Hope messages influence health behavior intentions more than fear messages: An experimental study during COVID-19

BACKGROUND

Fear tactics were used in the pandemic of Coronavirus Disease 2019.

PURPOSE

We tested how messaging style, fear vs. hope, and differences in age and political affiliation related to intentions to engage in preventive behaviors during Coronavirus Disease 2019.

METHODS

Participants (N = 606) aged 18 to 94 were randomly assigned to receive health messages that emphasized the dangers of the virus (fear messages) or the ability of health behaviors to mitigate the impact of the virus (hope messages). The primary outcome was health behavior intentions.

DISCUSSION

Hope messaging rather than fear messaging promoted health behavior intentions with no moderation by age or political affiliation. Older and Democratic-identified adults had higher health behavior intentions. Health behaviors were mediated by death anxiety and perceived credibility of the messages.

CONCLUSION

Tailored hope messaging may improve health behaviors by increasing the credibility of messages.

Compliance in the public versus the private realm: Economic preferences, institutional trust and COVID-19 health behaviors

To what extent do economic preferences and institutional trust predict compliance with physical distancing rules during the COVID-19 pandemic? We reexamine this question by introducing the theoretical and empirical distinction between individual health behaviors in the public and in the private domain (e.g., keeping a distance from strangers vs. abstaining from private gatherings with friends). Using structural equation modeling to analyze survey data from Germany's second wave of the pandemic (N = 3350), we reveal the following major differences between compliance in both domains: Social preferences, especially (positive) reciprocity, play an essential role in predicting compliance in the public domain but are barely relevant in the private domain. Conversely, individuals' degree of trust in the national government matters predominantly for increasing compliance in the private domain. The clearly strongest predictor in this domain is the perception pandemic-related threats. Our findings encourage tailoring communication strategies to either domain-specific circumstances or factors common across domains. Tailored communication may also help promote compliance with other health-related regulatory policies beyond COVID-19.

Correlates of COVID-19 Preventative Behaviors before and after Vaccination Availability

As the COVID-19 pandemic progressed, various preventative behaviors and eventually vaccinations became available to decrease the spread of the virus. The current study examined a variety of variables (i.e., age, COVID-19-related economic hardship, interpersonal concern, personality, fear of COVID-19, normative beliefs, political beliefs, and vaccine hesitancy) to better understand predictors of preventative behaviors and vaccination status at different points throughout the pandemic. Online questionnaires, administered through Qualtrics, were used to collect data using two convenience samples. One was a small sample (N = 44) of non-student participants before the vaccine was readily available. The other sample (N = 274) included college student participants and occurred after the vaccine had been available to all participants. Results suggest that several variables (i.e., fear of COVID-19, normative beliefs, interpersonal concern, and openness) were consistent predictors of public health behaviors at both points in time and across differently aged samples. Other variables (i.e., agreeableness, extraversion, conscientiousness, and economic hardship) were less consistent with their relationships with public health behaviors. Implications related to both research and public health are discussed.

Communicating with ethnic minorities during COVID-19: An experimental test of the effect of self-, ingroup-, and intergroup-focused messages

Developing messaging to encourage minorities to adhere to health recommendations has been a complex task for governments worldwide during the COVID-19 crisis. Here, we propose and tests a new typology of messages among minorities that can be used to mobilize compliance and engagement. This typology comprises three messaging treatments emphasizing personal, ingroup, and intergroup benefits. We examine, via an experimental field study, whether there is a difference in the effect of these messages on two policy outcomes, social distancing and vaccine hesitancy, among the Arab minority living in Israel. The findings suggest that social messages, i.e., ingroup and intergroup messages, positively affect social distancing, while self-messaging harms social distancing compliance. Regarding vaccine intake, within the social messages tested, intergroup-focused messages were more effective than ingroup-focused messages for vaccination intentions only among citizens with low trust in the government. We discuss the findings in detail and propose new avenues in theory and practice to foster health policy compliance among minorities.

Combating COVID-19 with charisma: Evidence on governor speeches in the United States

Using field and laboratory data, we show that leader charisma can affect COVID-related mitigating behaviors. We coded a panel of U.S. governor speeches for charisma signaling using a deep neural network algorithm. The model explains variation in stay-at-home behavior of citizens based on their smart phone data movements, showing a robust effect of charisma signaling: stay-at-home behavior increased irrespective of state-level citizen political ideology or governor party allegiance. Republican governors with a particularly high charisma signaling score impacted the outcome more relative to Democratic governors in comparable conditions. Our results also suggest that one standard deviation higher charisma signaling in governor speeches could potentially have saved 5,350 lives during the study period (02/28/2020-05/14/2020). Next, in an incentivized laboratory experiment we found that politically conservative individuals are particularly prone to believe that their co-citizens will follow governor appeals to distance or stay at home when exposed to a speech that is high in charisma; these beliefs in turn drive their preference to engage in those behaviors. These results suggest that political leaders should consider additional "soft-power" levers like charisma-which can be learned-to complement policy interventions for pandemics or other public heath crises, especially with certain populations who may need a "nudge."

Hyperbolic modeling and assessment of hypothetical health behaviors during a viral outbreak using crowdsourced samples

The COVID-19 pandemic provided an opportunity to investigate factors related to public response to public health measures, which could help better prepare implementation of similar measures for inevitable future pandemics. To understand individual and environmental factors that influence likelihood in engaging in personal and public health measures, three crowdsourced convenience samples from Amazon Mechanical Turk (MTurk) completed likelihood-discounting tasks of engaging in health behaviors given a variety of hypothetical viral outbreak scenarios. Experiment 1 assessed likelihood of mask wearing for a novel virus. Experiment 2 assessed vaccination likelihood based on efficacy and cost. Experiment 3 assessed likelihood of seeking health care based on number of symptoms and cost of treatment. Volume-based measures and three-dimensional modeling were used to analyze hypothetical decision making. Hypothetical public and personal health participation increased as viral fatality increased and generally followed a hyperbolic function. Public health participation was moderated by political orientation and trust in science, whereas treatment-seeking was only moderated by income. Analytic methods used in this cross-sectional study predicted population-level outcomes that occurred later in the pandemic and can be extended to various health behaviors.

Scientific reasoning is associated with rejection of unfounded health beliefs and adherence to evidence-based regulations during the Covid-19 pandemic

Scientific reasoning and trust in science are two facets of science understanding. This paper examines the contribution of science understanding, over and above analytic thinking, to the endorsement of conspiracy and pseudoscientific beliefs about COVID-19 and behavioral intentions to engage in the recommended preventive behavior. We examined the direct and indirect effects of science understanding on normative health behavior in a representative sample of the Slovak population (N = 1024). The results showed more support for the indirect pathway: individuals with a better understanding of science generally had fewer epistemically suspect beliefs and as a consequence tended to behave more in line with the evidence-based guidelines and get vaccinated. Neither scientific reasoning nor trust in science directly predicted non-compliance with preventive measures, but analytic thinking correlated positively with non-compliance with preventive measures. The strongest predictor of epistemically suspect beliefs was trust in science, which also directly predicted the intention to get vaccinated against COVID-19. Therefore, reasoning about which experts or sources to believe (second-order scientific reasoning) has become more important than directly evaluating the original evidence (first-order scientific reasoning).

Supplementary information

The online version contains supplementary material available at 10.1007/s12144-023-04284-y.

Using normative language when describing scientific findings: Randomized controlled trial of effects on trust and credibility (Preprint)

BACKGROUND

Scientists often make cognitive claims (eg, the results of their work) and normative claims (eg, what should be done based on those results). Yet, these types of statements contain very different information and implications. This randomized controlled trial sought to characterize the granular effects of using normative language in science communication.

OBJECTIVE

Our study examined whether viewing a social media post containing scientific claims about face masks for COVID-19 using both normative and cognitive language (intervention arm) would reduce perceptions of trust and credibility in science and scientists compared with an identical post using only cognitive language (control arm). We also examined whether effects were mediated by political orientation.

METHODS

This was a 2-arm, parallel group, randomized controlled trial. We aimed to recruit 1500 US adults (age 18+) from the Prolific platform who were representative of the US population census by cross sections of age, race/ethnicity, and gender. Participants were randomly assigned to view 1 of 2 images of a social media post about face masks to prevent COVID-19. The control image described the results of a real study (cognitive language), and the intervention image was identical, but also included recommendations from the same study about what people should do based on the results (normative language). Primary outcomes were trust in science and scientists (21-item scale) and 4 individual items related to trust and credibility; 9 additional covariates (eg, sociodemographics, political orientation) were measured and included in analyses.

RESULTS

From September 4, 2022, to September 6, 2022, 1526 individuals completed the study. For the sample as a whole (eg, without interaction terms), there was no evidence that a single exposure to normative language affected perceptions of trust or credibility in science or scientists. When including the interaction term (study arm × political orientation), there was some evidence of differential effects, such that individuals with liberal political orientation were more likely to trust scientific information from the social media post's author if the post included normative language, and political conservatives were more likely to trust scientific information from the post's author if the post included only cognitive language (β=0.05, 95% CI 0.00 to 0.10; P=.04).

CONCLUSIONS

This study does not support the authors' original hypotheses that single exposures to normative language can reduce perceptions of trust or credibility in science or scientists for all people. However, the secondary preregistered analyses indicate the possibility that political orientation may differentially mediate the effect of normative and cognitive language from scientists on people's perceptions. We do not submit this paper as definitive evidence thereof but do believe that there is sufficient evidence to support additional research into this topic, which may have implications for effective scientific communication.

TRIAL REGISTRATION

OSF Registries osf.io/kb3yh; https://osf.io/kb3yh.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/41747.

Young people's media use and adherence to preventive measures in the "infodemic": Is it masked by political ideology?

BACKGROUND

Navigating in the COVID-19 "infodemic" and adhering to preventive measures is especially challenging for young people. The use of information sources and political ideology are empirically important factors for adherence behavior. How these two are interconnected and if political ideology on its own contributes to adherence is not yet well established in young people.

OBJECTIVE

This study investigates what role political ideology and political extremism, use of information sources, trust and risk perception play for adhering to preventive measures in young people.

METHODS

Cross-sectional online survey in a representative random sample of young people aged 15-34 in two German-speaking and one Italian-speaking canton of Switzerland. The hypotheses were tested with logistic regression and multivariate regression analysis.

RESULTS

The odds for using the following information sources decreases for young people positioning themselves towards the right pole of the ideology scale: health-based sources 0.90 (CI: 0.84-0.97), news sources 0.93 (CI 0.87-0.997) and other websites 0.83 (CI: 0.75-0.92). In contrast, the odds of using broadcasting sources increases for young people positioning themselves towards the right pole of the ideology scale (OR: 1.08, CI 1.01-1.15). The odds of using social media decreases with higher political extremism (OR 0.88, CI 0.78-0.99). Political extremism was related with lower adherence to preventive measures in young people with low trust in the government, scientists, and journalists.

CONCLUSION

Young peoples' use of information sources is associated with their political ideology and political extremism needs to be taken in account in conjunction with low trust.

Community Mitigation Strategies, Mobility, and COVID-19 Incidence Across Three Waves in the United States in 2020

BACKGROUND

Summarizing the impact of community-based mitigation strategies and mobility on COVID-19 infections throughout the pandemic is critical for informing responses and future infectious disease outbreaks. Here, we employed time-series analyses to empirically investigate the relationships between mitigation strategies and mobility on COVID-19 incident cases across US states during the first three waves of infections.

METHODS

We linked data on daily COVID-19 incidence by US state from March to December 2020 with the stringency index, a well-known index capturing the strictness of mitigation strategies, and the trip ratio, which measures the ratio of the number of trips taken per day compared with the same day in 2019. We utilized multilevel models to determine the relative impacts of policy stringency and the trip ratio on COVID-19 cumulative incidence and the effective reproduction number. We stratified analyses by three waves of infections.

RESULTS

Every five-point increase in the stringency index was associated with 2.89% (95% confidence interval = 1.52, 4.26%) and 5.01% (3.02, 6.95%) reductions in COVID-19 incidence for the first and third waves, respectively. Reducing the number of trips taken by 50% compared with the same time in 2019 was associated with a 16.2% (-0.07, 35.2%) decline in COVID-19 incidence at the state level during the second wave and 19.3% (2.30, 39.0%) during the third wave.

CONCLUSIONS

Mitigation strategies and reductions in mobility are associated with marked health gains through the reduction of COVID-19 infections, but we estimate variable impacts depending on policy stringency and levels of adherence.

Political attitude change over time following COVID-19 lockdown: Rallying effects and differences between left and right voters

Restrictions to curb the spread of COVID-19 have required widespread compliance over long periods, but citizens' attitudes to these often change over time. Here, we examine the time course of political attitudes in New Zealand over the months before and after the announcement of the country's first nationwide COVID-19 lockdown in 2020 using a large-scale national survey (Ns = 41,831-42,663). Government satisfaction increased immediately following the lockdown announcement and remained elevated 5 months later. Trust in institutions and political efficacy also increased gradually over the same period. However, these trends varied by political party vote: Compared to center-left voters who supported the largest governing party, center-right voters who supported the opposition party returned to baseline levels of government satisfaction quicker and showed more pronounced dips in their satisfaction with the economy. These same attitudes also predicted compliance with COVID-19 guidelines. Results illustrate a rally-around-the-flag effect during the pandemic and suggest that support wanes faster among center-right (opposition party) voters.

Is social capital associated with individual social responsibility? The case of social distancing during the Covid-19 pandemic

Individual social responsibility is essential to achieving the sustainable development goals of the society, yet there has been very little research on whether and how social and cultural factors influence individual social responsibility. Using the Covid-19 pandemic as our empirical context, this research examines the relationship between social capital and individual social distancing behaviors during the pandemic. Social distancing is a form of socially responsible behavior because it is critical in mitigating the spread of the Covid-19 virus. By exploiting daily mobile GPS location data, we provide strong evidence for the divergent relationships between the two constituents of social capital-civic norms and social networks-and social distancing behaviors. While civic norms are positively associated with social distancing, social networks have a negative association with social distancing. These results are consistent with a nuanced view of social capital: civic norms facilitate cooperation and self-sacrifice for the common good, whereas social networks increase individual embeddedness and hence inertia in maintaining social interactions, resulting in opposite effects on social distancing. Our results contribute to the research at the intersection of social capital and individual social responsibility by highlighting the nuanced effects of social capital on individual responses to the pandemic and provide valuable insights for policymakers and businesses in disaster management.

Jerarquización de zonas de atención prioritaria para la minimización del riesgo biológico en situación de crisis

Objetivo Proponer una herramienta para identificar sectores de población que requieren mayor atención por parte de autoridades locales o gubernamentales en situaciones de crisis biológica, considerando los factores que influyen en la adherencia a las normas de minimización de riesgos. Metodología Se implementó un algoritmo de ordenamiento, tomando como referencia las restricciones de julio del 2021 en Ecuador. El contexto del estudio se resume en siete sectores urbanos de la ciudad de Guayaquil, con una población caracterizada por un nivel de educación promedio por debajo de la educación secundaria superior (70%) y más del 50% entre 20-34 años, con alguna ocupación en el medio de una economía popular debilitada. Siete factores de riesgo fueron identificados después de un análisis estructural de la hipóótesis de adherencia (χ2/gl=3,6; CFI≥0,91; TLI≥0,90; RMSEA≤0,05), basado en una muestra aleatoria de n=515 adultos viviendo en las áreas afectadas. Resultados El seguimiento de las normas está influenciado por la percepción del clima de seguridad, el riesgo percibido y el entendimiento del riesgo. El umbral de ordenmiento (h) permite establecer relaciones unidireccionales entre variables. Conclusiones Los resultados muestran que Vergeles, Norte y Fertisa representan los sectores con mayor prioridad de atención en materia de salud pública {A4,A5,A6}>{A2}>{A3}>{A1}>{A7}. Se requiere identificar más factores para garantizar una diferenciación óptima.

Community Health Resources, Globalization, Trust in Science, and Voting as Predictors of COVID-19 Vaccination Rates: A Global Study with Implications for Vaccine Adherence

The COVID-19 global pandemic requires, not only an adequate supply of, but public adherence to safe and effective vaccinations. This study analyzes the human and economic resources and political and public attitudinal factors that influence widely varying country-level coronavirus vaccination rates. Using data on up to 95 countries, we found that countries’ strength of community health training and research (CHTR), education index, globalization, and vaccine supply are associated with a greater COVID-19 vaccination rate. In a separate analysis, certain political factors, and public attitudes (perceived government effectiveness, government fiscal decentralization, trust in science, and parliamentary voter turnout) predicted vaccination rates. Perceived corruption and actual freedoms (political rights and civil liberties) related to vaccination rates in prior studies were not significantly predictive when controlling for the above factors. The results confirm our prior findings on the importance of CHTR resources for increasing COVID-19 vaccination rates. They also suggest that to motivate vaccine adherence countries need, not only an adequate vaccine supply (which depends on a country having either its own resources or effective global political, social, and economic connections) and community health workforce training and research, but also a population that trusts in science, and is actively engaged in the political process.

The influence of social norms varies with "others" groups: Evidence from COVID-19 vaccination intentions

The theory that health behaviors spread through social groups implies that efforts to control COVID-19 through vaccination will succeed if people believe that others in their groups are getting vaccinated. But "others" can refer to many groups, including one's family, neighbors, fellow city or state dwellers, or copartisans. One challenge to examining these understudied distinctions is that many factors may confound observed relationships between perceived social norms (what people believe others do) and intended behaviors (what people themselves will do), as there are plausible common causes for both. We address these issues using survey data collected in the United States during late fall 2020 (n = 824) and spring 2021 (n = 996) and a matched design that approximates pair-randomized experiments. We find a strong relationship between perceived vaccination social norms and vaccination intentions when controlling for real risk factors (e.g., age), as well as dimensions known to predict COVID-19 preventive behaviors (e.g., trust in scientists). The strength of the relationship declines as the queried social group grows larger and more heterogeneous. The relationship for copartisans is second in magnitude to that of family and friends among Republicans but undetectable for Democrats. Sensitivity analysis shows that these relationships could be explained away only by an unmeasured variable with large effects (odds ratios between 2 and 15) on social norms perceptions and vaccination intentions. In addition, a prediction from the "false consensus" view that intentions cause perceived social norms is not supported. We discuss the implications for public health policy and understanding social norms.

The Association between the Sense of Coherence and the Self-Reported Adherence to Guidelines during the First Months of the COVID-19 Pandemic in Israel

(1) Background: Social distancing became a central strategy employed to limit the spread of the SARS-CoV-2 virus. We explore self-reported adherence (SRA) and factors associated with SRA among Israeli adults at the end of the first national lockdown in Israel. (2) Methods: We conducted a cross-sectional consumer panel survey of 820 Israeli adults aged 18 to 70 in May and June 2020. We collected data on the SRA to the social distancing measures, sociodemographic variables, perceptions of pandemic-related danger and of protection provided by the social distancing measures, as well as Sense of Coherence (SoC). (3) Results: 60% of respondents reported complying with 7 measures. Higher SoC was associated with higher SRA (p = 0.04), and was related to income, marital status, age, profession, and education. The SRA was higher among Jews than Arabs (Jews: Mean = 10.5, SD = 4.5; Arabs: Mean = 9.1, SD = 4.1, p < 0.001) and among males (Males: Mean = 10.8, SD = 4.7; Females: Mean = 9, SD = 4.1; p = 0.003). SoC, perception of protection and perception of danger were associated with higher SRA (p = 0.42, p < 0.001 and p = 0.005 respectively). Single people reported higher levels of SRA than people in relationships (Partnered: Mean = 9.7, SD = 4.2, Non-partnered: Mean = 10.9, SD = 4.7, p = 0.033). (4) Conclusions: At the time of exit from the first lockdown, compliance with social distancing measures was high, with Jewish, single and male Israelis more likely to adhere to the guidelines. We identified the populations at risk for non-adherence and associated factors, reporting for the first time the correlation between SoC and SRA. Further research is needed to assess the role of these factors in Jewish and Arab populations.

Antecedents and consequences of COVID-19 conspiracy beliefs: A systematic review

RATIONALE

Belief in COVID-19 conspiracy theories can have severe consequences; it is therefore crucial to understand this phenomenon, in its similarities with general conspiracy belief, but also in how it is context-dependent.

OBJECTIVE

The aim of this systematic review is to provide a comprehensive overview of the available research on COVID-19 conspiracy beliefs and to synthesise this research to make it widely accessible.

METHODS

We present a synthesis of COVID-19 conspiracy belief research from 85 international articles, identified and appraised through a systematic review, in line with contemporary protocols and guidelines for systematic reviews.

RESULTS

We identify a number of potential antecedents of COVID-19 conspiracy beliefs (individual differences, personality traits, demographic variables, attitudes, thinking styles and biases, group identity, trust in authorities, and social media use), their consequences (protective behaviours, self-centred and misguided behaviours such as hoarding and pseudoscientific health practices, vaccination intentions, psychological wellbeing, and other negative social consequences such as discrimination and violence), and the effect sizes of their relations with the conspiracy beliefs.

CONCLUSIONS

We conclude that understanding both the potential antecedents and consequences of conspiracy beliefs and how they are context-dependent is highly important to tackle them, whether in the COVID-19 pandemic or future threats, such as that of climate change.

COVID-19 risk perceptions of social interaction and essential activities and inequity in the USA: results from a nationally representative survey

INTRODUCTION

SARS-CoV-2 has disproportionately affected disadvantaged communities across the USA. Risk perceptions for social interactions and essential activities during the COVID-19 pandemic may vary by sociodemographic factors.

METHODS

We conducted a nationally representative online survey of 1592 adults in the USA to understand risk perceptions related to transmission of COVID-19 for social (eg, visiting friends) and essential activities (eg, medical visits or returning to work). We assessed relationships for activities using bivariate comparisons and multivariable logistic regression modelling, between responses of safe and unsafe, and participant characteristics. Data were collected and analysed in 2020.

RESULTS

Among 1592 participants, risk perceptions of unsafe for 13 activities ranged from 29.2% to 73.5%. Large gatherings, indoor dining and visits with elderly relatives had the highest proportion of unsafe responses (>58%), while activities outdoor, accessing healthcare and going to the grocery store had the lowest (<36%). Older respondents were more likely to view social gatherings and indoor activities as unsafe but less likely for other activities, such as going to the grocery store and accessing healthcare. Compared with white/Caucasian respondents, black/African-American and Hispanic/Latino respondents were more likely to view activities such as dining and visiting friends outdoor as unsafe. Generally, men versus women, Republicans versus Democrats and independents, and individuals with higher versus lower income were more likely to view activities as safe.

CONCLUSION

Evidence-based interventions should be tailored to sociodemographic differences in risk perception, access to information and health behaviours when implementing efforts to control the COVID-19 pandemic.

Intervening on Trust in Science to Reduce Belief in COVID-19 Misinformation and Increase COVID-19 Preventive Behavioral Intentions: Randomized Controlled Trial

Background

Trust in science meaningfully contributes to our understanding of people’s belief in misinformation and their intentions to take actions to prevent COVID-19. However, no experimental research has sought to intervene on this variable to develop a scalable response to the COVID-19 infodemic.

Objective

Our study examined whether brief exposure to an infographic about the scientific process might increase trust in science and thereby affect belief in misinformation and intention to take preventive actions for COVID-19.

Methods

This two-arm, parallel-group, randomized controlled trial aimed to recruit a US representative sample of 1000 adults by age, race/ethnicity, and gender using the Prolific platform. Participants were randomly assigned to view either an intervention infographic about the scientific process or a control infographic. The intervention infographic was designed through a separate pilot study. Primary outcomes were trust in science, COVID-19 narrative belief profile, and COVID-19 preventive behavioral intentions. We also collected 12 covariates and incorporated them into all analyses. All outcomes were collected using web-based assessment.

Results

From January 22, 2021 to January 24, 2021, 1017 participants completed the study. The intervention slightly improved trust in science (difference-in-difference 0.03, SE 0.01, t₁₀₀₀=2.16, P=.031). No direct intervention effect was observed on belief profile membership, but there was some evidence of an indirect intervention effect mediated by trust in science (adjusted odds ratio 1.06, SE 0.03, 95% CI 1.00-1.12, z=2.01, P=.045) on membership in the “scientific” profile compared with the others. No direct nor indirect effects on preventive behaviors were observed.

Conclusions

Briefly viewing an infographic about science appeared to cause a small aggregate increase in trust in science, which may have, in turn, reduced the believability of COVID-19 misinformation. The effect sizes were small but commensurate with our 60-second, highly scalable intervention approach. Researchers should study the potential for truthful messaging about how science works to serve as misinformation inoculation and test how best to do so.

Trial Registration

NCT04557241; https://clinicaltrials.gov/ct2/show/NCT04557241

International Registered Report Identifier (IRRID)

RR2-10.2196/24383