The Delivery of Public Health Interventions via the Internet: Actualizing Their Potential

Efficacy of an mHealth-delivered behavioral intervention on weight loss and cardiometabolic risk in African American postpartum people with overweight or obesity: the SnapBack randomized controlled trial

OBJECTIVE

The objective of this study was to evaluate the efficacy of a mobile health (mHealth)-delivered behavioral intervention on changes in postpartum weight and cardiometabolic risk factors (blood pressure [BP], lipids, and hemoglobin A1c) over 12 months.

METHODS

A randomized controlled trial of 300 African American postpartum people with overweight and obesity enrolled in Philadelphia Women, Infants, and Children (WIC) clinics was conducted. Participants were randomized to usual WIC care (n = 151) or a 12-month mHealth-delivered intervention (n = 149) comprising behavior change goals, interactive self-monitoring text messages, and counseling support.

RESULTS

Intervention and usual-care participants did not significantly differ in 12-month mean postpartum weight change (1.1 vs. 1.6 kg, p = 0.5; difference -0.6 kg, 95% CI: -2.3 to 1.2). However, high intervention engagement led to weight loss compared with weight gain among those who were less engaged (-0.6 vs. 2.4 kg, p = 0.01; difference -3.0 kg, 95% CI: -5.4 to -0.6). The intervention reduced systolic BP relative to usual care (-1.6 vs. 2.4 mm Hg, p = 0.02; difference -4.0 mm Hg, 95% CI: -7.5 to -0.5), but this effect did not extend to other cardiometabolic risk factors.

CONCLUSIONS

Among African American postpartum people enrolled in WIC, an mHealth-delivered intervention reduced systolic BP but not additional cardiometabolic risk factors or weight. Intervention participants with high engagement had significantly better postpartum weight outcomes, and thus, next steps include addressing barriers to engagement.

Impact of an internet-based insomnia intervention on suicidal ideation and associated correlates in veterans at elevated suicide risk

Improving public health approaches to suicide prevention requires scalable evidence-based interventions that can be easily disseminated. Given empirical data supporting the association between insomnia and suicide risk, internet-delivered insomnia interventions are promising candidates to meet this need. The purpose of this study was to examine whether an unguided internet-delivered cognitive-behavioral therapy for insomnia (iCBT-I) improved insomnia severity, suicidal ideation (SI), and suicide risk correlates (depression, post-traumatic stress disorder, anxiety, hostility, belongingness, hopelessness, agitation, irritability, concentration) in a sample of veterans. Secondary data analysis of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (n = 50) with clinically significant insomnia and elevated SI drawn from a larger randomized controlled trial (RCT) of an iCBT-I, Sleep Healthy Using the Internet (SHUTi). Two-sample t-tests or Wilcoxon rank sum tests were used to evaluate between-group differences (SHUTi vs. Insomnia Education Website control) in symptom improvement from baseline to post-intervention. SHUTi participants experienced a significant improvement in insomnia severity (P < .001; d = -1.08) and a non-significant with small (subthreshold medium) effect size reduction of SI (P = .17, d = 0.40), compared to control participants. Significant improvement in hopelessness was observed (medium effect size), with non-significant small to medium effect size reductions in most remaining suicide risk correlates. Self-administered iCBT-I was associated with improvements in insomnia severity in veterans at elevated risk for suicide. These preliminary findings suggest that SI and suicide risk correlates may improve following an iCBT-I intervention, demonstrating the need for future well-powered iCBT-I RCTs targeted for populations at elevated suicide risk.

Evaluation of two study demands-resources-based interventions: a randomized controlled trial

Introduction

Higher education students experience significant levels of exhaustion in their studies, yet there are limited evidence-based support programs available. Therefore, this study evaluated a novel intervention approach by testing the effectiveness of two online interventions based on the study demands-resources framework. These interventions aimed to balance demands and resources. Derived from the theoretical assumptions of the framework, we hypothesized that the interventions would increase study and personal resources, engagement, and study crafting, and decrease study demands, exhaustion, and self-undermining. Additionally, we hypothesized that demands and resources would mediate the effects of the intervention on engagement, exhaustion, study crafting, and self-undermining.

Methods

Conducted as a randomized controlled trial with a waitlist control group (n = 71), the study involved participants in two intervention groups who engaged with the interventions for 2 weeks. Intervention group 1 (n = 64) focused on adapting demands, while intervention group 2 (n = 70) focused on increasing resources. The design allowed for a comparison of the effectiveness of these different approaches. Participants completed questionnaires before and after the intervention, and at a 5-week follow-up.

Results

Results of the analyses of variance with repeated measures revealed that the interventions had significant positive effects on the personal resource mindfulness, two study crafting strategies, self-undermining, and exhaustion. Notably, intervention group 2 exhibited more positive outcomes. The hypothesized mediation effects through mindfulness were partially supported.

Discussion

The study demonstrates the considerable potential of interventions based on the study demands-resources framework for higher education institutions in supporting student well-being.

Digital preconception interventions targeting weight, diet and physical activity: A systematic review

AIM

Optimising preconception health increases the likelihood of conception, positively influences short- and long-term pregnancy outcomes and reduces intergenerational chronic disease risk. Our aim was to synthesise study characteristics and maternal outcomes of digital or blended (combining face to face and digital modalities) interventions in the preconception period.

METHODS

We searched six databases (PubMed, Cochrane, Embase, Web of Science, CINHAL and PsycINFO) from 1990 to November 2022 according to the PRISMA guidelines for randomised control trials, quasi-experimental trials, observation studies with historical control group. Studies were included if they targeted women of childbearing age, older than 18 years, who were not currently pregnant and were between pregnancies or/and actively trying to conceive. Interventions had to be delivered digitally or via digital health in combination with face-to-face delivery and aimed to improve modifiable behaviours, including dietary intake, physical activity, weight and supplementation. Studies that included women diagnosed with type 1 or 2 diabetes were excluded. Risk of bias was assessed using the Academy of Nutrition and Dietetics quality criteria checklist. Study characteristics, intervention characteristics and outcome data were extracted.

RESULTS

Ten studies (total participants n=4,461) were included, consisting of nine randomised control trials and one pre-post cohort study. Seven studies received a low risk of bias and two received a neutral risk of bias. Four were digitally delivered and six were delivered using blended modalities. A wide range of digital delivery modalities were employed, with the most common being email and text messaging. Other digital delivery methods included web-based educational materials, social media, phone applications, online forums and online conversational agents. Studies with longer engagement that utilised blended delivery showed greater weight loss.

CONCLUSION

More effective interventions appear to combine both traditional and digital delivery methods. More research is needed to adequately test effective delivery modalities across a diverse range of digital delivery methods, as high heterogeneity was observed across the small number of included studies.

Perceived burdensomeness, thwarted belongingness, and hopelessness as predictors of future suicidal ideation in Spanish university students

The Interpersonal Theory of Suicide (IPTS) has received support for its role in understanding suicidal thoughts and behaviors. However, few longitudinal studies have focused on testing this theory in university students. The present study aimed to confirm the theoretical model of the IPTS in a sample of 225 Spanish university students, using path analysis in a longitudinal study. We assessed thwarted belongingness and perceived burdensomeness at T1 and hopelessness and suicidal ideation at T2, 12-14 weeks later. Moreover, we assessed suicidal ideation weekly for 14 weeks. Path analyses confirmed the Interpersonal Theory of Suicide model, with thwarted belongingness and perceived burdensomeness as direct and indirect predictors of suicidal ideation through hopelessness. Providers of guidance and clinical services in university settings should be trained to identify perceived burdensomeness, social belongingness, hopelessness, and suicidal ideation when screening for suicide prevention.

Meaning in life mediates the association between depressive symptoms and future frequency of suicidal ideation in Spanish university students: A longitudinal study

INTRODUCTION

There is a need for longitudinal studies that focus on protective factors against suicide in Spain. We analyzed the estimated prevalence of suicidal ideation in a sample of Spanish university students. Second, we explored the relationship between future suicidal ideation, depressive symptoms, suicidal ideation at T1, and meaning in life and its dimensions of meaning and purpose. Third, we analyzed the mediation role of meaning in life between depressive symptoms and suicidal ideation evaluated with Ecological Momentary Assessment (EMA).

METHOD

In this longitudinal study, a total of 718 Spanish university students were assessed at T1, of whom 279 completed questionnaires along with EMA (T2).

RESULTS

The estimated prevalence of suicidal ideation was 8.4%. Levels of depressive symptoms were positively correlated with suicidal ideation and negatively with meaning in life and its dimensions of meaning and purpose. Meaning in life and its dimensions mediated the relationship between depressive symptoms and subsequent suicidal ideation.

DISCUSSION

There is a high prevalence of suicidal ideation among Spanish university students, and it is associated with depressive symptoms and meaning in life, with the latter acting as a protective factor. Thus, psychotherapeutic prevention programs from a logotherapeutic perspective could help to reduce students' suicide risk.

How to inform college students about meningitis B vaccine? Comparative effectiveness of an online theory-based text and video intervention

Objective The purpose of this study was to compare the effect of text and video formats of an online theory-based Meningitis B (MenB) health message intervention on college students. Participants: College freshmen and transfer students admitted at a Southern U.S. University. Methods: In a 2-arm randomized study, knowledge, perceptions, and intention to receive the vaccine were compared pre- and post-intervention. Results: Post intervention, participants in both the written and video interventions had significantly higher scores of knowledge, perceptions, and intentions. Upon comparing the change in scores pre- to post-intervention between both text and video groups, no significant differences were found between both groups. Conclusions: This study, a first in using a theory-based MenB online education intervention and questionnaire to compare text and video formats, suggests that both text and video formats are equally effective in raising young adults' awareness about the MenB vaccine.

Digital health behaviour change interventions in severe mental illness: a systematic review

The use of digital technologies as a method of delivering health behaviour change (HBC) interventions is rapidly increasing across the general population. However, the role in severe mental illness (SMI) remains overlooked. In this study, we aimed to systematically identify and evaluate all of the existing evidence around digital HBC interventions in people with an SMI. A systematic search of online electronic databases was conducted. Data on adherence, feasibility, and outcomes of studies on digital HBC interventions in SMI were extracted. Our combined search identified 2196 titles and abstracts, of which 1934 remained after removing duplicates. Full-text screening was performed for 107 articles, leaving 36 studies to be included. From these, 14 focused on physical activity and/or cardio-metabolic health, 19 focused on smoking cessation, and three concerned other health behaviours. The outcomes measured varied considerably across studies. Although over 90% of studies measuring behavioural changes reported positive changes in behaviour/attitudes, there were too few studies collecting data on mental health to determine effects on psychiatric outcomes. Digital HBC interventions are acceptable to people with an SMI, and could present a promising option for addressing behavioural health in these populations. Feedback indicated that additional human support may be useful for promoting adherence/engagement, and the content of such interventions may benefit from more tailoring to specific needs. While the literature does not yet allow for conclusions regarding efficacy for mental health, the available evidence to date does support their potential to change behaviour across various domains.

The Web-Based Pain-at-Work Toolkit With Telephone Support for Employees With Chronic or Persistent Pain: Protocol for a Cluster Randomized Feasibility Trial

BACKGROUND

Chronic or persistent pain affects one's ability to work or be productive at work, generating high societal and economic burden. However, the provision of work-related advice and support for people with chronic pain is variable or lacking. The Pain-at-Work (PAW) Toolkit was cocreated with people who live with pain, health care professionals, and employers. It aims to increase knowledge about employee rights and how to access support for managing a painful chronic condition in the workplace and provides advice on lifestyle behaviors that facilitate the management of chronic pain.

OBJECTIVE

We aimed to establish the feasibility of conducting a definitive cluster randomized controlled trial comparing access to the PAW Toolkit and telephone support calls from an occupational therapist (PAW) with treatment as usual (ie, standard support from their employer). Our primary outcomes are establishing parameters of feasibility, acceptability, usability, and safety of this digital workplace health intervention. We will assess the candidate primary and secondary outcomes' feasibility and test research processes for a definitive trial.

METHODS

This is an open-label, parallel 2-arm pragmatic feasibility cluster randomized controlled trial with exploratory health economics analysis and a nested qualitative interview study. We aim to recruit 120 participants from at least 8 workplace clusters (any type, >10 employees) in England. The recruitment of workplaces occurs via personal approach, and the recruitment of individual participants is web based. Eligible participants are vocationally active adults aged ≥18 years with internet access and self-reporting chronic pain interfering with their ability to undertake or enjoy productive work. A restricted 1:1 cluster-level randomization is used to allocate employment settings to PAW or treatment as usual; participants are unblinded to group allocation. Following site- and individual-level consent, participants complete a web-based baseline survey (time 0), including measures of work capacity, health and well-being, and health care resource use. Follow-up is performed at 3 months (time 1) and 6 months (time 2). Feasibility outcomes relate to recruitment; intervention fidelity (eg, delivery, reach, uptake, and engagement); retention; and follow-up. Qualitative evaluation (time 2) is mapped to the Capability, Opportunity, Motivation-Behavior model and will explore intervention acceptability to employees and employers, along with individual and contextual factors influencing the delivery and uptake of the intervention.

RESULTS

Ethics approval was obtained in March 2023. Trial recruitment began in June 2023.

CONCLUSIONS

The PAW Toolkit is the first evidence-based digital health intervention aimed at supporting the self-management of chronic or persistent pain at work. This study will inform the design of a definitive trial, including sample size estimation, approaches to cluster site identification, primary and secondary outcomes' selection, and the final health economic model. Findings will inform approaches for the future delivery of this digital health intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05838677; https://clinicaltrials.gov/study/NCT05838677.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51474.

Effects of a Web-Based Lifestyle Intervention on Physical Fitness and Health in Physically Inactive Adults: A Randomized Controlled Trial

Web-based lifestyle interventions are a new area of health research. This randomized controlled trial evaluated the effectiveness of an interactive web-based health program on physical fitness and health. N = 189 healthy adults participated in a 12-week interactive (intervention) or non-interactive (control) web-based health program. The intervention provided a web-based lifestyle intervention to promote physical activity and fitness through individualized activities as part of a fully automated, multimodal health program. The control intervention included health information. Cardiorespiratory fitness measured as maximum oxygen uptake (VO2max) was the primary outcome, while musculoskeletal fitness, physical activity and dietary behavior, and physiological health outcomes were assessed as secondary outcomes (t0: 0 months, t1: 3 months, t2: 9 months, t3: 15 months). Statistical analysis was performed with robust linear mixed models. There were significant time effects in the primary outcome (VO2max) (t0-t1: p = 0.018) and individual secondary outcomes for the interactive web-based health program, but no significant interaction effects in any of the outcomes between the interactive and non-interactive web-based health program. This study did not demonstrate the effectiveness of an interactive compared with a non-interactive web-based health program in physically inactive adults. Future research should further develop the evidence on web-based lifestyle interventions.

Perinatal Women's Perspectives of, and Engagement in, Digital Emotional Well-Being Training: Mixed Methods Study

BACKGROUND

Psychological distress in the early postpartum period can have long-lasting deleterious effects on a mother's well-being and negatively affect her infant's development. Intervention approaches based in contemplative practices such as mindfulness and loving-kindness and compassion are intended to alleviate distress and cultivate well-being and can be delivered effectively as digital mental health interventions (DMHIs).

OBJECTIVE

To understand the feasibility of engaging perinatal women in digital interventions, this study aimed to document participants' experiences in the Mums Minds Matter (MMM) study, a pilot randomized controlled trial comparing mindfulness, loving-kindness and compassion, and progressive muscle relaxation training delivered in a digital format and undertaken during pregnancy. To assess the different stages of engagement during and after the intervention, we adapted the connect, attend, participate, enact (CAPE) framework that is based on the idea that individuals go through different stages of engagement before they are able to enact change.

METHODS

The MMM study was nested within a longitudinal birth cohort, The ORIGINS Project. We aimed to recruit 25 participants per randomization arm. Data were collected sequentially during the intervention through regular web-based surveys over 8 weeks, with opportunities to provide regular feedback. In the postintervention phase, qualitative data were collected through purposive sampling.

RESULTS

Of 310 eligible women, 84 (27.1% [connect rate]) enrolled to participate in MMM. Of the remaining 226 women who did not proceed to randomization, 223 (98.7%) failed to complete the baseline surveys and timed out of eligibility (after 30 weeks' gestation), and 3 (1.3%) displayed high psychological distress scores. Across all program groups, 17 (20% [attend rate]) of the 84 participants actively opted out, although more may have disengaged from the intervention but did not withdraw. The main reasons for withdrawal were busy life and other priorities. In this study, we assessed active engagement and ongoing skills use (participate and enact) through postintervention interviews. We undertook 15 participant interviews, conducted 1 month to 3 months after the intervention. Our results provide insights into participant barriers and enablers as well as app changes, such as the ability to choose topics, daily reminders, case studies, and diversity in sounds. Implementing a DMHI that is brief, includes frequent prompts or nudges, and is easily accessible is a key strategy to target perinatal women.

CONCLUSIONS

Our research will enable future app designs that are sufficiently nuanced to maximize the uptake, engagement, and application of mental health skills and contemplative practices in the perinatal period. Providing convenient access to engaging and effective prevention programs is critical and should be part of prenatal self-care. Our research underscores the appeal and feasibility of digital intervention approaches based in contemplative practices for perinatal women.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) 12620000672954p; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12620000672954p.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/19803.

Online remote behavioural intervention for tics in 9- to 17-year-olds: the ORBIT RCT with embedded process and economic evaluation

Background

Behavioural therapy for tics is difficult to access, and little is known about its effectiveness when delivered online.

Objective

To investigate the clinical and cost-effectiveness of an online-delivered, therapist- and parent-supported therapy for young people with tic disorders.

Design

Single-blind, parallel-group, randomised controlled trial, with 3-month (primary end point) and 6-month post-randomisation follow-up. Participants were individually randomised (1 : 1), using on online system, with block randomisations, stratified by site. Naturalistic follow-up was conducted at 12 and 18 months post-randomisation when participants were free to access non-trial interventions. A subset of participants participated in a process evaluation.

Setting

Two hospitals (London and Nottingham) in England also accepting referrals from patient identification centres and online self-referrals.

Participants

Children aged 9-17 years (1) with Tourette syndrome or chronic tic disorder, (2) with a Yale Global Tic Severity Scale-total tic severity score of 15 or more (or > 10 with only motor or vocal tics) and (3) having not received behavioural therapy for tics in the past 12 months or started/stopped medication for tics within the past 2 months.

Interventions

Either 10 weeks of online, remotely delivered, therapist-supported exposure and response prevention therapy (intervention group) or online psychoeducation (control).

Outcome

Primary outcome: Yale Global Tic Severity Scale-total tic severity score 3 months post-randomisation; analysis done in all randomised patients for whom data were available. Secondary outcomes included low mood, anxiety, treatment satisfaction and health resource use. Quality-adjusted life-years are derived from parent-completed quality-of-life measures. All trial staff, statisticians and the chief investigator were masked to group allocation.

Results

Two hundred and twenty-four participants were randomised to the intervention (n = 112) or control (n = 112) group. Participants were mostly male (n = 177; 79%), with a mean age of 12 years. At 3 months the estimated mean difference in Yale Global Tic Severity Scale-total tic severity score between the groups adjusted for baseline and site was -2.29 points (95% confidence interval -3.86 to -0.71) in favour of therapy (effect size -0.31, 95% confidence interval -0.52 to -0.10). This effect was sustained throughout to the final follow-up at 18 months (-2.01 points, 95% confidence interval -3.86 to -0.15; effect size -0.27, 95% confidence interval -0.52 to -0.02). At 18 months the mean incremental cost per participant of the intervention compared to the control was £662 (95% confidence interval -£59 to £1384), with a mean incremental quality-adjusted life-year of 0.040 (95% confidence interval -0.004 to 0.083) per participant. The mean incremental cost per quality-adjusted life-year gained was £16,708. The intervention was acceptable and delivered with high fidelity. Parental engagement predicted child engagement and more positive clinical outcomes.

Harms

Two serious, unrelated adverse events occurred in the control group.

Limitations

We cannot separate the effects of digital online delivery and the therapy itself. The sample was predominately white and British, limiting generalisability. The design did not compare to face-to-face services.

Conclusion

Online, therapist-supported behavioural therapy for young people with tic disorders is clinically and cost-effective in reducing tics, with durable benefits extending up to 18 months.

Future work

Future work should compare online to face-to-face therapy and explore how to embed the intervention in clinical practice.

Trial registration

This trial is registered as ISRCTN70758207; ClinicalTrials.gov (NCT03483493). The trial is now complete.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Technology Assessment programme (project number 16/19/02) and will be published in full in Health and Technology Assessment; Vol. 27, No. 18. See the NIHR Journals Library website for further project information.

Social Media Usage as a Form of Breastfeeding Support Among Black Mothers: A Scoping Review of the Literature

INTRODUCTION

Social support has been identified in the literature as a key facilitator of breastfeeding success among Black mothers. Over the past decade, there has been a surge of social media groups that can now be used as a means of support for various health and social issues. Social media breastfeeding groups have been used as sources of additional support. A scoping review of the literature was conducted to explore social media usage as a form of social support among Black women in the postpartum period and how it may affect breastfeeding behaviors.

METHODS

Using the 5-stage scoping review methodology, scholarly databases were searched for relevant articles. English-language articles on studies conducted both in and outside of the United States were included. Original studies that focused on social media as a form of breastfeeding support and included Black mothers as part of the study population were included.

RESULTS

After screening 551 articles, 6 studies fulfilled the study criteria. Participants reported being provided with various forms of social support through social media within the included articles. Primary themes included (1) a sense of community and (2) self-efficacy and empowerment. Breastfeeding support through social media appears to positively influence breastfeeding intention and duration rates among Black mothers.

DISCUSSION

Social media is an accessible avenue for breastfeeding information and support. Moreover, it provides a safe space for Black women to interact with others of shared cultural experiences. Therefore, incorporating social media into breastfeeding interventions can positively affect breastfeeding rates among Black women. More research is needed to assess the direct effect of social media breastfeeding support groups on the breastfeeding behaviors and experiences of Black women.

Effects of a Web-Based Lifestyle Intervention on Weight Loss and Cardiometabolic Risk Factors in Adults With Overweight and Obesity: Randomized Controlled Clinical Trial

BACKGROUND

The high proportion of people with overweight and obesity has become a worldwide problem in recent decades, mainly due to health consequences, such as cardiovascular diseases, neoplasia, and type 2 diabetes mellitus. Regarding effective countermeasures, the digitization of health services offers numerous potentials, which, however, have not yet been sufficiently evaluated. Web-based health programs are becoming increasingly interactive and can provide individuals with effective long-term weight management support.

OBJECTIVE

The purpose of this randomized controlled clinical trial was to evaluate the effectiveness of an interactive web-based weight loss program on anthropometric, cardiometabolic, and behavioral variables and to compare it with a noninteractive web-based weight loss program.

METHODS

The randomized controlled trial included people who were aged between 18 and 65 years (mean 48.92, SD 11.17 years) and had a BMI of 27.5 to 34.9 kg/m² (mean 30.71, SD 2.13 kg/m²). Participants (n=153) were assigned to either (1) an interactive and fully automated web-based health program (intervention) or (2) a noninteractive web-based health program (control). The intervention program focused on dietary energy density and allowed for dietary documentation with appropriate feedback on energy density and nutrients. The control group only received information on weight loss and energy density, but the website did not contain interactive content. Examinations were performed at baseline (t0), at the end of the 12-week intervention (t1), and at 6 months (t2) and 12 months (t3) thereafter. The primary outcome was body weight. The secondary outcomes were cardiometabolic variables as well as dietary and physical activity behaviors. Robust linear mixed models were used to evaluate the primary and secondary outcomes.

RESULTS

The intervention group showed significant improvements in anthropometric variables, such as body weight (P=.004), waist circumference (P=.002), and fat mass (P=.02), compared with the control group over the course of the study. The mean weight loss after the 12-month follow-up was 4.18 kg (4.7%) in the intervention group versus 1.29 kg (1.5%) in the control group compared with the initial weight. The results of the nutritional analysis showed that the energy density concept was significantly better implemented in the intervention group. Significant differences in cardiometabolic variables were not detected between the 2 groups.

CONCLUSIONS

The interactive web-based health program was effective in reducing body weight and improving body composition in adults with overweight and obesity. However, these improvements were not associated with relevant changes in cardiometabolic variables, although it should be noted that the study population was predominantly metabolically healthy.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00020249; https://drks.de/search/en/trial/DRKS00020249.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.3390/ijerph19031393.

Predicting Disengagement to Better Support Outcomes in a Web-Based Weight Loss Program Using Machine Learning Models: Cross-Sectional Study

BACKGROUND

Engagement is key to interventions that achieve successful behavior change and improvements in health. There is limited literature on the application of predictive machine learning (ML) models to data from commercially available weight loss programs to predict disengagement. Such data could help participants achieve their goals.

OBJECTIVE

This study aimed to use explainable ML to predict the risk of member disengagement week by week over 12 weeks on a commercially available web-based weight loss program.

METHODS

Data were available from 59,686 adults who participated in the weight loss program between October 2014 and September 2019. Data included year of birth, sex, height, weight, motivation to join the program, use statistics (eg, weight entries, entries into the food diary, views of the menu, and program content), program type, and weight loss. Random forest, extreme gradient boosting, and logistic regression with L1 regularization models were developed and validated using a 10-fold cross-validation approach. In addition, temporal validation was performed on a test cohort of 16,947 members who participated in the program between April 2018 and September 2019, and the remaining data were used for model development. Shapley values were used to identify globally relevant features and explain individual predictions.

RESULTS

The average age of the participants was 49.60 (SD 12.54) years, the average starting BMI was 32.43 (SD 6.19), and 81.46% (39,594/48,604) of the participants were female. The class distributions (active and inactive members) changed from 39,369 and 9235 in week 2 to 31,602 and 17,002 in week 12, respectively. With 10-fold-cross-validation, extreme gradient boosting models had the best predictive performance, which ranged from 0.85 (95% CI 0.84-0.85) to 0.93 (95% CI 0.93-0.93) for area under the receiver operating characteristic curve and from 0.57 (95% CI 0.56-0.58) to 0.95 (95% CI 0.95-0.96) for area under the precision-recall curve (across 12 weeks of the program). They also presented a good calibration. Results obtained with temporal validation ranged from 0.51 to 0.95 for area under a precision-recall curve and 0.84 to 0.93 for area under the receiver operating characteristic curve across the 12 weeks. There was a considerable improvement in area under a precision-recall curve of 20% in week 3 of the program. On the basis of the computed Shapley values, the most important features for predicting disengagement in the following week were those related to the total activity on the platform and entering a weight in the previous weeks.

CONCLUSIONS

This study showed the potential of applying ML predictive algorithms to help predict and understand participants' disengagement with a web-based weight loss program. Given the association between engagement and health outcomes, these findings can prove valuable in providing better support to individuals to enhance their engagement and potentially achieve greater weight loss.

Cultural accommodation of internet-based interventions for substance use and related disorders: a proposed comprehensive framework based on a pilot study and a literature review

Despite the low utilization rates of substance use and related disorders services, and the ability of internet-based interventions for substance use and related disorders (IBIS) to address challenges related to service engagement, limited attention has been placed on the processes for the accommodation of these interventions to diverse cultural settings. This study aimed to develop a framework for the cultural accommodation of IBIS across populations based on a pilot study and a literature review. A pilot study of cultural accommodation of an existing internet intervention for alcohol use was carried out in Israel, which involved focus groups and daily online surveys of prospective consumers (N = 24) as well as interviews with experts (N = 7) in the substance abuse treatment field. Thematic analysis revealed a range of themes that relate to the general Israeli culture and the specific Israeli drinking subculture, identified as needing to be addressed in the process of intervention accommodation. A comprehensive framework for cultural accommodation of IBIS is suggested, consisting of five stages: Technical and cultural feasibility; Engagement of target group; Identification of accommodation variables, Accommodation, and evaluation of the accommodated intervention. In addition, the framework consists of four dimensions of accommodation: Barriers and facilitators; Audio-visual materials and language; Mechanisms of change; Intersectional factors. We suggest that the proposed framework may serve as a guide for the cultural accommodation of existing internet-based interventions for substance use and related disorders across a range of cultural and geographical settings, thus augmenting the ecological validity of internet-based interventions for substance use and related disorders, expanding cross-cultural intervention research, and reducing health disparities worldwide.

Using patient-reported outcome measures to assess the effectiveness of social media networking programs for people living with overweight and obesity to adopt a healthier lifestyle

Introduction

Overweight, obesity, and their associated health complications have become a major public health issue. Online approaches have been rarely attempted to address the problem. The aim of this study was to evaluate the effectiveness of using social media networking for people living with overweight and obesity to adopt a healthier lifestyle with a three-month multidisciplinary healthcare program. Effectiveness was assessed through questionnaires on patient-related outcome measures (PROMs).

Materials and methods

Two non-profit associations designed the program delivered to people living with overweight and obesity in a closed group via Facebook, the popular social network. The three-month program had three main axes, namely nutrition, psychology, and physical activity. Anthropomorphic data and sociodemographic profiles were collected. Quality of life (QoL) was assessed at the beginning and at the end of the intervention using PROM questionnaires for six different domains, i.e., body image, eating behavior, physical, sexual, social, and psychological functioning.

Results

Six hundred and twenty persons participated in the program; 567 persons consented for the study, and 145 completed the questionnaires entirely. QoL was significantly improved in five out of six domains, i.e., body image, eating behavior, as well as physical, sexual, and psychological functioning. The improvement was valid regardless of age, gender, initial body mass index, person with or without children, educational level (primary versus secondary versus high school), and occupation (employment compared to unemployment or any kind of social assistance). In multivariate analysis, living as a couple was an independent factor correlated to a positive progression in four domains, i.e., body image, eating behavior, as well as physical, and psychological functioning.

Conclusion

This study showed that an online lifestyle intervention might be a promising way of improving the quality of life of people living with overweight or obesity.

Participant Preferences for the Development of a Digitally Delivered Gardening Intervention to Improve Diet, Physical Activity, and Cardiovascular Health: Cross-sectional Study

BACKGROUND

Low dietary intake of fruits and vegetables and physical inactivity are 2 modifiable risk factors for cardiovascular disease. Fruit and vegetable gardening can provide access to fresh produce, and many gardening activities are considered moderate physical activity. This makes gardening interventions a potential strategy for cardiovascular disease risk reduction. Previously developed gardening interventions have relied on in-person delivery models, which limit scalability and reach.

OBJECTIVE

The purpose of this study was to ascertain participant insight on intervention components and topics of interest to inform a digitally delivered, gardening-focused, multiple health behavior change intervention.

METHODS

A web-based survey was delivered via Amazon Mechanical Turk (MTurk), including quantitative and open-ended questions. Eligible participants were aged ≥20 years, could read and write in English, were US residents, and had at least a 98% MTurk task approval rating. A multilevel screening process was used to identify and exclude respondents with response inattention, poor language fluency, or suspected automated web robots (bots). Participants were asked about their interest in gardening programming, their preferences for intervention delivery modalities (1-hour expert lectures, a series of brief <5-minute videos, or in-person meetings), and what information is needed to teach new gardeners. Comparisons were made between never gardeners (NG) and ever gardeners (EG) in order to examine differences in perceptions based on prior experience. Quantitative data were summarized, and differences between groups were tested using chi-square tests. Qualitative data were coded and organized into intervention functions based on the Behavior Change Wheel.

RESULTS

A total of 465 participants were included (n=212, 45.6% NG and n=253, 54.4% EG). There was a high level of program interest overall (n=355, 76.3%), though interest was higher in EG (142/212, 67% NG; 213/253, 84.2% EG; P<.001). The majority of participants (n=282, 60.7%) preferred a series of brief <5-minute videos (136/212, 64.2% NG; 146/253, 57.7% EG; P=.16) over 1-hour lectures (29/212, 13.7% NG; 50/253, 19.8% EG; P=.08) or in-person delivery modes (47/212, 22.2% NG; 57/253, 22.5% EG; P=.93). Intervention functions identified were education and training (performing fundamental gardening and cooking activities), environmental restructuring (eg, social support), enablement (provision of tools or seeds), persuasion (offering encouragement and highlighting the benefits of gardening), and modeling (using content experts and participant testimonials). Content areas identified included the full lifecycle of gardening activities, from the fundamentals of preparing a garden site, planting and maintenance to harvesting and cooking.

CONCLUSIONS

In a sample of potential web-based learners, participants were interested in a digitally delivered gardening program. They preferred brief videos for content delivery and suggested content topics that encompassed how to garden from planting to harvesting and cooking. The next step in this line of work is to identify target behavior change techniques and pilot test the intervention to assess participant acceptability and preliminary efficacy.

Overcoming challenges in adherence and engagement digital interventions: The development of the ALGEApp for chronic pain management

Despite the growing body of evidence for the effectiveness of clinic-based interventions in increasing daily functioning in individuals with chronic pain, many sufferers still remain untreated or inadequately treated. Digital psychological interventions have been proposed as a means to overcome many of the barriers to face-to-face treatment (e.g., access, mobility, transportation problems) with the aim to improve health care for persons with chronic conditions in the convenience of their own space and time (home care). The main challenge of digital interventions however, is low user engagement and adherence. Focusing on users' engagement during the design phase of a digital intervention development can increase adherence, effectiveness, and acceptability. The purpose of this paper is to illustrate how we leveraged a recently proposed four-dimensional framework with evidence-based best practices and recommendations to develop a new digital intervention for chronic pain management, called the ALGEApp. A detailed presentation of how ALGEApp was designed and developed to adopt the recommendations and how this can aid engagement within digital interventions is proposed.

"I don't see myself represented:" Strategies and considerations for engaging gay male Native Hawaiian and Other Pacific Islander teens in research and HIV prevention services

Significant efforts have been applied to the development of sexual health programs for minority young gay males. Given the absence of research with Native Hawaiian and other Pacific Islander (NHOPI) gay teen males, this study was done to assess how to reach them. Interviews were conducted with 20 NHOPI gay males ages 19-24 as near peers that can inform reaching teens. Data was analyzed using the Reflexive Thematic Analysis method. Three themes were identified: (1) Culture is a crucial factor for recruitment and engagement-whether participants realized it or not; (2) Confidentiality is key in recruitment to provide a safe space for NHOPI gay teen male research participation; and (3) NHOPI gay teen males experience multiple identity conflicts that must be considered for recruitment and engagement initiatives. Online recruitment efforts are optimal and should reflect distinct NHOPI cultures. More research is needed when it comes to understanding the cultural acceptance and understanding of homosexuality in NHOPI communities and how to integrate cultural education into recruitment methods and interventions.

Social media analytics and their applications to evaluate an activity in online health interventions using CRITIC and TOPSIS techniques

The usage of social media is increasing by leaps and bounds in our day-to-day lives. It affects daily routines and brings a lot of change in different departments like health and education systems during the COVID-19 pandemic. Healthcare research and practice have been significantly impacted by the astounding growth of social media. Social media are changing health information management in several ways, from offering appropriate ways to enhance healthcare professional contact and share health-related knowledge and experience to facilitating the development of innovative medical research and wisdom. Social media analytics (SMAs) are efficient and effective interaction instruments that can be useful for both patients and clinicians in health interventions. Moreover, a significant portion of those involved in clinical practices (such as clinicians, professional colleges, and departments of health) are unaware of the importance of social media, its potential applications in their daily lives, as well as the possible consequences and how these will be handled. In the presented study, we proposed MCDM-based approaches known as "Criteria Importance Through Inter Correlation" (CRITIC) and Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) in order to identify the effective alternative among several options and make a better decision. After extracting features from the literature review, we choose six significant and relevant features and assign weights to them using CRITIC techniques while utilizing the TOPSIS technique to rank the alternatives based on their performance values. After the implementation of both methods and evaluation procedure, it is determined that the alternative with the highest score is placed at the top and called the "best alternative," while the alternative with the lowest score is placed at the bottom and called the worst alternative. Finally, we suggest a variety of research initiatives and new research areas where the aforementioned procedures become extremely useful in evaluating SMAs and their uses in online health interventions.

"Get Stuck and Can't Walk Out": Exploring the Needs for Support Among Chinese Immigrant Women Experiencing Intimate Partner Violence in the United States

Chinese immigrant survivors of intimate partner violence (IPV) in the United States have been overlooked and underserved. The purpose of this study was to explore their perceptions of resources for assistance as well as their priority needs. We conducted phone interviews with 20 Chinese immigrant women who had experienced IPV in the past year. The women expressed their needs for emotional support, culturally specific services, a variety of online resources to meet different demands, being empowered, raising the Chinese community's awareness about IPV, and batterer intervention programs. These women's testimonies shows that greater effort should be directed toward addressing those needs in order to reduce IPV and its impacts on health in this vulnerable group of women.

Enhancing Self-care Among Oral Cancer Survivors: Protocol for the Empowered Survivor Trial

BACKGROUND

Survivors of oral cavity and oropharyngeal cancer frequently experience difficulties in swallowing; tasting; speaking; chewing; and maintaining comfortable movements of the head, neck, and shoulder. Engagement in regular self-care can reduce further loss of function and mitigate late effects. Despite the substantial self-care requirements, there are no empirically based interventions to enhance the skills and confidence of these survivors in managing their ongoing care.

OBJECTIVE

The aim of this study is to describe the rationale and methodology for a randomized controlled trial evaluating Empowered Survivor (ES) versus Springboard Beyond Cancer, a general web-based program for cancer survivors, on self-efficacy in managing care, preparedness for managing survivorship, and health-related quality of life (QOL).

METHODS

This study will recruit a total of 600 individuals who were diagnosed with oral cavity or oropharyngeal cancer in the past 3 years and are currently cancer free primarily from state cancer registries; these individuals will be randomly assigned to either the ES or Springboard Beyond Cancer condition. The participants complete measures of self-efficacy in managing care, preparedness for survivorship, health-related QOL, and engagement in oral self-examination and head and neck strengthening and flexibility exercises at baseline and 2 and 6 months after baseline. The primary aim of this study is to evaluate the impact of ES versus Springboard Beyond Cancer on self-efficacy, preparedness, and health-related QOL. The secondary aim is to examine the mediators and moderators of ES's impact on self-efficacy in managing care, preparedness, and health-related QOL at 6 months. The exploratory aim is to conduct a process evaluation of ES to identify potential oncology or community settings for future implementation.

RESULTS

Multilevel modeling will be used to examine whether there are significant differences between the ES and Springboard Beyond Cancer interventions over time. Mediational models will evaluate the indirect effects of ES on outcomes. Quantitative analyses will evaluate the predictors of ES use, and qualitative analyses will evaluate the preferred timing and settings for the implementation of ES.

CONCLUSIONS

This randomized controlled trial evaluates a completely web-based intervention, ES, versus a general web-based program for cancer survivors, Springboard Beyond Cancer, on self-efficacy in managing care, preparedness for managing survivorship, and health-related QOL and identifies the putative mediators and moderators of the intervention's effects. If an effect on the primary outcomes is illustrated, the next step could be an implementation trial to evaluate the intervention's uptake in and impact on an oncology care setting or nonprofit organizations.

TRIAL REGISTRATION

ClincalTrials.gov NCT04713449; https://clinicaltrials.gov/ct2/show/NCT04713449.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/39996.

Cost-effectiveness of Internet Interventions Compared With Treatment as Usual for People With Mental Disorders: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

The economic costs of mental disorders for society are huge. Internet-based interventions are often coined as cost-effective alternatives to usual care, but the evidence is mixed.

OBJECTIVE

The aim was to review the literature on the cost-effectiveness of internet interventions for mental disorders compared with usual care and to provide an estimate of the monetary benefits of such interventions compared with usual care.

METHODS

A systematic review and meta-analysis of randomized controlled trials was conducted, which included participants with symptoms of mental disorders; investigated a telephone- or internet-based intervention; included a control condition in the form of treatment as usual, psychological placebo, waiting list control, or bibliotherapy; reported outcomes on both quality of life and costs; and included articles published in English. Electronic databases such as PubMed (including MEDLINE), Embase, Emcare, PsycINFO, Web of Science, and the Cochrane Library were used. Data on risk of bias, quality of the economic evaluation, quality-adjusted life years, and costs were extracted from the included studies, and the incremental net benefit was calculated and pooled.

RESULTS

The search yielded 6226 abstracts, and 37 studies with 14,946 participants were included. The quality of economic evaluations of the included studies was rated as moderate, and the risk of bias was high. A random-effects approach was maintained. Analyses suggested internet interventions were slightly more effective than usual care in terms of quality-adjusted life years gain (Hedges g=0.052, 95% CI 0.010-0.094; P=.02) and equally expensive (Hedges g=0.002, 95% CI -0.080 to 0.84; P=.96). The pooled incremental net benefit was US $255 (95% CI US $91 to US $419; P=.002), favoring internet interventions over usual care. The perspective of the economic evaluation and targeted mental disorder moderated the results.

CONCLUSIONS

The findings indicate that the cost-effectiveness of internet interventions for mental disorders compared with a care-as-usual approach is likely, but generalizability to new studies is poor given the substantial heterogeneity. This is the first study in the field of mental health to pool cost-effectiveness outcomes in an aggregate data meta-analysis.

TRIAL REGISTRATION

PROSPERO CRD42019141659; https://tinyurl.com/3cu99b34.

Adherence to e-health interventions for substance use and the factors influencing it: Systematic Review, meta-analysis, and meta-regression

Background

Substance use disorders affect 36 million people globally, but only a small proportion of them receive the necessary treatment. E-health interventions have been developed to address this issue by improving access to substance use treatment. However, concerns about participant engagement and adherence to these interventions remain. This review aimed to evaluate adherence to e-health interventions targeting substance use and identify hypothesized predictors of adherence.

Methods

A systematic review of literature published between 2009 and 2020 was conducted, and data on adherence measures and hypothesized predictors were extracted. Meta-analysis and meta-regression were used to analyze the data. The two adherence measures were (a) the mean proportion of modules completed across the intervention groups and (b) the proportion of participants that completed all modules. Four meta-regression models assessed each covariate including guidance, blended treatment, intervention duration and recruitment strategy.

Results

The overall pooled adherence rate was 0.60 (95%-CI: 0.52-0.67) for the mean proportion of modules completed across 30 intervention arms and 0.47 (95%-CI: 0.35-0.59) for the proportion of participants that completed all modules across 9 intervention arms. Guidance, blended treatment, and recruitment were significant predictors of adherence, while treatment duration was not.

Conclusion

The study suggests that more research is needed to identify predictors of adherence, in order to determine specific aspects that contribute to better exposure to intervention content. Reporting adherence and predictors in future studies can lead to improved meta-analyses and the development of more engaging interventions. Identifying predictors can aid in designing effective interventions for substance use disorders, with important implications for e-health interventions targeting substance use.

Effects of a Web-Based Weight Loss Program on the Healthy Eating Index-NVS in Adults with Overweight or Obesity and the Association with Dietary, Anthropometric and Cardiometabolic Variables: A Randomized Controlled Clinical Trial

This randomized, controlled clinical trial examined the impact of a web-based weight loss intervention on diet quality. Furthermore, it was investigated whether corresponding changes in diet quality were associated with changes in measures of cardiovascular risk profile. Individuals with a body mass index (BMI) of 27.5 to 34.9 kg/m2 and an age of 18 to 65 y were assigned to either an interactive and fully automated web-based weight loss program focusing on dietary energy density (intervention) or a non-interactive web-based weight loss program (control). Examinations were performed at baseline (t0), after the 12-week web-based intervention (t1), and after an additional 6 (t2) and 12 months (t3). Based on a dietary record, the Healthy Eating Index-NVS (HEI-NVS) was calculated and analyzed using a robust linear mixed model. In addition, bootstrapped correlations were performed independently of study group to examine associations between change in HEI-NVS and change in dietary, anthropometric, and cardiometabolic variables. A total of n = 153 participants with a mean BMI of 30.71 kg/m2 (SD 2.13) and an average age of 48.92 y (SD 11.17) were included in the study. HEI-NVS improved significantly in the intervention group from baseline (t0) to t2 (p = 0.003) and to t3 (p = 0.037), whereby the course was significantly different up to t2 (p = 0.013) and not significantly different up to t3 (p = 0.054) compared to the control group. Independent of study group, there was a significant negative association between change in HEI-NVS and dietary energy density. A higher total score in HEI-NVS did not correlate with improvements in cardiovascular risk profile. The interactive and fully automated web-based weight loss program improved diet quality. Independent of study group, changes in HEI-NVS correlated with changes in energy density, but there was no association between improvements in HEI-NVS and improvements in cardiovascular risk profile.

Usage of a Web-Based Workplace and Symptom Self-Management Intervention Tool to Improve Work Ability for Breast Cancer Survivors

This work aimed to evaluate the usage of a web-based intervention (WISE: Work ability Improvement through Symptom and Ergonomic strategies) developed to improve work ability for women recently diagnosed with breast cancer. Twenty-two women undergoing adjuvant treatment for breast cancer were provided access to WISE. This website includes content pages (e.g., information on ergonomics, symptom management, and other work-related resources) and worksheets (e.g., journals to track symptoms or goals). It could be personalized based on individual work activities and symptoms. Measures assessed at 3 months included usage of the website and perceived usefulness. Thirteen of the 22 participants (60%) accessed WISE; 11 personalized their information. Content and worksheet pages had 97 and 79 visits, respectively. Most frequently visited pages were "setting goals" (i.e., prioritize and track symptoms; 45 visits) and "steps to creating your WISE plan" (i.e., incorporate symptom and ergonomic strategies; 16 visits). Median duration time was 11.05 (range 0.35-79.55) minutes. Usefulness of the content and worksheet pages assessed via a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree) was 5.08 (SD = 1.59) and 4.26 (SD = 2.03), respectively. Participants were likely to recommend WISE to other women undergoing cancer treatment (mean = 6.11; SD = 1.05). The majority of participants personalized WISE work and symptom strategies. Overall, participants agreed that WISE content pages were useful and would recommend WISE for other breast cancer survivors. Results support that majority of breast cancer survivors, undergoing treatment with curative intent, accessed a web-based intervention that provided personalized information on workplace and symptom strategies.

Low Level of Agreement Between Self-Report and Clinical Assessment of Passive Suicidal Ideation

OBJECTIVE

Discrepancies between patient reports during clinical evaluations and self-reported suicide ideation are of vital importance. We study the agreement in passive suicidal ideation between reports made by clinicians and patients' self-reports.

METHOD

Wish of death in 648 outpatients was assessed by attending clinicians. Within 24 h after clinical evaluation, patients completed a self-report questionnaire in which they were asked whether they had no desire to live. We used cluster analysis to determine the clinical profile of a population of patients according to the concordance between reports made by clinicians and self-reported information.

RESULTS

A low level of agreement (kappa = 0.072) was found between clinicians and patients, as 56.4% (n = 366) of clinician reports classified as containing no death-related ideas although on self-report the patient did state that they had no desire to live. In this group containing discrepancies between the two reports, two clusters were found to have shared characteristics: female sex, middle age, cohabitation, active employment, no history of suicidal behavior, and diagnosis of neurotic, stress-related, and somatoform disorders. In a third, more severe cluster, patients self-reported sleep disturbances, less appetite, poor treatment adherence, and aggressiveness.

CONCLUSIONS

We found low agreement between self-reports and clinician assessments regarding the death wish. Self-reporting may be useful in assessing suicide risk. HIGHLIGHTSLow agreement was found between self-reports and clinician assessments regarding passive suicidal ideation.Most patients in whom the clinician underestimated the risk of suicide were women.Our results suggest that clinicians require adequate documentation of suicidal risk assessment to identify the high-risk population.

Pragmatic implementation of a fully automated online obesity treatment in primary care

OBJECTIVE

Behavioral obesity treatment implemented in primary care is efficacious but typically involves face-to-face or phone contact. This study evaluated enrollment, engagement, and 12-week weight loss in a fully automated online behavioral weight-loss intervention implemented pragmatically in a primary care network.

METHODS

As part of routine primary care, providers and nurse care managers offered a no-cost online obesity treatment program to 1,721 patients. Of these, 721 consented and were eligible (aged 18-75 years with BMI ≥ 25 kg/m² and internet access), and 464 started the program. The program included 12 weekly online lessons, a self-monitoring platform, and automated feedback.

RESULTS

More than one-quarter of patients who were offered the program (26%) initiated treatment. In intent-to-treat analyses using all data available, mean 12-week weight change was -5.10% (SE = 0.21). Patients who submitted their weights on all 12 weeks (37% of 464) lost an estimated 7.2% body weight versus 3.4% in those submitting less frequently.

CONCLUSIONS

This fully automated online program, implemented into the routine workflow of a primary care setting without any human counseling or researcher involvement, produced clinically meaningful short-term weight loss. Greater program engagement was associated with greater weight loss; efforts are needed to understand barriers to engagement.

Direct-to-Consumer Genetic Testing on Social Media: Topic Modeling and Sentiment Analysis of YouTube Users' Comments

Background

With direct-to-consumer (DTC) genetic testing enabling self-responsible access to novel information on ancestry, traits, or health, consumers often turn to social media for assistance and discussion. YouTube, the largest social media platform for videos, offers an abundance of DTC genetic testing-related videos. Nevertheless, user discourse in the comments sections of these videos is largely unexplored.

Objective

This study aims to address the lack of knowledge concerning user discourse in the comments sections of DTC genetic testing-related videos on YouTube by exploring topics discussed and users' attitudes toward these videos.

Methods

We employed a 3-step research approach. First, we collected metadata and comments of the 248 most viewed DTC genetic testing-related videos on YouTube. Second, we conducted topic modeling using word frequency analysis, bigram analysis, and structural topic modeling to identify topics discussed in the comments sections of those videos. Finally, we employed Bing (binary), National Research Council Canada (NRC) emotion, and 9-level sentiment analysis to identify users' attitudes toward these DTC genetic testing-related videos, as expressed in their comments.

Results

We collected 84,082 comments from the 248 most viewed DTC genetic testing-related YouTube videos. With topic modeling, we identified 6 prevailing topics on (1) general genetic testing, (2) ancestry testing, (3) relationship testing, (4) health and trait testing, (5) ethical concerns, and (6) YouTube video reaction. Further, our sentiment analysis indicates strong positive emotions (anticipation, joy, surprise, and trust) and a neutral-to-positive attitude toward DTC genetic testing-related videos.

Conclusions

With this study, we demonstrate how to identify users' attitudes on DTC genetic testing by examining topics and opinions based on YouTube video comments. Shedding light on user discourse on social media, our findings suggest that users are highly interested in DTC genetic testing and related social media content. Nonetheless, with this novel market constantly evolving, service providers, content providers, or regulatory authorities may still need to adapt their services to users' interests and desires.

Applying Collective Intelligence in Health Recommender Systems for Smoking Cessation: A Comparison Trial

Background: Health recommender systems (HRSs) are intelligent systems that can be used to tailor digital health interventions. We compared two HRSs to assess their impact providing smoking cessation support messages. Methods: Smokers who downloaded a mobile app to support smoking abstinence were randomly assigned to two interventions. They received personalized, ratable motivational messages on the app. The first intervention had a knowledge-based HRS (n = 181): it selected random messages from a subset matching the users’ demographics and smoking habits. The second intervention had a hybrid HRS using collective intelligence (n = 190): it selected messages applying the knowledge-based filter first, and then chose the ones with higher ratings provided by other similar users in the system. Both interventions were compared on: (a) message appreciation, (b) engagement with the system, and (c) one’s own self-reported smoking cessation status, as indicated by the last seven-day point prevalence report in different time intervals during a period of six months. Results: Both interventions had similar message appreciation, number of rated messages, and abstinence results. The knowledge-based HRS achieved a significantly higher number of active days, number of abstinence reports, and better abstinence results. The hybrid algorithm led to more quitting attempts in participants who completed their user profiles.

Evaluating the effectiveness of Internet-based communication for public health: a systematic review (Preprint)

Background

Communicating strategically is a key issue for health organizations. Over the past decade, health care communication via social media and websites has generated a great deal of studies examining different realities of communication strategies. However, when it comes to systematic reviews, there is fragmentary evidence on this type of communication.

Objective

The aim of this systematic review was to summarize the evidence on web institutional health communication for public health authorities to evaluate possible aim-specific key points based on these existing studies.

Methods

Guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, we conducted a comprehensive review across 2 electronic databases (PubMed and Web of Science) from January 1, 2011, to October 7, 2021, searching for studies investigating institutional health communication. In total, 2 independent researchers (AN and SS) reviewed the articles for inclusion, and the assessment of methodological quality was based on the Kmet appraisal checklist.

Results

A total of 78 articles were selected. Most studies (35/78, 45%) targeted health promotion and disease prevention, followed by crisis communication (24/78, 31%), general health (13/78, 17%), and misinformation correction and health promotion (6/78, 8%). Engagement and message framing were the most analyzed aspects. Few studies (14/78, 18%) focused on campaign effectiveness. Only 23% (18/78) of the studies had an experimental design. The Kmet evaluation was used to distinguish studies presenting a solid structure from lacking studies. In particular, considering the 0.75-point threshold, 36% (28/78) of the studies were excluded. Studies above this threshold were used to identify a series of aim-specific and medium-specific suggestions as the communication strategies used differed greatly.

Conclusions

Overall, the findings suggest that no single strategy works best in the case of web-based health care communication. The extreme variability of outcomes and the lack of a unitary measure for assessing the end points of a specific campaign or study lead us to reconsider the tools we use to evaluate the efficacy of web-based health communication.

Using digital media to improve dementia care in India: A pilot randomised control trial (Preprint)

Background

Objective

Methods

Results

Conclusions

Trial Registration

International Registered Report Identifier (IRRID)

Barriers and Considerations in the Design and Implementation of Digital Behavioral Interventions: Qualitative Analysis

Background

Digital behavioral interventions have become increasingly popular for their ability to support patient diagnosis and treatment, chronic disease self-management, behavior change, and adherence to recommended care. However, digital intervention development is impeded by challenges such as limited technical skills, limited access to developers, and cost. The purpose of this study is to elicit in-depth qualitative feedback from intervention developers who have interest in digital behavioral interventions but lack programming skills regarding the barriers they experience and key considerations in the design and implementation of digital interventions.

Objective

This study aims to understand barriers in the design and implementation of digital behavioral interventions, as well as to identify key considerations for researchers who are developing these interventions.

Methods

We conducted semistructured qualitative interviews with 18 researchers who had experience either designing (but not coding) digital behavioral interventions or running research studies with them. Participants were a convenience sample of users of the Computerized Intervention Authoring System platform, an existing no-code development platform for building digital intervention content, and were recruited through either direct email solicitation or snowball sampling. All interviews were conducted and recorded over videoconference between February and April 2020. Recordings from interviews were transcribed and thematically analyzed by multiple coders.

Results

Interviews were completed with 18 participants and lasted between 24 and 65 (mean 46.9, SD 11.3) minutes. Interviewees were predominantly female (17/18, 94%) and represented different job roles, ranging from researcher to project/study staff. Three key barriers in the development of digital behavior interventions were identified during interviews: lack of cross-disciplinary understanding; variability in recipients’ technology access, infrastructure, and literacy; and the idea that evidence-based in-person interactions do not translate directly to digital interactions. Interviewees identified several key considerations that interventionists learned to prioritize, which have the potential to overcome these barriers and lead to successful interventions.

Conclusions

Barriers in the development of digital behavioral interventions are often created by a lack of cross-disciplinary understanding, which can lead to difficulties conceptualizing interventions, unrealistic expectations in terms of cost, and confusion about the development process. Moreover, concerns about research study participant characteristics and access to technology, as well as the translation of in-person interventions to digital, are apparent. Appropriate training in how to work with software development teams may help future digital behavior intervention creators overcome these barriers and may lead to new, exciting innovations in this space.

Testing the Effectiveness of a Blended Intervention to Reduce Suicidal Ideation among School Adolescents in Chile: A Protocol for a Cluster Randomized Controlled Trial

Suicidal ideation is prevalent in adolescents and is a marker for subsequent psychiatric vulnerability and symptom severity. Literature shows that blended care (integrating online and offline components in a treatment process) could improve the effectiveness and adherence of interventions targeting suicidal ideation in adolescents, but the evidence is inconclusive. Thus, we will test the effectiveness of a blended intervention to reduce suicidal ideation (primary outcome) in school settings using a single-blind two-armed cluster randomized controlled trial (cRCT). The internet-based component corresponds to the Reframe-IT, a program encompassing eight online sessions based on cognitive-behavioral therapy (CBT) principles. The face-to-face intervention will be delivered through four CBT sessions. Additionally, we will assess the effect of the intervention on the following secondary outcomes: suicidal attempts, depressive symptoms, hopelessness, emotional regulation, and problem-solving skills. Primary and secondary outcomes will be assessed at post-intervention, 3-month, 6-month, and 12-month follow-up. Finally, we will explore the mediation role of cognitive, emotional, and behavioral correlates of suicide on the effect of the intervention. Results will inform whether the intervention can reduce suicide among school adolescents and be implemented on a large scale in Chile.

Strategies to promote the use of online health applications for early detection and raising awareness of chronic diseases among members of the general public: A systematic literature review

INTRODUCTION

Engagement is essential to achieve intended outcomes of online interventions, but achieving such engagement is a key challenge for many researchers and practitioners. This systematic literature review aims to identify strategies and tools to promote the use of online health interventions for early detection and raising awareness of chronic diseases among the public, and to investigate the evidence regarding the effectiveness of such strategies.

MATERIALS AND METHODS

We performed a systematic search of seven electronic databases: Embase, Medline All Ovid, Web of Science, Cochrane Central Register of Controlled Trials, PsycINFO, CINAHL and Google Scholar. The study protocol is registered in PROSPERO (CRD42020200471).

RESULTS

The database search identified 8,526 articles, 47 were included in the review. Thirty-two studies reported strategies to promote the use of their online intervention, including online advertisements on social media (n = 17), a dating application (n = 10), and a website (n = 3). Social media were not only used for promotion of the intervention, but also as main intervention platform (n = 18). Seven studies reported traditional promotion methods such as printed advertisement and (offline) campaigns. Twenty-seven studies reported strategies to keep users engaged, including reminders (n = 12), sharing of posts on social media (n = 4), rewards (n = 3), weekly group discussions (n = 2), follow-up phone calls (n = 2), interactive games (n = 1), monthly quizzes (n = 1), links to provision of a test kit (n = 1), and a deposit-return system (n = 1).

CONCLUSIONS

No study conducted a formal evaluation of the effectiveness of the engagement strategies. Examining the effectiveness of engagement strategies is an important area for further research.

Online-Delivered Over Staff-Delivered Parenting Intervention for Young Children With Disruptive Behavior Problems: Cost-Minimization Analysis

BACKGROUND

High-prevalence childhood mental health problems like early-onset disruptive behavior problems (DBPs) pose a significant public health challenge and necessitate interventions with adequate population reach. The treatment approach of choice for childhood DBPs, namely evidence-based parenting intervention, has not been sufficiently disseminated when relying solely on staff-delivered services. Online-delivered parenting intervention is a promising strategy, but the cost minimization of this delivery model for reducing child DBPs is unknown compared with the more traditional staff-delivered modality.

OBJECTIVE

This study aimed to examine the cost-minimization of an online parenting intervention for childhood disruptive behavior problems compared with the staff-delivered version of the same content. This objective, pursued in the context of a randomized trial, made use of cost data collected from parents and service providers.

METHODS

A cost-minimization analysis (CMA) was conducted comparing the online and staff-delivered parenting interventions. Families (N=334) with children 3-7 years old, who exhibited clinically elevated disruptive behavior problems, were randomly assigned to the two parenting interventions. Participants, delivery staff, and administrators provided data for the CMA concerning family participation time and expenses, program delivery time (direct and nondirect), and nonpersonnel resources (eg, space, materials, and access fee). The CMA was conducted using both intent-to-treat and per-protocol analytic approaches.

RESULTS

For the intent-to-treat analyses, the online parenting intervention reflected significantly lower program costs (t₁₆₈=23.2; P<.001), family costs (t₁₈₅=9.2; P<.001), and total costs (t₁₇₁=19.1; P<.001) compared to the staff-delivered intervention. The mean incremental cost difference between the interventions was $1164 total costs per case. The same pattern of significant differences was confirmed in the per-protocol analysis based on the families who completed their respective intervention, with a mean incremental cost difference of $1483 per case. All costs were valued or adjusted in 2017 US dollars.

CONCLUSIONS

The online-delivered parenting intervention in this randomized study produced substantial cost minimization compared with the staff-delivered intervention providing the same content. Cost minimization was driven primarily by personnel time and, to a lesser extent, by facilities costs and family travel time. The CMA was accomplished with three critical conditions in place: (1) the two intervention delivery modalities (ie, online and staff) held intervention content constant; (2) families were randomized to the two parenting interventions; and (3) the online-delivered intervention was previously confirmed to be non-inferior to the staff-delivered intervention in significantly reducing the primary outcome, child disruptive behavior problems. Given those conditions, cost minimization for the online parenting intervention was unequivocal.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02121431; https://clinicaltrials.gov/ct2/show/NCT02121431.

Impact of dementia literacy interventions for non-health-professionals: systematic review and meta-analysis

OBJECTIVES

To assess evidence regarding the effects of interventions aimed at improving dementia literacy for different groups of non-health-professionals.

METHODS

A systematic search for relevant interventions was conducted using a range of online databases (e.g. CINAHL, Embase, Medline, ProQuest, and PsycINFO) and hand-searching of reference lists. Eligible interventions were identified based on predefined inclusion/exclusion criteria and methodological quality criteria. Meta analyses were performed using a random-effects model.

RESULTS

The final review included 14 interventions, which were either randomised controlled trials or non-randomised controlled trials. The interventions had varied contents, approaches, settings, and outcome measures. Evidence of improved dementia literacy in various aspects was found, and the intervention effects were strongest on knowledge of dementia.

DISCUSSION

There is evidence for the positive impact of dementia literacy interventions on different groups of non-health-professionals. Best practices in intervention contents, approaches, and outcome measures should be examined to guide future interventions.

Fostering participation in digital contact tracing

Digital contact tracing is a promising digital public health intervention to manage epidemics. However, in order to reach its full potential, the technology has to be widely adopted and used. During the SARS-CoV-2 pandemic, this has not necessarily been the case. We review the literature with a focus on how participation in digital contact tracing could be fostered and provide policy recommendations on how to increase its adoption and usage as well as recommendations for further research.

Moving from intention to behaviour: a randomised controlled trial protocol for an app-based physical activity intervention (i2be)

INTRODUCTION

Efficacy tests of physical activity interventions indicate that many have limited or short-term efficacy, principally because they do not sufficiently build on theory-based processes that determine behaviour. The current study aims to address this limitation.

METHODS AND ANALYSIS

The efficacy of the 8-week intervention will be tested using a three-condition randomised controlled trial delivered through an app, in women with a prior hypertensive pregnancy disorder. The intervention is based on the integrated behaviour change model, which outlines the motivational, volitional and automatic processes that lead to physical activity. The mechanisms by which the behaviour change techniques lead to physical activity will be tested.Following stratification on baseline factors, participants will be randomly allocated in-app to one of three conditions (1:1:1). The information condition will receive information, replicating usual care. Additionally to what the information condition receives, the motivation condition will receive content targeting motivational processes. Additionally to what the motivation condition receives, the action condition will receive content targeting volitional and automatic processes.The primary outcome is weekly minutes of moderate-to-vigorous physical activity, as measured by an activity tracker (Fitbit Inspire 2). Secondary outcomes include weekly average of Fitbit-measured daily resting heart rate, and self-reported body mass index, waist-hip ratio, cardiorespiratory fitness and subjective well-being. Tertiary outcomes include self-reported variables representing motivational, volitional, and automatic processes. Outcome measures will be assessed at baseline, immediately post-intervention, and at 3 and 12 months post-intervention. Physical activity will also be investigated at intervention midpoint. Efficacy will be determined by available case analysis. A process evaluation will be performed based on programme fidelity and acceptability measures.

ETHICS AND DISSEMINATION

The Medical Ethics Committee of the Erasmus MC has approved this study (MEC-2020-0981). Results will be published in peer reviewed scientific journals and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

Netherlands trial register, NL9329.

The Development of iManage-PC, an Online Symptom Monitoring and Self-management Tool for Men With Clinically Localized Prostate Cancer

BACKGROUND

Prostate cancer (PC) often impacts 4 major aspects of health-related quality of life (HRQL): urinary, sexual, and bowel dysfunction, and anxiety. Online tools may be helpful in supporting the development of self-management skills that can improve HRQL.

OBJECTIVE

The aim of this study was to develop and pilot-test an online symptom monitoring and self-management program, iManage-PC.

METHODS

A literature search, input from experts, and feedback from patients were used to develop iManage-PC. A 4-week, single-arm pilot study was conducted with 96 men with prostate cancer. We evaluated system usability, acceptance, and satisfaction and examined preliminary effects on patient-reported outcomes.

RESULTS

Rates of retention (94.8%) and adherence to symptom monitoring (95.0%-97.0%) were high. Most participants rated the tool as satisfactory and acceptable (81.2%-94.3%). Related-samples Wilcoxon signed rank tests revealed that participants reported increased self-efficacy related to their ability to manage their adverse effects (T = 1772.0, P < .001, r = 0.39), physical discomfort (T = 1259.0, P < .001, r = 0.40), and stress and worry (T = 1108.5, P = .001, r = 0.34). Global mental and physical health also improved (T = 1322.0, P = .032, r = 0.23, and T = 1409.0, P = .001, r = 0.35, respectively).

CONCLUSIONS

Future research with such tools should examine the potential role of cut-score-derived management interventions to improve engagement, symptom management self-efficacy, and HRQL.

IMPLICATIONS FOR PRACTICE

Our findings are consistent with a growing body of literature that supports the feasibility and acceptability of remotely delivered interventions.

Efficacy of Web-Based Supportive Interventions in Quality of Life in COPD Patients, a Systematic Review and Meta-Analysis

Background: Adults living with Chronic Obstructive Pulmonary Disease (COPD) often have difficulties when trying to access health care services. Interactive communication technologies are a valuable tool to enable patients to access supportive interventions to cope with their disease. The aim of this revision and meta-analysis is to analyze the content and efficacy of web-based supportive interventions in quality of life in COPD. Methods: Medline (via PubMed), Web of Science, and Scopus were the databases used to select the studies for this systematic review. A screening, analysis, and assessment of the methodological quality was carried out by two independent researchers. A meta-analysis of the extracted data was performed. Results: A total of 9 of the 3089 studies reviewed met the inclusion criteria. Most repeated web content elements were educational and involved communication with healthcare professional content. Finally, seven of the nine studies were included in a quantitative analysis. Web-based supportive interventions significantly improved quality of life when added to usual care (SMD = −1.26, 95% CI = −1.65, −0.86; p < 0.001) but no significant differences were found when compared with an autonomous pedometer walking intervention (p = 0.64) or a face-to-face treatment (p = 0.82). Conclusion: This systematic review and meta-analysis suggests that web-based supportive interventions may complement or accompany treatments in COPD patients due to the advantages of online interventions. The results obtained should be treated with caution due to the limited number of studies in this area and methodological weaknesses.

Selecting and Evaluating Mobile Health Apps for the Healthy Life Trajectories Initiative: Development of the eHealth Resource Checklist

Background

The ubiquity of smartphones and mobile devices in the general population presents an unprecedented opportunity for preventative health. Not surprisingly, the use of electronic health (eHealth) resources accessed through mobile devices in clinical trials is becoming more prevalent; the selection, screening, and collation of quality eHealth resources is necessary to clinical trials using these technologies. However, the constant creation and turnover of new eHealth resources can make this task difficult. Although syntheses of eHealth resources are becoming more common, their methodological and reporting quality require improvement so as to be more accessible to nonexperts. Further, there continues to be significant variation in quality criteria employed for assessment, with no clear method for developing the included criteria. There is currently no single existing framework that addresses all six dimensions of mobile health app quality identified in Agarwal et al’s recent scoping review (ie, basic descriptions of the design and usage of the resource; technical features and accessibility; health information quality; usability; evidence of impact; and user engagement and behavior change). In instances where highly systematic tactics are not possible (due to time constraints, cost, or lack of expertise), there may be value in adopting practical and pragmatic approaches to helping researchers and clinicians identify and disseminate e-resources.

Objective

The study aimed to create a set of guidelines (ie, a checklist) to aid the members of the Healthy Life Trajectories Initiative (HeLTI) Canada trial—a preconception randomized controlled clinical trial to prevent child obesity—to assist their efforts in searching, identifying, screening, and including selected eHealth resources for participant use in the study intervention.

Methods

A framework for searching, screening, and selecting eHealth resources was adapted from the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) checklist for systematic and scoping reviews to optimize the rigor, clarity, and transparency of the process. Details regarding searching, selecting, extracting, and assessing quality of eHealth resources are described.

Results

This study resulted in the systematic development of a checklist consisting of 12 guiding principles, organized in a chronological versus priority sequence to aid researchers in searching, screening, and assessing the quality of various eHealth resources.

Conclusions

The eHealth Resource Checklist will assist researchers in navigating the eHealth resource space by providing a mechanism to detail their process of developing inclusion criteria, identifying search location, selecting and reviewing evidence, extracting information, evaluating the quality of the evidence, and synthesizing the extracted evidence. The overarching goal of this checklist is to provide researchers or generalists new to the eHealth field with a tool that balances pragmatism with rigor and that helps standardize the process of searching and critiquing digital material—a particularly important aspect given the recent explosion of and reliance on eHealth resources. Moreover, this checklist may be useful to other researchers and practitioners developing similar health interventions.

Recommendations for the Development of HIV Prevention Interventions Among Latino Young Sexual Minority Groups

Introduction

Epidemiological trends in the USA have shown an increase in HIV incidence among adolescent men who have sex with men (AMSM). Sexual and ethnic minorities in this group are at increased risk for infection. The use of health services and information delivered or enhanced through the Internet or related technologies-known as eHealth-is an important strategy to reduce HIV disparities and to engage with some minority populations such as Spanish-speaking Latino AMSM. Despite the new opportunities that eHealth provides, little is known about the implementation of such interventions for HIV prevention among Spanish-speaking Latino AMSM.

Method

A systematic literature review was conducted to examine eHealth HIV prevention interventions targeted to Spanish-speaking Latino AMSM. A systematic search using PubMed database was conducted to identify peer-reviewed publications between January 1, 2006, and May 31, 2019. Eligible publications were those including (1) adolescents ages 13 to 18 years old as its main population, (2) described and tested HIV prevention interventions, (3) AMSM, (4) eHealth interventions, and (5) Latino/Hispanic participants.

Results

A total of n = 52 publications were identified. From those, only n = 12 (27.3%) were targeted to AMSM (13-18 years old) and Latino/Hispanic populations, and there was no evidence of interventions addressing eHealth HIV prevention interventions targeted to Spanish-speaking Latino AMSM.

Conclusions

Results indicate the scarcity of scientific evidence of eHealth interventions targeted to populations at increased risk for infection. Further, there is a call for the development of culturally and linguistically congruent eHealth HIV prevention interventions for Spanish-speaking Latino youth and to consider implementation and methodological approaches for these populations.

Understanding how young African adults interact with peer-generated sexual health information on Facebook and uncovering strategies for successful organic engagement

Background

The use of social media for sexual health communication is gaining intense discussion both globally and in Africa. Despite this reality, it remains unclear whether and how young African adults use digital innovations like social media to access sexual health information. More importantly, the unique properties of messages that increase message reach and propagation are not well understood. This study aims to fill the gaps in scholarship by identifying post features and content associated with greater user engagement.

Methods

We analyzed a corpus of 3533 sexual and reproductive health messages shared on a public Facebook group by and for young African adults between June 1, 2018, and May 31, 2019, to understand better the unique features associated with higher engagement with peer-generated sexual health education. Facebook posts were independently classified into thematic categories such as topic, strategy, and tone of communication.

Results

The participants generally engaged with posts superficially by liking (x̃ = 54; x̄ = 109.28; σ = 159.24) rather than leaving comments (x̃ = 10; x̄ = 32.03; σ = 62.65) or sharing (x̃ = 3; x̄ = 11.34; σ = 55.12) the wallposts. Messages with fear [IRR:0.75, 95% CI: 0.66–0.86] or guilt [IRR:0.82, 95% CI: 0.72–0.92] appeals received a significantly lower number of reactions compared to neutral messages. Messages requesting an opinion [IRR:4.25, 95% CI: 3.57–5.10] had a significantly higher number of comments compared to status updates. The use of multimedia and storytelling formats were also significantly associated with a higher level of engagement and propagation of sexual health messages on the group.

Conclusion

Young adults in our sample tend to superficially interact with peer-communicated sexual health information through likes than engage (comments) or propagate such messages. Message features that increase engagements and propagation of messages include multimedia and engaging styles like storytelling. Our findings provide valuable insight and pave the way for the design of effective and context-specific sexual health information use of features that attract young African adults.

The Efficacy of a Personalized mHealth Coaching Program During Pregnancy on Maternal Diet, Supplement Use, and Physical Activity: Protocol for a Parallel-Group Randomized Controlled Trial

Background

Adequate intake of macro- and micronutrients and adoption of an active lifestyle during pregnancy are essential for optimum maternal and fetal health and offspring development. Dietary counseling and advice regarding adequate physical activity are integral components of antenatal care. Personalized coaching through the use of mobile health (mHealth) that supports behavior modification is an innovative approach that needs exploration.

Objective

Our primary aim is to assess the efficacy of an mHealth program in improving diet, supplement use, and physical activity during pregnancy. Secondary objectives include evaluation of the program’s effect on maternal and offspring health outcomes and assessment of its compliance and usability.

Methods

A randomized controlled trial was initiated at the Aga Khan University Hospital in Karachi, Pakistan, in January 2020. We aim to recruit 300 pregnant women in their first trimester who have smartphones, do not have comorbidities, and are not taking medications. The intervention group will be trained to use an mHealth app called PurUmeed Aaghaz. Through this app, the subjects will report information about their diet, supplement use, and physical activity and will receive personalized advice and three push messages as weekly reminders. The research assistant will obtain similar information from the control group via a paperless questionnaire; this group will receive standard face-to-face counseling regarding diet, supplement use, and physical activity. Data will be collected at enrollment and during four follow-up sessions scheduled 6 weeks apart. Primary study outcomes include improvements in diet (ie, change in mean dietary risk score from baseline to each follow-up), supplement use (ie, changes in mean supplement use score and biochemical levels of folic acid, iron, calcium, and vitamin D on a study subset), and mean duration of reported physical activity (minutes). Secondary study outcomes relate to maternal health (ie, gestational diabetes mellitus, gestational hypertension, pre-eclampsia, and gestational weight gain), newborn health (ie, birth weight and length and gestational age at delivery), and infant health (ie, BMI and blood pressure at 1 year of age). Compliance will be determined by the proportion of participants who complete the 6-month coaching program. Usability will be assessed based on features related to design, interface, content, coaching, perception, and personal benefit.

Results

The study was approved by the Ethics Review Committee of the Aga Khan University in 2017. The recruitment of study participants was completed in September 2021. All follow-ups and outcome assessments are expected to be completed by March 2023 and analysis is expected to be completed by June 2023. We expect the results to be published by the end of 2023.

Conclusions

This study will be an important step toward evaluating the role of mHealth in improving behaviors related to a healthy diet, supplement use, and promotion of physical activity during pregnancy, as well as in influencing maternal and offspring outcomes. If proven effective, mHealth interventions can be scaled up and included in antenatal care packages at tertiary care hospitals of low- and middle-income countries.

Trial Registration

ClinicalTrials.gov NCT04216446; https://clinicaltrials.gov/ct2/show/NCT04216446

International Registered Report Identifier (IRRID)

DERR1-10.2196/31611

Systemic and Environmental Contributors to Obesity Inequities in Marginalized Racial and Ethnic Groups

Obesity is a multifactorial disease that disproportionally affects diverse racial and ethnic groups. Structural racism influences racial inequities in obesity prevalence through environmental factors, such as racism and discrimination, socioeconomic status, increased levels of stress, and bias in the health care delivery system. Researchers, clinicians, and policy makers must work to address the environmental and systematic barriers that contribute to health inequities in the United States. Specifically, clinicians should quantitatively and qualitatively assess environmental and social factors and proactively engage in patient-centered care to tailor available treatments based on identified needs and experiences.

Factors influencing participants' engagement with an interactive text-message intervention to improve sun protection behaviors: "SunText" randomized controlled trial

There is growing evidence suggesting that text-message-based interventions are effective to promote sun protection behaviors. However, it is still unclear how engagement and adherence with the intervention messages can be optimized through intervention design. This study evaluated the effect of different combinations of personalized and two-way interactive messages on participant engagement with a theory-based skin cancer prevention intervention. In the SunText study conducted in February-July 2019 in Queensland, Australia participants 18-40 years were randomized to four different text message schedules using a Latin square design. This study analyzed if the order and intensity in which the schedules were received were associated with participants' level of engagement, and if this differed by demographic factors. Out of the 389 participants enrolled in the study, 375 completed the intervention period and remained for analysis. The overall intervention engagement rate was 71% and decreased from the beginning to the end of the study (82.2%-61.4%). The group starting with personalized, but not interactive messaging showed the lowest engagement rate. The intervention involving interactive messages three times a week for 4 weeks achieved the highest engagement rate. The intervention with increasing frequency (personalized and interactive three times a week for 2 weeks; then daily for 2 weeks) had lower engagement than intervention with constant or decreasing frequency. Engagement with two-way interactive messages was high across all intervention groups. Results suggest enhanced engagement with constant or decreasing message frequency compared to increasing frequency.

Health communication and trust in institutions during the COVID-19 lockdown in China's urban communities

Communicating health knowledge effectively at the community level is essential for shaping resilient urban governance in a pandemic period. This paper examines how three styles of community health communication, namely traditional authoritative communication (TAC), authoritative communication via social media (ACSM), and interactive communication via social media (ICSM), were associated with public trust in different types of “institutions”, namely the community administration and scientists, in a context where the respondents were in strict lockdown. This research was conducted with an online survey in February 2020 of 4595 respondents in urban China not long after the strict lockdown was introduced. Embedded in the theory of public trust in institutions during pandemic, the regressions established that traditional authoritative communication played a significant role in maintaining the public's trust in both community administrators and scientists. Interactive communication via social media damaged trust in scientists and increased trust in administrators when used effectively. It is suggested that policymakers, government officials, and healthcare professionals should not abandon traditional authoritative health communication, and greater efforts can be devoted to quality improvement. Moreover, the study highlighted the need to gain a better understanding of what the targeted audience perceive to be “good communication” before communication.