by these respondents. Responses from the pilot study were included. Ultimately, 20 valid responses were acquired (Fig. 2 ). Demographics and mean scores Combining the valid results from the pilot study, the initial 2022 release of the survey and the 2024 release, and after excluding bots, 63 responses were acquired. Most respondents were female (57.1%; 36/63), Caucasian (90.5%; 57/63), aged between 46–65 and 56 − 55 years (30.2%; 19/63 for both), were never smokers (57.1%; 36/63), did not take lutein, zeaxanthin and/or meso-zeaxanthin supplements (82.5%; 52/63), and had an affected parental relative (91.8%; 59/63). The mean pooled MedDiet score was 5.222 (SD = ± 2.218); for the instruments that captured knowledge of lifestyle/individual and dietary risk factors, they were 3.20 [potential minimum-maximum (pmin-max) =-3 to 5] and 0.79 (pmin-max=-3 to 2) respectively; for the cooking and food skills, scores were 32.317 (SD = ± 10.696) (pmin-max = 0–49) and 23.841 (SD = ± 9.976) (pmin-max = 0–42) respectively. The pooled proportion who ate fruit (≥ 2 servings/day) was 65.1% (41/63); for vegetables (≥ 3 servings/day), it was 38.1% (24/63), and for fish (≥ 3 servings/week), it was 15.9% (10/63). Perceptions about diet and AMD. The responses from the Food Choice Questionnaire (FCQ) and the Exploratory Factor Analysis (EFA)-validated instruments are below (Figs. 3 – 7 ). In the FCQ, all respondents who completed it reported how pleasurable sensations were important influences on food choice (61/61; 100%). The majority stated that monitoring mood (21/62; 29%) was not at all important/ unimportant/ somewhat unimportant in influencing food choice (Fig. 3 ). In the Social Norms instrument, the majority of participants agreed that friends and family encourage them to eat fruits and vegetables (35/63; 56%); most participants disagreed that they felt pressure from others to eat fruits and vegetables (47/62; 76%) (Fig. 4 ). In the Cues to Action instrument, the majority of participants agreed that their feelings about themselves would change if they developed AMD (33/63; 52%), and most participants disagreed (36/62; 58%) that when they think about AMD their hearts beat faster (Fig. 5 ). The majority of participants who completed the lifestyle and individual knowledge instrument reported that physical activity decreased the risk of AMD (23/39; 59%). Moreover, a majority of participants believed that an increased risk of AMD results from hypertension (40/42; 95%), being overweight (39/40; 95%), ageing (52/52; 100%), family history (44/45; 98%), smoking (34/36; 94%) and genetic background (41/43; 95%) (Fig. 6 ). Among the respondents that completed the dietary knowledge instrument, a majority reported that a decreased risk of AMD resulted from intake of carotenoids (31/35; 89%), fish (32/34; 94%) and omega-3 and 6 fats (29/35; 83%). Most participants reported that saturated fats increased the risk of AMD (25/34; 74%) (Fig. 7 ). Question: It is important to me that the food I eat on a typical day is… Mood = Is a way of monitoring my mood (e.g., a good feeling or coping with stress); Weight_control = Helps me control my weight; Convenient = Is convenient (in buying and preparing); Pleasurable_sensations = Provides me with pleasurable sensations (e.g., texture, appearance, smell and taste). The percentages on the left represent those which state not at all “Not at all important/Unimportant/Somewhat important” whilst those on the right represent those which state “Very important/Important/Somewhat Important”. Question: To what extent do you disagree or agree with the statements below? Social_1 = My friends and family encourage me to eat fruits and vegetables; Social_2 = My family and friends remind me not to eat junk food; Social_3 = Others would be upset if I did not eat fruits and vegetables; Social_4 = I feel pressure from others to eat fruits and vegetables; Social_5 = I want others to approve of me; Social_6 = I want others to see I can eat fruits and vegetables; Social_7 = I don't want to let others down. Percentages on the left represent those which state “Strongly Disagree/Disagree” whilst those on the right represent those which state “Agree/Strongly Agree”. Question: To what extent would you disagree or agree with the statements below... CuestoAct_1 = When I think about AMD my heart beats faster; CuestoAct_2 = My feelings about myself would change if I develop AMD; CuestoAct_3 = Changing my diet can help me reduce my chance of developing AMD; CuestoAct_4 = Having risk factor(s) for AMD makes me think I have to change my diet; CuestoAct_5 = Learning more about AMD from the media makes me think I have to change my diet; CuestoAct_6 = Knowing family member(s) with AMD makes me think I have to change my diet; CuestoAct_7 = I am able to make differences in my diet that will change the risk of developing AMD. Percentages on the left represent those which state “Strongly Disagree/Disagree” whilst those on the right represent those which state “Agree/Strongly Agree”. Question: How do you think the lifestyle and individual factors below impact risk of AMD? Percentages on the left represent those that state “Dencreases risk” whilst those on the right represent those that state “Increases risk”. Question: How do you think the dietary behaviours below impact risk of AMD? Carotenoids = Intake of carotenoids (a substance found highly in foods like fruit and vegetables); SatFats = Intake of saturated fats (these are a specific type of fat that is high found highly in foods like red meat, cheese and milk); Omega3and6Fats = Intake of omega-3 and omega-6 fats (these are also a specific type of fat). Percentages on the left represent those that state “Decreases risk” whilst those on the right represent those that state “Increases risk”. The inter-relationships between fruit, vegetable and fish intake, adherence to Mediterranean diet and determinants of food choice. Those who scored highly on MedDiet score were more likely to make food choices based on: controlling mood [minimum-maximum correlation (min-max cor):0.234; 0.255]; weight control (min-max cor:0.34; 0.347); health (min-max cor:0.536; 0.551); natural content (min-max cor: 0.347; 0.396); animal welfare (min-max cor: 0.382; 0.424); and environmental friendliness (min-max cor: 0.39; 0.4) (Table 4 A). Those with a better knowledge of individual/lifestyle risk factors of AMD were more likely to adhere to a Mediterranean-style diet (MedDiet score,cor = 0.333). The rest of the questionnaires were not significantly correlated to the MedDiet score (Table 4 A). Frequent fruit intake (≥ 2 portions/ day) was higher in those participants who had a good knowledge of AMD individual/lifestyle risk factors (cor = 0.372) and for dietary risk factors (cor = 0.234). Additionally, frequent fruit intake was associated with perceptions of natural content (min-max cor: 0.363; 0.41) and health (min-max cor: 0.321; 0.334)(Table 4 B). In contrast, lower fruit (< 2 portions/ day) intake was associated with prioritising convenience (min-max cor: -0.263; -0.224). Lower vegetable intake (< 3 servings/day) was associated with adherence to perceived social norms (min-max cor: -0.343; -0.306), while high vegetable intake (≥ 3 servings/day) was associated with perceived weight control (min-max cor: 0.231; 0.241), affordability (min-max cor: 0.259; 0.27) and considerations around intake of animal products (min-max cor: 0.329; 0.367) (Table 4 C). Low fish intake (≥ 3/servings per week) was correlated with concerns about fair trade (min-max cor: -0.237; -0.212 ) ( Appendix T7 ). There were overlapping food influences between MedDiet adherence, fruit intake and vegetable intake: those eating more fruit and adhering to a MedDiet made their food choices based on how natural or healthy a food was. Both Med diet adherence and higher vegetable intake were driven by concerns about eating animal products and maintaining weight control. Scores for the questionnaires capturing knowledge of lifestyle, individual and dietary risk factors were associated with higher MedDiet score and fruit intake. This suggests some awareness of risk factors of AMD may influence a healthier diet. Despite this, less than half (41%) of those who completed the Cues to Action instrument agree/strongly agree that having risk factors for AMD makes them consider changing their diet (Fig. 5 ). Moreover, less than half (44%) agree/strongly agree that changing their diet can help reduce the chance of developing AMD and that they can make differences in their diet that will impact their risk of AMD (Fig. 5 ). Indeed, there was a low mean MedDiet score[5.222 (SD = ± 2.218); pmin-max = 0 to 14] in the sample and a majority reported not frequently eating vegetables (< 3 servings/day; 39/63; 61.9%); nonetheless, a majority reported frequent intake of fruit (≥ 2 servings/day) 65.1% (41/63). Hence, there may be poor motivation to consume frequent vegetables and adhere to an overall Mediterranean-type diet in this cohort, but there is sufficient motivation to consume a high fruit intake. Identifying behaviour change intervention types It is worth noting that the significant latent constructs that positively correlate with MedDiet, fruit intake and vegetable intake commonly fall under the reflective sub-domain in the COM-B model (Tables 4 A-C). Encouraging MedDiet adherence, fruit and vegetable intake among those with a first-degree relative with AMD may be more successful if they include behaviour change techniques that are informed by the following behaviour intervention types: coercion (i.e., punishment/cost), education, incentivisation (i.e., rewarding), modelling (i.e., an example for people to imitate) and/or persuasion techniques (i.e., using communication methods such as imagery) 14 . It is worth noting that the questionnaire construct that indicated an association with fish intake is negative, whereas the associations are positive with MedDiet and the other food components: this must be noted when selecting appropriate BCTs that appropriately encapsulate the different associations. Due to significant associations of vegetable intake with social norms and affordability, the behaviour intervention types of training, enablement, environmental restructuring, modelling and restriction could be used to identify BCTs that encourage vegetable intake (Table 4 C). Similarly, owing to significant correlations between knowledge scores for individual, lifestyle and/or dietary risk factors with fruit intake (Table 4 B) and MedDiet adherence (Table 4 A), additional behaviour change intervention types under the psychological sub-domain such as training and enablement could be used to recommend BCTs to encourage fruit intake and MedDiet adherence in this cohort. Moreover, owing to correlations with convenience, additional intervention types that could inform the most appropriate BCTs for fruit intake could be the following: environmental restructuring and restriction (Table 4 B). Table 4 A . Mediterranean diet and COM-B model COM-B model for Mediterranean diet CAPABILITY OPPORTUNITY MOTIVATION PSYCHOLOGICAL PHYSICAL SOCIAL PHYSICAL AUTOMATIC REFLECTIVE Food choice questionnaire °Familiarity C=-0.17; -0.149 °Affordability C=-0.151; -0.129 °Convenience C=-0.193; -0.145 °Mood C = 0.234; 0.255 °Sensory appeal C = 0.101; 0.134 °Weight control C = 0.34; 0.347 °Natural content C = 0.347; 0.396 °Health C = 0.536; 0.551 °Environmental friendliness C = 0.39; 0.4 °Animal friendliness C = 0.382; 0.424 °Fairly traded C = 0.15; 0.19 Cooking and Food Skills Questionnaire °Cooking skills C = 0.079 °Food skills C = 0.162 Social norms/ Theory of Planned Behaviour °Perceived social norms C = 0.025; 0.069 Cues to Action Questionnaire °Cues to action C = 0.195; 0.198 Knowledge Questionnaire °Knowledge score diet C = 0.194 Knowledge score individual/lifestyle C = 0.333 Relevant intervention types Ed, En, Tr En, Tr En, Er, Mo, Re En, Er, Re, Tr Co, En, Er, In, Mo, Pe, Tr Co, Ed, In, Mo, Pe Emboldened are significantly correlated with the Mediterranean diet score (4A) or its components (Fruit at 4B and Vegetables at 4C). C = Correlation. Underlined and italicised indicate relevant behaviour change intervention types. Ed = Education; En = Enablement; Er = Environmental restructuring; Co = Coercion; In = Incentivisation; Mo = Modelling; Pe = Persuasion; Re = Restriction; Tr = Training. Table 4 B . Fruit intake and COM-B model COM-B model for fruit intake CAPABILITY OPPORTUNITY MOTIVATION PSYCHOLOGICAL PHYSICAL SOCIAL PHYSICAL AUTOMATIC REFLECTIVE Food choice questionnaire °Familiarity C=-0.053; -0.036 °Affordability C=-0.119; -0.098 °Convenience C=-0.263; -0.224 °Mood C = 0.101; 0.121 °Sensory appeal C = 0.085; 0.115 °Weight control C = 0.112; 0.119 °Natural content C = 0.363; 0.41 °Health C = 0.321; 0.334 °Environmental friendliness C = 0.203;0.215 °Animal friendliness C = 0.068; 0.106 °Fairly traded C = 0.15; 0.19 Cooking and Food Skills Questionnaire °Cooking skills score C = 0.188 °Food skills confidence score C = 0.079 Social norms/ Theory of Planned Behaviour °Perceived social norms C = 0.209; 0.133 Cues to Action Questionnaire °Cues to action C = 0.336; 0.19 Knowledge Questionnaire °Knowledge score diet C = 0.234 °Knowledge score individual/lifestyle C = 0.372 Relevant intervention types Ed, En, Tr En, Tr En, Er, Mo, Re En, Er, Re, Tr Co, En, Er, In, Mo, Pe, Tr Co, Ed, In, Mo, Pe C = Correlation. Underlined and italicised indicate relevant behaviour change intervention types. Ed = Education; En = Enablement; Er = Environmental restructuring; Co = Coercion; In = Incentivisation; Mo = Modelling; Pe = Persuasion; Re = Restriction; Tr = Training. Table 4 C : Vegetable intake and COM-B model COM-B model for vegetable intake CAPABILITY OPPORTUNITY MOTIVATION COM-B categories PSYCHOLOGICAL PHYSICAL SOCIAL PHYSICAL AUTOMATIC REFLECTIVE Food choice questionnaire °Familiarity C=-0.096; -0.081 °Affordability C = 0.259; 0.27 °Convenience C=-0.017; 0.039 °Mood C=-0.008; 0.03 °Sensory appeal C = 0.016; 0.049 °Weight control C = 0.231; 0.241 °Natural content C = 0.152; 0.18 °Health C = 0.189; 0.202 °Environmental friendliness C = 0.054; 0.073 °Animal friendliness C = 0.329; 0.367 °Fairly traded C = 0.072; 0.114 Cooking and Food Skills Questionnaire °Cooking skills score C = 0.054 °Food skills confidence score C = 0.171 Social norms/ Theory of Planned Behaviour °Perceived social norms C=-0.343; -0.306 Cues to Action Questionnaire °Cues to action C = 0.029; 0.03 Knowledge Questionnaire °Knowledge score diet C = 0.078 °Knowledge score individual/lifestyle C = 0.062 Relevant intervention types Ed, En, Tr En, Tr En, Er, Mo, Re En, Er, Re, Tr Co, En, Er, In, Mo, Pe, Tr Co, Ed, In, Mo, Pe C = Correlation. Underlined and italicised indicate relevant behaviour change intervention types. Ed = Education; En = Enablement; Er = Environmental restructuring; Co = Coercion; In = Incentivisation; Mo = Modelling; Pe = Persuasion; Re = Restriction; Tr = Training. Discussion To our knowledge, this is the first study to investigate the perceptions of food and what influences dietary behaviours among relatives of AMD patients. Overall, we found that many influences and constructs may encourage a healthier diet despite participants harbouring perceptions that discourage risk-lowering dietary and behaviour change. Knowledge of individual, lifestyle and dietary risk factors could influence fruit intake and MedDiet adherence. Similarly, in a qualitative study among UK-living males, high consumption of fruit was associated with the perceived decreased risk of such a diet against chronic health conditions 37 . Hence, knowledge of risk factors could be exploited to encourage healthy dietary behaviours among those with a family history of AMD to possibly prevent or lower their risk of AMD incidence. It is worth noting that fruit intake was negatively and significantly associated with convenience, suggesting that fruit is difficult to access for this sample. Nonetheless, since the majority of this study’s cohort of AMD-affected relatives ate 2 ≥ servings of fruit/day, difficulty in accessing fruit in this cohort evidently did not discourage frequent fruit intake. A higher MedDiet score was associated with greater knowledge of risk factors in the sample. Nonetheless, only a minority of participants (< 45%) reported that awareness of such risk factors would motivate them or that they could change their diet in order to modify their risk of AMD. Furthermore, it has been reported that more women adopt dietary regimens for weight control compared to men 38 , and since a majority of the respondents in this study were female (57.1%), this may explain why weight control may be a motivating factor of MedDiet adherence and vegetable intake as these are dietary choices which promote low-calorie intake 39 . MedDiet adherence and fruit intake were also associated with choosing more “natural” food as captured by the FCQ; this is echoed by a recent study among French adults (2017), whereby "naturalness" of food, that is, the absence of additives and chemical exposure, was associated with a healthy dietary pattern, particularly among women 40 . Furthermore, our findings report that MedDiet score was correlated with the items capturing health reasons, environmental friendliness and animal welfare in the single-item FCQ. Turning to an international sample without any chronic disease within Europe and Africa study (2019), it was similarly found that MedDiet adherence was motivated by health, political and environmental concerns 41 . Thus, many potential influences encourage adherence to the MedDiet, some of which overlap with its components fruit and vegetables. Furthermore, vegetable intake was associated with concerns about eating animal products in our sample; it has been reported that such concerns motivate the vegetarian diet. Hence, the link between animal welfare and vegetable intake may reflect the dietary preference of vegetarianism 42 . Contrastingly, social norms were significantly negatively associated with vegetable intake. There is some evidence that awareness of the social pressure of vegetables could potentially decrease in selection of vegetables with meals; this could be due to the reactance effect whereby a person experiences a threat to their freedom and opposes or resists the pressure to conform 43 . Indeed, it was reported in this study that the majority of respondents agreed they feel pressure from family and friends to eat fruits and vegetables yet the frequency of vegetable intake is low [only 38.1% (24/63) consumed ≥ 3 servings/week]; hence, a lack of pressure from the environment may better encourage vegetable consumption in this cohort. Consumption of fish was negatively associated with a sustainability label, i.e., fairly traded. This is echoed in a UK-based study, whereby there is no willingness to pay for sustainably acquired fish 44 . Indeed, the UK population only eat one serving of fish per week 45 which is similar to this study’s cohort, whereby only 15.9% of people manage to eat three or more servings of fish weekly. Given the previous associations between fish intake and reduced AMD risk 5 , 7 and that no positive influences of fish intake were identified in this study, further work should be done in this specific cohort through an in-depth qualitative interview study to identify such positive influences. Dietary influences under the Opportunity section of COM-B model were significantly associated with adherence to intake of fruit and vegetables, but not for, fish intake. This contrasted with findings from a qualitative study done in Northern Ireland, UK whereby those who were at risk of developing cardiovascular disease reported how fish, fruit and vegetables were considered expensive in the sample, highlighting the importance of affordability of healthy foods to encourage a healthy diet 46 . Failure to capture the impact of affordability for fish and fruit intake in this quantitative survey’s UK-based sample is perhaps due to the slightly smaller sample size in the study (n = 63) and how the majority of participants are based in England, which may differ in perceptions among those residing in Northern Ireland. Moreover, there exist differences between qualitative and quantitative methods; qualitative methods explore in-depth personal motivations and are thus able to capture more constructs of dietary influences. Advantages of the study include the following: despite the issue with bot responses in the first round, a robust screening procedure alongside an accredited panel provider was used for the remainder of the study to acquire data, which reduced the risk of bot responses. Moreover, reliability and validity for the majority of the instruments in capturing specific dietary and lifestyle constructs were statistically achieved. Initially, we intended to have a sample size > 40, but only 20 were captured in the initial run. Even when correlation analysis was not possible, it provided the opportunity to refine the instruments and validate them via exploratory factor analysis. In the second release, we were able to exceed the targeted sample size as ultimately we had > 60 respondents (including participants in the initial release). Limitations of this study may include selection bias, as those who entered and completed the survey may be more motivated to lead a healthy lifestyle relative to the general population of those with a family history of AMD. The cross-sectional design of the study is of note: there is a risk of reverse causation. We assume that the possible constructs driving dietary intake among relatives of AMD patients, which were identified in this study, crystallised before their dietary behaviour, i.e., that the dietary influences and constructs affect dietary behaviours and not the obverse. Although less than half of the total participants agreed that having an AMD-affected relative makes them want to change their diet, indicating poor motivation to change their dietary lifestyle, it was encouraging that MedDiet adherence had many dietary influences identifiable (some of which were similarly influencing fruit and vegetable intake). These could be exploited to encourage behavioural change in future. To attain this aim, behaviour change intervention types in the COM-B model were identified. As mentioned, some dietary influences were overlapping between MedDiet and fruit intake; specifically, dietary influences owing to knowledge of AMD risk factors and the perceptions of health and “naturalness” of food. Afterwards, behaviour change intervention types were identified, one of which would be education. As behaviour change intervention types were identified, BCTs could be chosen(Table 2 ) 47 . There are a variety of BCTs that could be selected as suggested by the BCT Taxonomy app version 1 26 , but the APEASE method could be used to decide the most appropriate BCTs to employ 48 . APEASE stands for: Acceptability, Practicability, Effectiveness, Affordability, Spill-over effects, and Equity. Practicability refers to how far a study or part of a study can or is likely to be delivered as planned and at the scale intended; whilst Spill-over effects refer to how far a study or part of a study has or is likely to have unintended positive or negative effects; and Equity refers to how the study impacts inequalities 49 . In conclusion, our survey has identified potential dietary factors which may motivate MedDiet adherence and fruit, vegetable and fish intake among those with AMD-affected relatives. After having identified relevant behaviour change intervention types, future research could use the BCT Taxonomy app version 1 to identify specific BCTs that would be most appropriately employed to encourage dietary change. The APEASE criteria could also be used to decide which BCT would be most appropriately selected. Hence, a theory-informed dietary modification study could thus be designed to promote a healthy diet among this study's population as a means of prevention or risk reduction against AMD incidence. Based on current findings, increasing fish intake is likely to pose a significant challenge since a deterrent to fish intake was only identified, rather than what encourages it. Hence, before proceeding, other studies should be undertaken (such as qualitative interview-based studies) to identify potential dietary influences and behaviour change intervention types relevant for increased fish intake and to triangulate, and thus increase the rigour of, the rest of the findings. Additional File File name: Additional_File_Manuscript_2035_May_28_citation_as_text.docx File format including the correct file extension for example .pdf, .xls, .txt, .pptx (including name and a URL of an appropriate viewer if format is unusual) : Word.docx Title of data: Appendix Description of data: The file contains text and tables describing construction of the knowledge questionnaires (lifestyle/individual and dietary) and their scoring systems, Moreover, text and diagrams that report details of exploratory factor analyses are present. Lastly, the scoring system of the adapted Mediterranean diet score is included. Abbreviations AMD Age-related macular degeneration APEASE Acceptability, Practicability, Effectiveness, Affordability, Spill-over effects, and Equity AREDS2 Age-Related Eye Disease Study 2 BCT Behaviour change technique Beh Reg Behavioural Regulation Bel Cap Beliefs about capabilities Bel Cons Beliefs about consequences COM-B Model Capability, Opportunity and Motivation Behaviour Model Cor Correlation EFA Exploratory Factor Analysis Em Emotion Env Environmental context and resources FCQ Food Choice Questionnaire Goals Goals, intentions and motivations Id Professional role and identity In Incentivisation IP Internet Protocol Know Knowledge MedDiet Mediterranean Diet Mem Memory, Attention and Decision Processes Pmin-max Potential Minimum-maximum SatFats Saturated Fats Soc Social influences TDF Theoretical Domains Framework Declarations Ethics approval and consent to participate Ethical approval for the qualitative research was granted by the Office for Research Ethics Committees, Northern Ireland, (MHLS 23_109 – Amendment 2) and informed consent was obtained from all participants. Moreover, the research was carried out is in compliance with the Helsinki Declaration. Consent for publication Not applicable Availability of data and materials Database available upon request. Contact Dr. Ruth Hogg at [email protected] . Competing interests The authors declare they have no competing interests. Funding This research was funded by UK Research and Innovation doctoral training grant (no: BB/T008776/1). Authors' contributions MG analysed data, interpreted results and drafted the article. REH helped plan the work, critically revised the article, gave final approval of the version to be published and is the guarantor. JW helped plan the work and critically revised the article. Acknowledgements Not applicable References National Institute of Health and Care Excellence. Age-related macular degeneration 2018 [Available from: https://www.nice.org.uk/guidance/ng82/evidence/full-guideline-pdf-170036251098 Handa JT, Bowes Rickman C, Dick AD, Gorin MB, Miller JW, Toth CA, et al. 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2","display":"","copyAsset":false,"role":"figure","size":33731,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of excluded and included responses of initial 2022 release and pilot release.\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-6761699/v1/65d42a4659a6332b4efbe000.png"},{"id":86193943,"identity":"13383a7d-3ec1-4ba7-9921-28f3f6e3685c","added_by":"auto","created_at":"2025-07-07 20:33:16","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":149048,"visible":true,"origin":"","legend":"\u003cp\u003eRaw results from the Food Choice Questionnaire instrument.\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-6761699/v1/57602408e1531735afa40454.png"},{"id":86193955,"identity":"363bfe88-5850-4be7-aa2f-e240ed1c80ba","added_by":"auto","created_at":"2025-07-07 20:33:17","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":98152,"visible":true,"origin":"","legend":"\u003cp\u003eRaw results from the Social Norms instrument.\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-6761699/v1/7816d617b520e8c44d815f8a.png"},{"id":86193956,"identity":"84badfd6-cfa1-4569-9afa-022d10d50436","added_by":"auto","created_at":"2025-07-07 20:33:17","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":101088,"visible":true,"origin":"","legend":"\u003cp\u003eRaw results from the Cues to Action instrument\u003c/p\u003e","description":"","filename":"image5.png","url":"https://assets-eu.researchsquare.com/files/rs-6761699/v1/5d7cd56eaf664dc3fb9775bc.png"},{"id":86193940,"identity":"bcbb4c77-f32e-45d2-bb8b-48959b0cf3a1","added_by":"auto","created_at":"2025-07-07 20:33:16","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":83318,"visible":true,"origin":"","legend":"\u003cp\u003eRaw results from the Lifestyle and Individual Knowledge instrument\u003c/p\u003e","description":"","filename":"image6.png","url":"https://assets-eu.researchsquare.com/files/rs-6761699/v1/b244719ebf3e3e93f7076810.png"},{"id":86194361,"identity":"4748300a-fd65-479a-a8f7-8fc75cc28437","added_by":"auto","created_at":"2025-07-07 20:41:16","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":52756,"visible":true,"origin":"","legend":"\u003cp\u003eRaw results from the Dietary Knowledge instrument\u003c/p\u003e","description":"","filename":"image7.png","url":"https://assets-eu.researchsquare.com/files/rs-6761699/v1/4a5aff3e48a85eeee5388401.png"},{"id":86194791,"identity":"3cd4a8c2-4fba-49c3-8a78-dcf88bd26ccd","added_by":"auto","created_at":"2025-07-07 20:57:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1851399,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6761699/v1/e3f2ece3-ca42-4bb1-9af9-2dddc297afda.pdf"},{"id":86193942,"identity":"6afa738a-f3d5-4a01-941b-8a191a3a5117","added_by":"auto","created_at":"2025-07-07 20:33:16","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":536472,"visible":true,"origin":"","legend":"\u003cp\u003eFile name: Additional_File_Manuscript_2035_May_28_citation_as_text.docx\u003c/p\u003e\n\u003cp\u003eFile format including the correct file extension for example .pdf, .xls, .txt, .pptx (including name and a URL of an appropriate viewer if format is unusual) : Word.docx\u003c/p\u003e\n\u003cp\u003eTitle of data: Appendix\u003c/p\u003e\n\u003cp\u003eDescription of data: The file contains text and tables describing construction of the knowledge questionnaires (lifestyle/individual and dietary) and their scoring systems, Moreover, text and diagrams that report details of exploratory factor analyses are present. Lastly, the scoring system of the adapted Mediterranean diet score is included.\u003c/p\u003e","description":"","filename":"AdditionalFileManuscript2025May28citationastext.docx","url":"https://assets-eu.researchsquare.com/files/rs-6761699/v1/0a2bc10b12bc670b2daa6446.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring health perceptions and behavioural drivers of diet in those with familial risk of AMD: A COM-B Model Approach.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAge-related macular degeneration (AMD) is a disease that spans the outer retina and choroid, which frequently progresses to central vision loss for one or both eyes. As we age waste products tend to build-up in the outer retina and the discrete deposits are called drusen. Drusen are hallmark features of AMD and are used to indicate severity of the disease, depending on their size, texture and position\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Currently, there is no cure for AMD; available treatments that contribute to the maintenance of sight are given lifelong. Such treatments are expensive, with intra-vitreal injection therapy costing the NHS \u0026pound;740-\u0026pound;816 per injection\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Preventing or delaying the onset of AMD is a worthy aim with the potential to prevent the substantial loss of quality of life experienced by those with late-stage AMD.\u003c/p\u003e\u003cp\u003eWhile drusen are considered the hallmark of AMD, not all with drusen progress to the sight-threatening stages of AMD. Risk factors can be categorised as 1. Lifestyle, e.g., smoking, diet high in fat or low in certain nutrients; and 2. Individual factors, which are outside human control, e.g., age, genetics, and family history of AMD\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. There is evidence that the progression of AMD can be slowed, or even prevented in the first place by a diet rich in vegetables, fruit and fish, such as the Mediterranean diet\u003csup\u003e\u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Hence, prevention or lowering the risk of AMD could involve modification of lifestyle factors, e.g., diet, among those with a family history of the disease. Indeed, one should consider providing advice to those at most risk of developing AMD in later life before the earliest stages of AMD appear. Current best practice guidelines in the UK advise a high intake of fruit, vegetables and fish among patients already with AMD\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Stevens et al. (2015) highlighted that some AMD patients may have poor motivation to eat vegetables and fruits\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. The team subsequently designed an educational resource for AMD patients, which improved motivation scores for daily intake of vegetables and daily AREDS2 supplementation\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. However, research which explores those who are AMD-free but are nonetheless at high risk of AMD is scarce; their motivations for lifestyle change and perceptions regarding health, AMD and diet are poorly understood. Determining factors associated with current dietary intake in this population could be used to design a behaviour modification study to effectively encourage behaviours that could lower their risk of AMD or delay onset. To achieve this, a behaviour change framework could be used to maximise the effect of such a study.\u003c/p\u003e\u003cp\u003eSeveral behaviour change frameworks have been developed but one developed in the UK context by Michie et al\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e is the the Capability Opportunity and Motivation Behaviour (COM-B) model which dictates that a behaviour must be influenced by physical and mental capability; social and environmental/physical opportunity; and motivation which is either automatic or has been reflected upon (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Moreover, behaviour change intervention types have been associated across different categories of the COM-B model (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), and each behaviour change intervention type has been associated with specific behaviour change techniques (BCTs) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). BCTs are the primary units that could be observed and replicated in a behaviour change modification study; BCTs, on their own, have the potential to cause behaviour change\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Thus, in this study, a battery of questionnaires was designed specifically for healthy offspring or siblings of AMD patients and was validated to determine the influences of diet and perceptions on food, health and AMD within this cohort. Ultimately, the aim is to identify the relevant behaviour change intervention types and, potentially, BCTs that could inform a future behaviour dietary modification study among those with a family history of AMD.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003ePreparing the survey\u003c/p\u003e\u003cp\u003eQuestionnaires that captured food and health perceptions were sourced from literature and were mostly developed and/or validated in the UK population to produce a battery of questionnaires. The survey consisted of eleven parts: (i) Food Choice Questionnaire (7-point scale Likert score from \u0026ldquo;Not at all important\u0026rdquo; to \u0026ldquo;Very important\u0026rdquo;) \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, (ii) Mediterranean Diet Score (range\u0026thinsp;=\u0026thinsp;0\u0026ndash;14 score) \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e, (iii) Cooking skills [7-point Likert score from \u0026ldquo;Never/rarely do it\u0026rdquo;=0 to \u0026ldquo;7 (very good)\u0026rdquo;] \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, (iv) Food skills [8-point Likert score from \u0026ldquo;Never/rarely do it\u0026rdquo;=0 to \u0026ldquo;7 (very good)\u0026rdquo;] \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, (v) Social Norms/Theory of Planned Behaviour (5-point scale from \u0026ldquo;Strongly Disagree\u0026rdquo; to \u0026ldquo;Strongly Agree\u0026rdquo;) \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, (vi) Participant Background, (vii) Cues to action questionnaire (5-point scale from \u0026ldquo;Strongly Disagree\u0026rdquo; to \u0026ldquo;Strongly Agree\u0026rdquo;) \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e (viii) Knowledge of Dietary Risk factors\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e, (ix) Knowledge of Lifestyle and Individual Risk Factors\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e, (x) Familial Case Background and (xi) Participant background. There were no validated instruments that captured knowledge of AMD; hence, they were created in this study. Note that a brief Mediterranean diet (MedDiet) questionnaire (which was previously validated in a UK population for indicating serum lutein and zeaxanthin carotenoids) was used\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. The development and validation of these instruments have been detailed in the Appendix (\u003cb\u003eAppendix Sections 1\u0026ndash;5; F8A-F8D; T5A-5D, T6 and T7\u003c/b\u003e). Ethical approval for this research was received from Queen\u0026rsquo;s University Belfast Research Ethics Committee.\u003c/p\u003e\u003cp\u003eThe Theoretical Domains Framework (TDF) are theoretical constructs that influence behaviour which can be captured by survey instruments. As each questionnaire captures specific constructs, the TDF ultimately aids in placing where in the COM-B model the captured construct is most relevant. Should a construct reveal a significant impact towards a specific dietary or food intake, the framework can be used to suggest the appropriate behaviour change intervention types\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. In our study, questionnaires i,iii-v, and vii-ix were captured and mapped onto the COM-B model (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). After the appropriate intervention types are identified, the appropriate BCTs could be determined as agreed upon in consensus by Michie et al. or as evidenced in the literature through the BCT Taxonomy v1 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. A similar process has been done previously in a UK population whereby specific behaviour change intervention types and therefore BCTs for dietary change were informed by the COM-B model\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe figure is adapted from Alexander et al. (2014)\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. B is for behaviour change technique. The green outer ring indicates the Capability, Opportunity and Motivation categories. The green inner ring indicates the subcategories of Capability which are i. Physical and ii. Psychological; for Opportunity, they are i. Social and ii. Physical; and for Motivation, they are i. Automatic and ii. Reflective. The yellow ring indicates the domains of the Theoretical Domains Framework. The domains under the category Capability, subcategories i. Physical and ii. Psychological have the sub-domains of Skills; Knowledge (Know); Behavioural Regulation (Beh Reg) and Memory, Attention and Decision Processes (Mem). The domains under the category Opportunity, sub-domains i. Social and ii. Physical are Social influences (Soc) and Environmental context and resources (Env). The category Motivation has the sub-domains i. Automatic and ii. Reflective which has the domains of Emotion (Em); Professional role and identity (Id); Beliefs about capabilities (Bel Cap); Goals, intentions and motivations (Goals); and Beliefs about consequences (Bel Cons).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBehaviour change intervention types under each subcategory of the Capability Opportunity and Motivation Behaviour (COM-B) model\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCOM-B model\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eCAPABILITY\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eOPPORTUNITY\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003eMOTIVATION\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCOM-B categories\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePHYSICAL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePSYCHOLOGICAL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePHYSICAL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSOCIAL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eAUTOMATIC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eREFLECTIVE\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"8\" rowspan=\"9\"\u003e\u003cp\u003eIntervention type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEducation (Ed)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePersuasion (Pe)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIncentivisation (In)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCoercion (Co)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTraining (Tr)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRestriction (Re)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEnvironmental restructuring (Er)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModelling (Mo)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEnablement (En)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e\u0026radic;\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAdapted from Reidy et al. (2020) \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Ticked boxes indicate which part of the COM-B model a specific behaviour change intervention type can most appropriately be used.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBehaviour change intervention type (Education) and appropriate behaviour change techniques (BCTs) as suggested in the BCT Taxonomy App version 1\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntervention type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMost frequently used BCTs\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDefinition of BCT\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInformation about social and environmental consequences\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProvide information (e.g. written, verbal, visual) about social and environmental consequences of performing the behaviour\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInformation about health consequences\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProvide information (e.g. written, verbal, visual) about health consequences of performing the behaviour\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFeedback on behaviour\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMonitor and provide informative or evaluative feedback on performance of the behaviour (e.g. form, frequency, duration, intensity\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFeedback on outcome(s) of the behaviour\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMonitor and provide feedback on the outcome of performance of the behaviour\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrompts/cues\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIntroduce or define environmental or social stimulus with the purpose of prompting or cueing the behaviour. The prompt or cue would normally occur at the time or place of performance\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf-monitoring of behaviour\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEstablish a method for the person to monitor and record their behaviour(s) as part of a behaviour change strategy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThis table is a snapshot of the taxonomy based on the BCT Taxonomy App version 1. The suggested BCTs for all behaviour change intervention types and definitions for each BCT are also provided in the App.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eConstructs regarding food and health perceptions captured by the questionnaires in the survey and where they map in the Capability Opportunity and Motivation Behaviour (COM-B) model\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCOM-B model\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eCAPABILITY\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eOPPORTUNITY\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eMOTIVATION\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCOM-B categories\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePSYCHOLOGICAL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePHYSICAL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSOCIAL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePHYSICAL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAUTOMATIC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eREFLECTIVE\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFood Choice Questionnaire\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e \u0026dagger;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026deg;Familiarity (Mem) \u0026dagger;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026deg;Affordability (Env) \u0026dagger;\u003c/p\u003e\u003cp\u003e\u0026deg;Convenience (Env) \u0026dagger;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026deg;Mood (Em) \u0026dagger;\u003c/p\u003e\u003cp\u003e\u0026deg;Sensory appeal (Em) \u0026dagger;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026deg;Natural content (Bel Cons) \u0026dagger;\u003c/p\u003e\u003cp\u003e\u0026deg;Health (Bel Cons) \u0026dagger;\u003c/p\u003e\u003cp\u003e\u0026deg;Ethical concern (Bel Cons) \u0026dagger;\u003c/p\u003e\u003cp\u003e\u0026deg;Weight control (Bel Cons) \u0026dagger;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCooking and Food Skills Questionnaire\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e \u0026dagger;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026deg;Cooking skills (range\u0026thinsp;=\u0026thinsp;0 to 49) and food skills confidence scores (range\u0026thinsp;=\u0026thinsp;0 to 42) (Phys) \u0026dagger;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial Norms/ Theory of Planned Behaviour\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e (adapted for fruit and veg intake) \u0026Dagger;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026deg;Perceived social norms (Soc) \u0026Dagger;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCues to Action Questionnaire\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e(adapted for age-related macular degeneration and dietary behaviour) \u0026Dagger;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026deg; Cues to action (Bel Cap) \u0026Dagger;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge Questionnaires for Diet and Demographics/ Lifestyle\u003csup\u003e1, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e ‖\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026deg;Knowledge scores for diet (range=-1 to 3) and for lifestyle/individual (range= -2 to 5) (Know) ‖\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBehaviour change intervention types\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eEd, En, Tr\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eEn, Tr\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eEm, Er, Mo, Re\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eEn, Er, Re, Tr\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003eCo, En, Er,In, Mo, Pe, Tr\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003eCo, Ed, In, Mo, Pe\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eKey: \u0026dagger;=Already construct validated in the UK population; \u0026Dagger;=Requires validation. ‖=Only content validated by eye clinicians in the UK in this study. These are the predicted constructs according to the originating literature. Relevant sections in the Theoretical Domains Framework covered are 1. Memory, Attention and Decision Processes (Mem); 2. Environmental Context and Resources (Env); 3. Emotion (Em); 4. Beliefs about Consequences (Bel Cons); 5. Physical skills (Phys); 6. Social influences (Soc); 7. Beliefs about capabilities (Bel Cap); 8. Behaviour change intervention types: Knowledge\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Ed\u0026thinsp;=\u0026thinsp;Education; En\u0026thinsp;=\u0026thinsp;Enablement; Er\u0026thinsp;=\u0026thinsp;Environmental restructuring; Co\u0026thinsp;=\u0026thinsp;Coercion; In =\u0026thinsp;Incentivisation; Mo\u0026thinsp;=\u0026thinsp;Modelling; Pe\u0026thinsp;=\u0026thinsp;Persuasion; Re\u0026thinsp;=\u0026thinsp;Restriction; Tr\u0026thinsp;=\u0026thinsp;Training.\u003c/p\u003e\u003cp\u003ePilot before the initial release\u003c/p\u003e\u003cp\u003eThe entire survey was prepared in Qualtrics and piloted online by relatives of AMD patients (n\u0026thinsp;=\u0026thinsp;3), by researcher colleagues in CPH QUB (n\u0026thinsp;=\u0026thinsp;5) and by adult laypersons (i.e., those outside the field of academia) who have no relatives with AMD (n\u0026thinsp;=\u0026thinsp;5) (overall respondents\u0026thinsp;=\u0026thinsp;13). The survey took\u0026thinsp;\u0026le;\u0026thinsp;25 minutes to complete. Minor changes were undertaken following their comments.\u003c/p\u003e\u003cp\u003eRecruitment strategy for initial release\u003c/p\u003e\u003cp\u003eNon-random sampling methods (i.e., opportunistic, volunteer sampling and snowballing methods) were used as they were the most pragmatic means of recruitment. A link for the survey was also disseminated through relevant Facebook groups such as the Royal National Institute of Blind People and Macular Society, each of which was approached and permission sought from the group administrator before any post was made. Additionally, permission was asked from Macular Society support groups whether physical copies of the survey could be distributed in the group for relatives of AMD patients, as they may attend the meeting. Copies were also provided to AMD patients so they could pass them on to their relatives. To ensure anonymity, the researcher attending the Macular Society support group meeting did not have access to the attendance list. In addition, recruitment was through word of mouth. The physical and online surveys were self-paced, so potential participants were given time to read the Patient Information Form and provide consent. Responses in the physical survey were added to Qualtrics. Inclusion criteria were: i. be 18 years or older, ii. live in the UK, iii. have either a biological parent or biological sibling with AMD, iv. have no diagnosis of AMD. In the initial release, there was a sufficient sample of participants (n\u0026thinsp;=\u0026thinsp;20) for validation and refinement of the instruments via exploratory factor analysis (EFA) (See \u003cb\u003eAppendix Section 5; F8A-F8D\u003c/b\u003e) but insufficient numbers for correlation analysis; hence, the survey was released in the second round through an accredited panel provider called Norstat (Norstat - Data to trust for decisions that matter) who identified those who self-reported as having a parent with AMD from their larger panel of potential participants.\u003c/p\u003e\u003cp\u003eSecondary release (March-July 2024)\u003c/p\u003e\u003cp\u003eThere were several changes in the second live release of the survey in addition to recruitment via Norstat: potential participants (i.e., screened before displaying the participant information sheet) were pre-screened to reduce the chance of invalid responses; the questionnaire instruments that were validated previously which had the number of items reduced (\u003cb\u003eAppendix F8A-F8D\u003c/b\u003e.) were used; and, with the guidance from the ethics committee, the consent form was reduced to one statement. Following these changes, the participant burden was decreased (i.e., reduction of five minutes) on account of shortening the overall survey. Moreover, measures that screened ineligible or bot respondents (using Captcha, honeypot questions, repeated questions and an open-ended comment box\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e) were used.\u003c/p\u003e\u003cp\u003eCorrelation method\u003c/p\u003e\u003cp\u003eThe method for correlation for multi-item factors followed those used by Michael Foley\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e (2020) and George Mount\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e (2020), whereby the MedDiet score, fruit, vegetables and fish variables were latentised and each survey instrument was tested whether they had a significantly associated correlation to the latentised MedDiet score, fruit, vegetables and fish variables. Standardisation was not necessary since items used in each questionnaire used identical scales. San-Cristobal et al. (2017) observed that the effect of food and health perceptions on the Mediterranean Diet score in a large international population (including the UK) was R\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.22 \u003csup\u003e32\u003c/sup\u003e. The f\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e was calculated from the equation f\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;R\u003csup\u003e2\u003c/sup\u003e / (1- R\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e) as recommended in previous literature\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. Hence, f\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e was 0.282. Using this effect size, the power was set at 0.8, alpha at 0.05, and the maximal number of predictors being two following concurrent validity. G*power calculated a total sample size of 38. Similarly, a minimum sample of 40 has been reported as sufficient to validly correlate a given model to the outcome of interest\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e; the outcomes in this study\u0026rsquo;s case are the MedDiet score, fish intake, fruit intake and vegetable intake. The mice package (V.3.16.0) was used to impute the dataset\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. The range of correlations across imputations was presented as minimum-maximum. The pooled p-values were acquired using the median-p-rule\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. P-values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were deemed significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eScreening of bots in the initial survey\u003c/p\u003e\u003cp\u003eAfter running the initial survey between September to December 2022, over 400 responses were gathered, but many of the responses were from bots which could be checked and removed where appropriate by using a scoring mechanism (Captcha score) in the Qualtrics software. There was also a spike of responses between December 10th -12th 2022. This is highly suspicious of bot activity; hence, respondents from the spike period were also removed. Furthermore, online responses from outside UK which could be determined based on their IP address (a unique but anonymous ID of an internet-connected device) were removed, unless they stated in the survey that they were currently outside UK. In this case, it was assumed that participants were UK residents who were temporarily outside UK by the time they completed the survey. Responses that did not progress past the consent form were removed as there was little (if any) data provided by these respondents. Responses from the pilot study were included. Ultimately, 20 valid responses were acquired (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eDemographics and mean scores\u003c/p\u003e\u003cp\u003eCombining the valid results from the pilot study, the initial 2022 release of the survey and the 2024 release, and after excluding bots, 63 responses were acquired. Most respondents were female (57.1%; 36/63), Caucasian (90.5%; 57/63), aged between 46\u0026ndash;65 and 56\u0026thinsp;\u0026minus;\u0026thinsp;55 years (30.2%; 19/63 for both), were never smokers (57.1%; 36/63), did not take lutein, zeaxanthin and/or meso-zeaxanthin supplements (82.5%; 52/63), and had an affected parental relative (91.8%; 59/63). The mean pooled MedDiet score was 5.222 (SD\u0026thinsp;=\u0026thinsp;\u0026plusmn;\u0026thinsp;2.218); for the instruments that captured knowledge of lifestyle/individual and dietary risk factors, they were 3.20 [potential minimum-maximum (pmin-max) =-3 to 5] and 0.79 (pmin-max=-3 to 2) respectively; for the cooking and food skills, scores were 32.317 (SD\u0026thinsp;=\u0026thinsp;\u0026plusmn;\u0026thinsp;10.696) (pmin-max\u0026thinsp;=\u0026thinsp;0\u0026ndash;49) and 23.841 (SD\u0026thinsp;=\u0026thinsp;\u0026plusmn;\u0026thinsp;9.976) (pmin-max\u0026thinsp;=\u0026thinsp;0\u0026ndash;42) respectively. The pooled proportion who ate fruit (\u0026ge;\u0026thinsp;2 servings/day) was 65.1% (41/63); for vegetables (\u0026ge;\u0026thinsp;3 servings/day), it was 38.1% (24/63), and for fish (\u0026ge;\u0026thinsp;3 servings/week), it was 15.9% (10/63).\u003c/p\u003e\u003cp\u003ePerceptions about diet and AMD.\u003c/p\u003e\u003cp\u003eThe responses from the Food Choice Questionnaire (FCQ) and the Exploratory Factor Analysis (EFA)-validated instruments are below (Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). In the FCQ, all respondents who completed it reported how pleasurable sensations were important influences on food choice (61/61; 100%). The majority stated that monitoring mood (21/62; 29%) was not at all important/ unimportant/ somewhat unimportant in influencing food choice (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In the Social Norms instrument, the majority of participants agreed that friends and family encourage them to eat fruits and vegetables (35/63; 56%); most participants disagreed that they felt pressure from others to eat fruits and vegetables (47/62; 76%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the Cues to Action instrument, the majority of participants agreed that their feelings about themselves would change if they developed AMD (33/63; 52%), and most participants disagreed (36/62; 58%) that when they think about AMD their hearts beat faster (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The majority of participants who completed the lifestyle and individual knowledge instrument reported that physical activity decreased the risk of AMD (23/39; 59%). Moreover, a majority of participants believed that an increased risk of AMD results from hypertension (40/42; 95%), being overweight (39/40; 95%), ageing (52/52; 100%), family history (44/45; 98%), smoking (34/36; 94%) and genetic background (41/43; 95%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Among the respondents that completed the dietary knowledge instrument, a majority reported that a decreased risk of AMD resulted from intake of carotenoids (31/35; 89%), fish (32/34; 94%) and omega-3 and 6 fats (29/35; 83%). Most participants reported that saturated fats increased the risk of AMD (25/34; 74%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eQuestion: \u003cb\u003eIt is important to me that the food I eat on a typical day is\u0026hellip;\u003c/b\u003e Mood\u0026thinsp;=\u0026thinsp;Is a way of monitoring my mood (e.g., a good feeling or coping with stress); Weight_control\u0026thinsp;=\u0026thinsp;Helps me control my weight; Convenient\u0026thinsp;=\u0026thinsp;Is convenient (in buying and preparing); Pleasurable_sensations\u0026thinsp;=\u0026thinsp;Provides me with pleasurable sensations (e.g., texture, appearance, smell and taste). The percentages on the left represent those which state not at all \u0026ldquo;Not at all important/Unimportant/Somewhat important\u0026rdquo; whilst those on the right represent those which state \u0026ldquo;Very important/Important/Somewhat Important\u0026rdquo;.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eQuestion: \u003cb\u003eTo what extent do you disagree or agree with the statements below?\u003c/b\u003e Social_1\u0026thinsp;=\u0026thinsp;My friends and family encourage me to eat fruits and vegetables; Social_2\u0026thinsp;=\u0026thinsp;My family and friends remind me not to eat junk food; Social_3\u0026thinsp;=\u0026thinsp;Others would be upset if I did not eat fruits and vegetables; Social_4\u0026thinsp;=\u0026thinsp;I feel pressure from others to eat fruits and vegetables; Social_5\u0026thinsp;=\u0026thinsp;I want others to approve of me; Social_6\u0026thinsp;=\u0026thinsp;I want others to see I can eat fruits and vegetables; Social_7\u0026thinsp;=\u0026thinsp;I don't want to let others down. Percentages on the left represent those which state \u0026ldquo;Strongly Disagree/Disagree\u0026rdquo; whilst those on the right represent those which state \u0026ldquo;Agree/Strongly Agree\u0026rdquo;.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eQuestion: \u003cb\u003eTo what extent would you disagree or agree with the statements below...\u003c/b\u003eCuestoAct_1\u0026thinsp;=\u0026thinsp;When I think about AMD my heart beats faster; CuestoAct_2\u0026thinsp;=\u0026thinsp;My feelings about myself would change if I develop AMD; CuestoAct_3\u0026thinsp;=\u0026thinsp;Changing my diet can help me reduce my chance of developing AMD; CuestoAct_4\u0026thinsp;=\u0026thinsp;Having risk factor(s) for AMD makes me think I have to change my diet; CuestoAct_5\u0026thinsp;=\u0026thinsp;Learning more about AMD from the media makes me think I have to change my diet; CuestoAct_6\u0026thinsp;=\u0026thinsp;Knowing family member(s) with AMD makes me think I have to change my diet; CuestoAct_7\u0026thinsp;=\u0026thinsp;I am able to make differences in my diet that will change the risk of developing AMD. Percentages on the left represent those which state \u0026ldquo;Strongly Disagree/Disagree\u0026rdquo; whilst those on the right represent those which state \u0026ldquo;Agree/Strongly Agree\u0026rdquo;.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eQuestion: How do you think the lifestyle and individual factors below impact risk of AMD? Percentages on the left represent those that state \u0026ldquo;Dencreases risk\u0026rdquo; whilst those on the right represent those that state \u0026ldquo;Increases risk\u0026rdquo;.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eQuestion: How do you think the dietary behaviours below impact risk of AMD?\u003c/p\u003e\u003cp\u003eCarotenoids\u0026thinsp;=\u0026thinsp;Intake of carotenoids (a substance found highly in foods like fruit and vegetables); SatFats\u0026thinsp;=\u0026thinsp;Intake of saturated fats (these are a specific type of fat that is high found highly in foods like red meat, cheese and milk); Omega3and6Fats\u0026thinsp;=\u0026thinsp;Intake of omega-3 and omega-6 fats (these are also a specific type of fat). Percentages on the left represent those that state \u0026ldquo;Decreases risk\u0026rdquo; whilst those on the right represent those that state \u0026ldquo;Increases risk\u0026rdquo;.\u003c/p\u003e\u003cp\u003eThe inter-relationships between fruit, vegetable and fish intake, adherence to Mediterranean diet and determinants of food choice.\u003c/p\u003e\u003cp\u003eThose who scored highly on MedDiet score were more likely to make food choices based on: controlling mood [minimum-maximum correlation (min-max cor):0.234; 0.255]; weight control (min-max cor:0.34; 0.347); health (min-max cor:0.536; 0.551); natural content (min-max cor: 0.347; 0.396); animal welfare (min-max cor: 0.382; 0.424); and environmental friendliness (min-max cor: 0.39; 0.4) (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e4\u003c/span\u003eA). Those with a better knowledge of individual/lifestyle risk factors of AMD were more likely to adhere to a Mediterranean-style diet (MedDiet score,cor\u0026thinsp;=\u0026thinsp;0.333). The rest of the questionnaires were not significantly correlated to the MedDiet score (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e4\u003c/span\u003eA).\u003c/p\u003e\u003cp\u003eFrequent fruit intake (\u0026ge;\u0026thinsp;2 portions/ day) was higher in those participants who had a good knowledge of AMD individual/lifestyle risk factors (cor\u0026thinsp;=\u0026thinsp;0.372) and for dietary risk factors (cor\u0026thinsp;=\u0026thinsp;0.234). Additionally, frequent fruit intake was associated with perceptions of natural content (min-max cor: 0.363; 0.41) and health (min-max cor: 0.321; 0.334)(Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e4\u003c/span\u003eB).\u003c/p\u003e\u003cp\u003eIn contrast, lower fruit (\u0026lt;\u0026thinsp;2 portions/ day) intake was associated with prioritising convenience (min-max cor: -0.263; -0.224). Lower vegetable intake (\u0026lt;\u0026thinsp;3 servings/day) was associated with adherence to perceived social norms (min-max cor: -0.343; -0.306), while high vegetable intake (\u0026ge;\u0026thinsp;3 servings/day) was associated with perceived weight control (min-max cor: 0.231; 0.241), affordability (min-max cor: 0.259; 0.27) and considerations around intake of animal products (min-max cor: 0.329; 0.367) (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e4\u003c/span\u003eC). Low fish intake (\u0026ge;\u0026thinsp;3/servings per week) was correlated with concerns about fair trade (min-max cor: -0.237; -0.212 ) (\u003cb\u003eAppendix T7\u003c/b\u003e).\u003c/p\u003e\u003cp\u003eThere were overlapping food influences between MedDiet adherence, fruit intake and vegetable intake: those eating more fruit and adhering to a MedDiet made their food choices based on how natural or healthy a food was. Both Med diet adherence and higher vegetable intake were driven by concerns about eating animal products and maintaining weight control.\u003c/p\u003e\u003cp\u003eScores for the questionnaires capturing knowledge of lifestyle, individual and dietary risk factors were associated with higher MedDiet score and fruit intake. This suggests some awareness of risk factors of AMD may influence a healthier diet. Despite this, less than half (41%) of those who completed the Cues to Action instrument agree/strongly agree that having risk factors for AMD makes them consider changing their diet (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Moreover, less than half (44%) agree/strongly agree that changing their diet can help reduce the chance of developing AMD and that they can make differences in their diet that will impact their risk of AMD (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Indeed, there was a low mean MedDiet score[5.222 (SD\u0026thinsp;=\u0026thinsp;\u0026plusmn;\u0026thinsp;2.218); pmin-max\u0026thinsp;=\u0026thinsp;0 to 14] in the sample and a majority reported not frequently eating vegetables (\u0026lt;\u0026thinsp;3 servings/day; 39/63; 61.9%); nonetheless, a majority reported frequent intake of fruit (\u0026ge;\u0026thinsp;2 servings/day) 65.1% (41/63). Hence, there may be poor motivation to consume frequent vegetables and adhere to an overall Mediterranean-type diet in this cohort, but there is sufficient motivation to consume a high fruit intake.\u003c/p\u003e\u003cp\u003eIdentifying behaviour change intervention types\u003c/p\u003e\u003cp\u003eIt is worth noting that the significant latent constructs that positively correlate with MedDiet, fruit intake and vegetable intake commonly fall under the reflective sub-domain in the COM-B model (Tables\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e4\u003c/span\u003eA-C). Encouraging MedDiet adherence, fruit and vegetable intake among those with a first-degree relative with AMD may be more successful if they include behaviour change techniques that are informed by the following behaviour intervention types: coercion (i.e., punishment/cost), education, incentivisation (i.e., rewarding), modelling (i.e., an example for people to imitate) and/or persuasion techniques (i.e., using communication methods such as imagery) \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. It is worth noting that the questionnaire construct that indicated an association with fish intake is negative, whereas the associations are positive with MedDiet and the other food components: this must be noted when selecting appropriate BCTs that appropriately encapsulate the different associations. Due to significant associations of vegetable intake with social norms and affordability, the behaviour intervention types of training, enablement, environmental restructuring, modelling and restriction could be used to identify BCTs that encourage vegetable intake (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e4\u003c/span\u003eC). Similarly, owing to significant correlations between knowledge scores for individual, lifestyle and/or dietary risk factors with fruit intake (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e4\u003c/span\u003eB) and MedDiet adherence (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e4\u003c/span\u003eA), additional behaviour change intervention types under the psychological sub-domain such as training and enablement could be used to recommend BCTs to encourage fruit intake and MedDiet adherence in this cohort. Moreover, owing to correlations with convenience, additional intervention types that could inform the most appropriate BCTs for fruit intake could be the following: environmental restructuring and restriction (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e4\u003c/span\u003eB).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eA\u003c/b\u003e. Mediterranean diet and COM-B model\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCOM-B model for Mediterranean diet\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eCAPABILITY\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eOPPORTUNITY\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eMOTIVATION\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePSYCHOLOGICAL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePHYSICAL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSOCIAL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePHYSICAL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAUTOMATIC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eREFLECTIVE\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFood choice questionnaire\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026deg;Familiarity\u003c/p\u003e\u003cp\u003eC=-0.17; -0.149\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026deg;Affordability \u003c/p\u003e\u003cp\u003eC=-0.151; -0.129\u003c/p\u003e\u003cp\u003e\u0026deg;Convenience\u003c/p\u003e\u003cp\u003eC=-0.193; -0.145\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e\u0026deg;Mood\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eC\u0026thinsp;=\u0026thinsp;0.234; 0.255\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026deg;Sensory appeal\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.101; 0.134\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e\u0026deg;Weight control \u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eC\u0026thinsp;=\u0026thinsp;0.34; 0.347\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e\u0026deg;Natural content\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eC\u0026thinsp;=\u0026thinsp;0.347; 0.396\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e\u0026deg;Health\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eC\u0026thinsp;=\u0026thinsp;0.536; 0.551\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e\u0026deg;Environmental friendliness\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eC\u0026thinsp;=\u0026thinsp;0.39; 0.4\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e\u0026deg;Animal friendliness\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eC\u0026thinsp;=\u0026thinsp;0.382; 0.424\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026deg;Fairly traded\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.15; 0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCooking and Food Skills Questionnaire\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026deg;Cooking skills\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.079\u003c/p\u003e\u003cp\u003e\u0026deg;Food skills\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.162\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial norms/ Theory of Planned Behaviour\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026deg;Perceived social norms \u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.025; 0.069\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCues to Action Questionnaire\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026deg;Cues to action\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.195; 0.198\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge Questionnaire\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026deg;Knowledge score diet\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.194\u003c/p\u003e\u003cp\u003e\u003cb\u003eKnowledge score individual/lifestyle\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eC\u0026thinsp;=\u0026thinsp;0.333\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelevant intervention types\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eEd, En, Tr\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEn, Tr\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEn, Er, Mo, Re\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eEn, Er, Re, Tr\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eCo, En, Er, In, Mo, Pe, Tr\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eCo, Ed, In, Mo, Pe\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eEmboldened are significantly correlated with the Mediterranean diet score (4A) or its components (Fruit at 4B and Vegetables at 4C). C\u0026thinsp;=\u0026thinsp;Correlation. Underlined and italicised indicate relevant behaviour change intervention types. Ed\u0026thinsp;=\u0026thinsp;Education; En\u0026thinsp;=\u0026thinsp;Enablement; Er\u0026thinsp;=\u0026thinsp;Environmental restructuring; Co\u0026thinsp;=\u0026thinsp;Coercion; In =\u0026thinsp;Incentivisation; Mo\u0026thinsp;=\u0026thinsp;Modelling; Pe\u0026thinsp;=\u0026thinsp;Persuasion; Re\u0026thinsp;=\u0026thinsp;Restriction; Tr\u0026thinsp;=\u0026thinsp;Training.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eB\u003c/b\u003e. Fruit intake and COM-B model\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCOM-B model for fruit intake\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eCAPABILITY\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eOPPORTUNITY\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eMOTIVATION\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePSYCHOLOGICAL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePHYSICAL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSOCIAL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePHYSICAL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAUTOMATIC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eREFLECTIVE\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFood choice questionnaire\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026deg;Familiarity\u003c/p\u003e\u003cp\u003eC=-0.053; -0.036\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026deg;Affordability \u003c/p\u003e\u003cp\u003eC=-0.119; -0.098\u003c/p\u003e\u003cp\u003e\u003cb\u003e\u0026deg;Convenience\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eC=-0.263; -0.224\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026deg;Mood\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.101; 0.121\u003c/p\u003e\u003cp\u003e\u0026deg;Sensory appeal\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.085; 0.115\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026deg;Weight control \u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.112; 0.119\u003c/p\u003e\u003cp\u003e\u003cb\u003e\u0026deg;Natural content\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eC\u0026thinsp;=\u0026thinsp;0.363; 0.41\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e\u0026deg;Health\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eC\u0026thinsp;=\u0026thinsp;0.321; 0.334\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026deg;Environmental friendliness\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.203;0.215\u003c/p\u003e\u003cp\u003e\u0026deg;Animal friendliness\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.068; 0.106\u003c/p\u003e\u003cp\u003e\u0026deg;Fairly traded\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.15; 0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCooking and Food Skills Questionnaire\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026deg;Cooking skills score\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.188\u003c/p\u003e\u003cp\u003e\u0026deg;Food skills confidence score \u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.079\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial norms/ Theory of Planned Behaviour\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026deg;Perceived social norms\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.209; 0.133\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCues to Action Questionnaire\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026deg;Cues to action\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.336; 0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge Questionnaire\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e\u0026deg;Knowledge score diet\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eC\u0026thinsp;=\u0026thinsp;0.234\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e\u0026deg;Knowledge score individual/lifestyle\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eC\u0026thinsp;=\u0026thinsp;0.372\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelevant intervention types\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eEd, En, Tr\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEn, Tr\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEn, Er, Mo, Re\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eEn, Er, Re, Tr\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eCo, En, Er, In, Mo, Pe, Tr\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eCo, Ed, In, Mo, Pe\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;Correlation. Underlined and italicised indicate relevant behaviour change intervention types. Ed\u0026thinsp;=\u0026thinsp;Education; En\u0026thinsp;=\u0026thinsp;Enablement; Er\u0026thinsp;=\u0026thinsp;Environmental restructuring; Co\u0026thinsp;=\u0026thinsp;Coercion; In =\u0026thinsp;Incentivisation; Mo\u0026thinsp;=\u0026thinsp;Modelling; Pe\u0026thinsp;=\u0026thinsp;Persuasion; Re\u0026thinsp;=\u0026thinsp;Restriction; Tr\u0026thinsp;=\u0026thinsp;Training.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eC\u003c/b\u003e: Vegetable intake and COM-B model\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eCOM-B model for vegetable intake\u003c/span\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eCAPABILITY\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eOPPORTUNITY\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eMOTIVATION\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCOM-B categories\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePSYCHOLOGICAL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePHYSICAL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSOCIAL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePHYSICAL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAUTOMATIC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eREFLECTIVE\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFood choice questionnaire\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026deg;Familiarity\u003c/p\u003e\u003cp\u003eC=-0.096; -0.081\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026deg;Affordability\u003c/b\u003e \u003c/p\u003e\u003cp\u003e\u003cb\u003eC\u0026thinsp;=\u0026thinsp;0.259; 0.27\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026deg;Convenience\u003c/p\u003e\u003cp\u003eC=-0.017; 0.039\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026deg;Mood\u003c/p\u003e\u003cp\u003eC=-0.008; 0.03\u003c/p\u003e\u003cp\u003e\u0026deg;Sensory appeal\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.016; 0.049\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e\u0026deg;Weight control \u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eC\u0026thinsp;=\u0026thinsp;0.231; 0.241\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026deg;Natural content\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.152; 0.18\u003c/p\u003e\u003cp\u003e\u0026deg;Health\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.189; 0.202\u003c/p\u003e\u003cp\u003e\u0026deg;Environmental friendliness\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.054; 0.073\u003c/p\u003e\u003cp\u003e\u003cb\u003e\u0026deg;Animal friendliness\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eC\u0026thinsp;=\u0026thinsp;0.329; 0.367\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026deg;Fairly traded\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.072; 0.114\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCooking and Food Skills Questionnaire\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026deg;Cooking skills score\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.054\u003c/p\u003e\u003cp\u003e\u0026deg;Food skills confidence score \u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.171\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSocial norms/ Theory of Planned Behaviour\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026deg;Perceived social norms\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eC=-0.343; -0.306\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCues to Action Questionnaire\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026deg;Cues to action\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.029; 0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge Questionnaire\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026deg;Knowledge score diet\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.078\u003c/p\u003e\u003cp\u003e\u0026deg;Knowledge score individual/lifestyle\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;0.062\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRelevant intervention types\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEd, En, Tr\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEn, Tr\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eEn, Er, Mo, Re\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eEn, Er, Re, Tr\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eCo, En, Er, In, Mo, Pe, Tr\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eCo, Ed, In, Mo, Pe\u003c/span\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eC\u0026thinsp;=\u0026thinsp;Correlation. Underlined and italicised indicate relevant behaviour change intervention types. Ed\u0026thinsp;=\u0026thinsp;Education; En\u0026thinsp;=\u0026thinsp;Enablement; Er\u0026thinsp;=\u0026thinsp;Environmental restructuring; Co\u0026thinsp;=\u0026thinsp;Coercion; In =\u0026thinsp;Incentivisation; Mo\u0026thinsp;=\u0026thinsp;Modelling; Pe\u0026thinsp;=\u0026thinsp;Persuasion; Re\u0026thinsp;=\u0026thinsp;Restriction; Tr\u0026thinsp;=\u0026thinsp;Training.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this is the first study to investigate the perceptions of food and what influences dietary behaviours among relatives of AMD patients. Overall, we found that many influences and constructs may encourage a healthier diet despite participants harbouring perceptions that discourage risk-lowering dietary and behaviour change. Knowledge of individual, lifestyle and dietary risk factors could influence fruit intake and MedDiet adherence. Similarly, in a qualitative study among UK-living males, high consumption of fruit was associated with the perceived decreased risk of such a diet against chronic health conditions\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. Hence, knowledge of risk factors could be exploited to encourage healthy dietary behaviours among those with a family history of AMD to possibly prevent or lower their risk of AMD incidence. It is worth noting that fruit intake was negatively and significantly associated with convenience, suggesting that fruit is difficult to access for this sample. Nonetheless, since the majority of this study\u0026rsquo;s cohort of AMD-affected relatives ate 2\u0026thinsp;\u0026ge;\u0026thinsp;servings of fruit/day, difficulty in accessing fruit in this cohort evidently did not discourage frequent fruit intake. A higher MedDiet score was associated with greater knowledge of risk factors in the sample. Nonetheless, only a minority of participants (\u0026lt;\u0026thinsp;45%) reported that awareness of such risk factors would motivate them or that they could change their diet in order to modify their risk of AMD.\u003c/p\u003e\u003cp\u003eFurthermore, it has been reported that more women adopt dietary regimens for weight control compared to men\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e, and since a majority of the respondents in this study were female (57.1%), this may explain why weight control may be a motivating factor of MedDiet adherence and vegetable intake as these are dietary choices which promote low-calorie intake\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. MedDiet adherence and fruit intake were also associated with choosing more \u0026ldquo;natural\u0026rdquo; food as captured by the FCQ; this is echoed by a recent study among French adults (2017), whereby \"naturalness\" of food, that is, the absence of additives and chemical exposure, was associated with a healthy dietary pattern, particularly among women\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e. Furthermore, our findings report that MedDiet score was correlated with the items capturing health reasons, environmental friendliness and animal welfare in the single-item FCQ. Turning to an international sample without any chronic disease within Europe and Africa study (2019), it was similarly found that MedDiet adherence was motivated by health, political and environmental concerns\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. Thus, many potential influences encourage adherence to the MedDiet, some of which overlap with its components fruit and vegetables.\u003c/p\u003e\u003cp\u003eFurthermore, vegetable intake was associated with concerns about eating animal products in our sample; it has been reported that such concerns motivate the vegetarian diet. Hence, the link between animal welfare and vegetable intake may reflect the dietary preference of vegetarianism\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e. Contrastingly, social norms were significantly negatively associated with vegetable intake. There is some evidence that awareness of the social pressure of vegetables could potentially decrease in selection of vegetables with meals; this could be due to the reactance effect whereby a person experiences a threat to their freedom and opposes or resists the pressure to conform\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. Indeed, it was reported in this study that the majority of respondents agreed they feel pressure from family and friends to eat fruits and vegetables yet the frequency of vegetable intake is low [only 38.1% (24/63) consumed\u0026thinsp;\u0026ge;\u0026thinsp;3 servings/week]; hence, a lack of pressure from the environment may better encourage vegetable consumption in this cohort.\u003c/p\u003e\u003cp\u003eConsumption of fish was negatively associated with a sustainability label, i.e., fairly traded. This is echoed in a UK-based study, whereby there is no willingness to pay for sustainably acquired fish\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e. Indeed, the UK population only eat one serving of fish per week\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e which is similar to this study\u0026rsquo;s cohort, whereby only 15.9% of people manage to eat three or more servings of fish weekly. Given the previous associations between fish intake and reduced AMD risk\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e and that no positive influences of fish intake were identified in this study, further work should be done in this specific cohort through an in-depth qualitative interview study to identify such positive influences.\u003c/p\u003e\u003cp\u003eDietary influences under the Opportunity section of COM-B model were significantly associated with adherence to intake of fruit and vegetables, but not for, fish intake. This contrasted with findings from a qualitative study done in Northern Ireland, UK whereby those who were at risk of developing cardiovascular disease reported how fish, fruit and vegetables were considered expensive in the sample, highlighting the importance of affordability of healthy foods to encourage a healthy diet \u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e. Failure to capture the impact of affordability for fish and fruit intake in this quantitative survey\u0026rsquo;s UK-based sample is perhaps due to the slightly smaller sample size in the study (n\u0026thinsp;=\u0026thinsp;63) and how the majority of participants are based in England, which may differ in perceptions among those residing in Northern Ireland. Moreover, there exist differences between qualitative and quantitative methods; qualitative methods explore in-depth personal motivations and are thus able to capture more constructs of dietary influences.\u003c/p\u003e\u003cp\u003eAdvantages of the study include the following: despite the issue with bot responses in the first round, a robust screening procedure alongside an accredited panel provider was used for the remainder of the study to acquire data, which reduced the risk of bot responses. Moreover, reliability and validity for the majority of the instruments in capturing specific dietary and lifestyle constructs were statistically achieved. Initially, we intended to have a sample size\u0026thinsp;\u0026gt;\u0026thinsp;40, but only 20 were captured in the initial run. Even when correlation analysis was not possible, it provided the opportunity to refine the instruments and validate them via exploratory factor analysis. In the second release, we were able to exceed the targeted sample size as ultimately we had\u0026thinsp;\u0026gt;\u0026thinsp;60 respondents (including participants in the initial release). Limitations of this study may include selection bias, as those who entered and completed the survey may be more motivated to lead a healthy lifestyle relative to the general population of those with a family history of AMD. The cross-sectional design of the study is of note: there is a risk of reverse causation. We assume that the possible constructs driving dietary intake among relatives of AMD patients, which were identified in this study, crystallised before their dietary behaviour, i.e., that the dietary influences and constructs affect dietary behaviours and not the obverse. Although less than half of the total participants agreed that having an AMD-affected relative makes them want to change their diet, indicating poor motivation to change their dietary lifestyle, it was encouraging that MedDiet adherence had many dietary influences identifiable (some of which were similarly influencing fruit and vegetable intake). These could be exploited to encourage behavioural change in future.\u003c/p\u003e\u003cp\u003eTo attain this aim, behaviour change intervention types in the COM-B model were identified. As mentioned, some dietary influences were overlapping between MedDiet and fruit intake; specifically, dietary influences owing to knowledge of AMD risk factors and the perceptions of health and \u0026ldquo;naturalness\u0026rdquo; of food. Afterwards, behaviour change intervention types were identified, one of which would be education. As behaviour change intervention types were identified, BCTs could be chosen(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) \u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e. There are a variety of BCTs that could be selected as suggested by the BCT Taxonomy app version 1\u003csup\u003e26\u003c/sup\u003e, but the APEASE method could be used to decide the most appropriate BCTs to employ\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e. APEASE stands for: Acceptability, Practicability, Effectiveness, Affordability, Spill-over effects, and Equity. Practicability refers to how far a study or part of a study can or is likely to be delivered as planned and at the scale intended; whilst Spill-over effects refer to how far a study or part of a study has or is likely to have unintended positive or negative effects; and Equity refers to how the study impacts inequalities\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn conclusion, our survey has identified potential dietary factors which may motivate MedDiet adherence and fruit, vegetable and fish intake among those with AMD-affected relatives. After having identified relevant behaviour change intervention types, future research could use the BCT Taxonomy app version 1 to identify specific BCTs that would be most appropriately employed to encourage dietary change. The APEASE criteria could also be used to decide which BCT would be most appropriately selected. Hence, a theory-informed dietary modification study could thus be designed to promote a healthy diet among this study's population as a means of prevention or risk reduction against AMD incidence. Based on current findings, increasing fish intake is likely to pose a significant challenge since a deterrent to fish intake was only identified, rather than what encourages it. Hence, before proceeding, other studies should be undertaken (such as qualitative interview-based studies) to identify potential dietary influences and behaviour change intervention types relevant for increased fish intake and to triangulate, and thus increase the rigour of, the rest of the findings.\u003c/p\u003e\u003cp\u003eAdditional File\u003c/p\u003e\u003cp\u003eFile name: Additional_File_Manuscript_2035_May_28_citation_as_text.docx\u003c/p\u003e\u003cp\u003eFile format including the correct file extension for example .pdf, .xls, .txt, .pptx (including name and a URL of an appropriate viewer if format is unusual) : Word.docx\u003c/p\u003e\u003cp\u003eTitle of data: Appendix\u003c/p\u003e\u003cp\u003eDescription of data: The file contains text and tables describing construction of the knowledge questionnaires (lifestyle/individual and dietary) and their scoring systems, Moreover, text and diagrams that report details of exploratory factor analyses are present. Lastly, the scoring system of the adapted Mediterranean diet score is included.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAMD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAge-related macular degeneration\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAPEASE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAcceptability, Practicability, Effectiveness, Affordability, Spill-over effects, and Equity\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAREDS2\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAge-Related Eye Disease Study 2\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBCT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBehaviour change technique\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBeh Reg\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBehavioural Regulation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBel Cap\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBeliefs about capabilities\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBel Cons\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBeliefs about consequences\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCOM-B Model\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCapability, Opportunity and Motivation Behaviour Model\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCor\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCorrelation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEFA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eExploratory Factor Analysis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEm\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEmotion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEnv\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEnvironmental context and resources\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFCQ\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFood Choice Questionnaire\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGoals\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGoals, intentions and motivations\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eId\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eProfessional role and identity\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIn\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIncentivisation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInternet Protocol\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKnow\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKnowledge\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMedDiet\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMediterranean Diet\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMem\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMemory, Attention and Decision Processes\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePmin-max\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePotential Minimum-maximum\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSatFats\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSaturated Fats\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSoc\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSocial influences\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTDF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTheoretical Domains Framework\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eEthical approval for the qualitative research was granted by the Office for Research Ethics Committees, Northern Ireland, (MHLS 23_109 \u0026ndash; Amendment 2) and informed consent was obtained from all participants.\u0026nbsp;Moreover, the research was carried out is in compliance with the Helsinki Declaration.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eDatabase available upon request. Contact Dr. Ruth Hogg at [email protected].\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research was funded by UK Research and Innovation doctoral training grant (no: BB/T008776/1).\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003eMG analysed data, interpreted results and drafted the article. REH helped plan the work, critically revised the article, gave final approval of the version to be published and is the guarantor. JW helped plan the work and critically revised the article.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNational Institute of Health and Care Excellence. 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The motivations that define eating patterns in some Mediterranean countries. Nutr food Sci. 2019;49(6):1126\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGhaffari M, Rodrigo PGK, Ekinci Y, Pino G. Consumers\u0026rsquo; motivations for adopting a vegan diet: A mixed-methods approach. Int J Consumer Stud. 2022;46(4):1193\u0026ndash;208.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBroers VJV, Van den Broucke S, Taverne C, Luminet O. Investigating the conditions for the effectiveness of nudging: Cue-to-action nudging increases familiar vegetable choice. Food Qual Prefer. 2019;71:366\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZander K, Feucht Y. Consumers\u0026rsquo; Willingness to Pay for Sustainable Seafood Made in Europe. J Int Food Agribusiness Mark. 2018;30(3):251\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWatson R, Seafood Consumption. (2024 Update) 2024 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.seafish.org/document/?id=31aa0a80-5285-4ac8-8b7b-9e295a14e312\u003c/span\u003e\u003cspan address=\"https://www.seafish.org/document/?id=31aa0a80-5285-4ac8-8b7b-9e295a14e312\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoore SE, McEvoy CT, Prior L, Lawton J, Patterson CC, Kee F, et al. Barriers to adopting a Mediterranean diet in Northern European adults at high risk of developing cardiovascular disease. J Hum Nutr Diet. 2018;31(4):451\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCline A, Knowles N, West J, Gould A. \u0026lsquo;Improving health and wellbeing: a guide to using behavioural science in policy and practice\u0026rsquo; 2024 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://phwwhocc.co.uk/wp-content/uploads/2024/02/Identifying-and-Applying-Behaviour-Change-Techniques-1.pdf\u003c/span\u003e\u003cspan address=\"https://phwwhocc.co.uk/wp-content/uploads/2024/02/Identifying-and-Applying-Behaviour-Change-Techniques-1.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChadwick P. What are the APEASE criteria? 2023 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.futurelearn.com/info/courses/behaviour-change-interventions/0/steps/242207\u003c/span\u003e\u003cspan address=\"https://www.futurelearn.com/info/courses/behaviour-change-interventions/0/steps/242207\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUniversity College London. Tools and Techniques for Behaviour Change 2025 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ucl.ac.uk/behaviour-change/resources/tools-and-techniques-behaviour-change#:~:text=Spillover%20effects%3B%20how%20far%20an,unintended%20positive%20or%20negative%20effects\u003c/span\u003e\u003cspan address=\"https://www.ucl.ac.uk/behaviour-change/resources/tools-and-techniques-behaviour-change#:~:text=Spillover%20effects%3B%20how%20far%20an,unintended%20positive%20or%20negative%20effects\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Age-related macular degeneration, Family history, COM-B model, Dietary influences, Mediterranean diet, Fruit, Vegetables, Fish","lastPublishedDoi":"10.21203/rs.3.rs-6761699/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6761699/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eAge-related macular degeneration (AMD) is the leading cause of sight loss in the UK. Those with a family history of AMD are at elevated risk; however, evidence suggests that AMD can be prevented or delayed through dietary modifications. This study aimed to explore the influences that encourage a healthy diet among adult children or siblings of AMD patients with the goal of designing a theory-based dietary intervention using the COM-B model.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eOnline and physical surveys with a battery of questionnaires were delivered. Participants completed a Mediterranean Diet (MedDiet) Score assessment (theoretical range 0\u0026ndash;14), established instruments measuring dietary influences, and newly developed tools assessing AMD-specific perceptions. Correlations between MedDiet scores, dietary components (fruit, vegetable, and fish intake), and dietary influences were examined. Appropriate behavioural intervention types were identified based on the COM-B model domains associated with dietary behaviour.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOverall, there were 63 valid respondents, the majority of which were female (57.1%; 36/63), Caucasian(90.2%;55/61)and were aged 46\u0026ndash;65 years(90.5%; 57/63). The mean MedDiet score was 5.22 (SD\u0026thinsp;=\u0026thinsp;\u0026plusmn;\u0026thinsp;2.22). The proportion who ate fruit (\u0026ge;\u0026thinsp;2 servings/day) was 65.1% (41/63); for those who ate vegetables (\u0026ge;\u0026thinsp;3 servings/week) it was 38.1% (24/63); for those who ate fish (\u0026ge;\u0026thinsp;3 servings/week) it was 15.9% (10/63). MedDiet adherence, fruit intake, and vegetable intake were positively associated with influences categorised under the reflective motivation domain of the COM-B model. This indicates that intervention strategies incorporating education, persuasion, incentivization, coercion, and/or modeling may be effective for promoting healthy dietary behaviours in this at-risk group. There was strong negativity around fish intake and and positive behavioural influences for fish intake were not identified.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThis study identified potential behavioural intervention types to enhance Mediterranean diet adherence and increase fruit and vegetable intake among individuals with a familial risk of AMD. This information can now be used to design targeted interventions. Further qualitative research is recommended to identify potential facilitators to increasing fish intake and to triangulate these findings.\u003c/p\u003e","manuscriptTitle":"Exploring health perceptions and behavioural drivers of diet in those with familial risk of AMD: A COM-B Model Approach.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-07 20:33:11","doi":"10.21203/rs.3.rs-6761699/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-21T09:59:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-06T16:12:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2025-09-29T13:40:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-17T09:45:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176382271522107084415966737731218502992","date":"2025-07-15T07:14:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"63950007286997169549691523413468534751","date":"2025-07-11T09:11:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-03T11:33:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-01T05:11:22+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-12T13:02:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-11T21:11:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nutrition","date":"2025-06-11T21:08:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"395a95b5-5706-4a4e-b0c6-2cf5fcd80a48","owner":[],"postedDate":"July 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-24T12:24:28+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-07 20:33:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6761699","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6761699","identity":"rs-6761699","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}