Effects of eHealth-Based Multiple Health Behavior Change Interventions on Physical Activity, Healthy Diet, and Weight in People With Noncommunicable Diseases: Systematic Review and Meta-analysis

Components of multiple health behaviour change interventions for patients with chronic conditions: a systematic review and meta-regression of randomized trials

Interventions addressing more than one health behaviour at a time could be an efficient way of intervening to manage chronic conditions. Within a systematic review of multiple health behaviour change (MBHC) interventions, we identified key components of interventions in patients with chronic conditions, assessed how they are linked to theory, behaviour change techniques implemented, and evaluated their impact on intervention effectiveness. Studies were identified by systematically searching five electronic databases. Subgroup analyses and meta-regressions were conducted to analyse the association between intervention components and behavioural changes. In total, 61 studies were included spanning different chronic conditions (e.g., cardiovascular conditions, type 2 diabetes). Most interventions sought to change behaviours simultaneously (72%), often targeting the 'physical activity, diet and smoking' cluster of behaviours (33%), and were not theory informed (55%). A total of 36 behaviour change techniques were identified, most commonly goal setting behaviour and self-monitoring of behaviour. Subgroup analyses indicated that MHBC interventions delivered entirely face-to-face might not be as effective for physical activity outcomes, and not using goal setting (behaviour) might be more effective for smoking cessation outcomes. Meta-regressions indicated that a longer intervention duration may work best to achieve better physical activity outcomes. This review provides a comprehensive understanding of interventions and contributes to the field of MHBC by facilitating data-driven insights for future optimisation and dissemination.

Moderators of a Diet and Physical Activity Intervention: who Responds Best to Sequential vs. Simultaneous Approaches

BACKGROUND

Given that low physical activity levels and poor dietary intake are co-occurring risk factors for chronic disease, there is a need for interventions that target both health behaviors, either sequentially or simultaneously. Little is known about participant characteristics that are associated with better or worse response to sequential and simultaneous interventions.

METHOD

The 12-month Counseling Advice for Lifestyle Management (CALM) randomized trial (N = 150; Mage = 55.3 years) targeted these two behaviors either via a sequential approach - dietary advice first then exercise advice added ("Diet-First") or exercise advice first then dietary advice added ("Exercise-First") - or via a simultaneous approach. The objective was to examine demographic, clinical, and psychosocial moderators of intervention effects on 12-month change in (1) moderate-to-vigorous physical activity (MVPA), (2) fruit/vegetable intake, (3) caloric intake from saturated fat, and (4) weight. Hierarchical regressions first compared Diet-First to Exercise-First, followed by comparisons of these arms combined ("sequential") to the simultaneous arm.

RESULTS

Older age, higher baseline BMI, and lower social support were associated with higher MVPA in Exercise-First vs. Diet-First, while lower tangible support was associated with higher fruit/vegetable intake in Exercise-First but not in Diet-First. Poor sleep was associated with higher levels of MVPA in the sequential arm than in the simultaneous arm. Lower vitality was associated with greater weight loss in the sequential arm than in the simultaneous arm, while the opposite was true for those who were not married.

CONCLUSION

Identifying moderators of treatment response can allow the behavioral medicine field to enhance intervention efficacy by matching participant subgroups to their best-fitting interventions.

TRIAL REGISTRATION

NCT00131105.

Effect of healthy dietary intention-behavior (in)consistency on depression and anxiety in the process of behavior change

Although an increasing number of people are now committed to pursuing a healthy diet, it remains unclear how mental health changes during this process. The present study aimed to examine the combined effect of healthy dietary intention and behavior on depression and anxiety across two sub-studies. This study consisted of two parts: a cross-sectional survey (Study 1) involving 1,433 college students and an 11-day daily diary study (Study 2) with 117 college students. Polynomial regression and response surface analysis indicated that in cases of congruence, individuals' intention and behavior align at a high level and were associated with lower levels of depression and anxiety in the motivational phase but were not found similar association in the volitional phase. In cases of incongruence, individuals with high intention-low behavior tend to experience lower levels of depression and anxiety in the motivational phase. However, individuals with high intention-low behavior tend to experience higher levels of depression and anxiety in the volitional phase. These findings not only enrich the current understanding of diet and health but also contribute to the development of holistic strategies for promoting a healthy diet.

An mHealth Intervention With Financial Incentives to Promote Smoking Cessation and Physical Activity Among Black Adults: Protocol for a Feasibility Randomized Controlled Trial

BACKGROUND

Black adults in the United States experience disproportionately high rates of tobacco- and obesity-related diseases, driven in part by disparities in smoking cessation and physical activity. Smartphone-based interventions with financial incentives offer a scalable solution to address these health disparities.

OBJECTIVE

This study aims to assess the feasibility and preliminary efficacy of a mobile health intervention that provides financial incentives for smoking cessation and physical activity among Black adults.

METHODS

A total of 60 Black adults who smoke (≥5 cigarettes/d) and are insufficiently physically active (engaging in <150 min of weekly moderate-intensity physical activity) will be randomly assigned to either HealthyCells intervention (incentives for smoking abstinence only) or HealthyCells+ intervention (incentives for both smoking abstinence and daily step counts). Participants will use study-provided smartphones, smartwatches, and carbon monoxide monitors for 9 weeks (1 wk prequit date through 8 wk postquit date). Feasibility will be evaluated based on recruitment rates, retention, and engagement. The primary outcomes include carbon monoxide-verified, 7-day smoking abstinence at 8 weeks postquit date and changes in average daily step count. Feasibility benchmarks include a recruitment rate of ≥5 participants per month, a retention rate of ≥75%, and a smoking abstinence rate of ≥20% at 8 weeks postquit date. Expected increases in physical activity include a net gain of 500 to 1500 steps per day compared to baseline.

RESULTS

Recruitment is expected to begin in February 2025 and conclude by September 2025, with data analysis completed by October 2025.

CONCLUSIONS

This study will evaluate the feasibility of a culturally tailored mobile health intervention combining financial incentives for smoking cessation and physical activity promotion. Findings will inform the design of larger-scale trials to address health disparities through scalable, technology-based approaches.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05188287; https://clinicaltrials.gov/ct2/show/NCT05188287.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/69771.

Improving Cooking Skills, Lifestyle Behaviors, and Clinical Outcomes for Adults at Risk for Cardiometabolic Disease: Protocol for a Randomized Teaching Kitchen Multisite Trial (TK-MT)

BACKGROUND/OBJECTIVES

This protocol describes a study to investigate the feasibility and preliminary efficacy of a novel Teaching Kitchen Multisite Trial (TK-MT) for adults with cardiometabolic abnormalities. The TK-MT protocol describes a hybrid lifestyle intervention combining in-person and virtual instruction in culinary skills, nutrition education, movement, and mindfulness with community support and behavior change strategies. This 18-month-long randomized controlled trial aims to evaluate the feasibility of implementing a 12-month, 24 class program, assess preliminary study efficacy, and identify barriers and facilitators to implementation.

METHODS

The intervention program includes 16 weeks of intensive hands-on culinary and lifestyle education classes followed by eight monthly virtual classes. Psychometric assessments and biometric data will be collected at baseline, 4, 12, and 18 months. Semi-structured interviews and open-ended surveys will be conducted during the 12-month follow-up assessment.

RESULTS

Feasibility will be assessed through recruitment, attendance, and fidelity data. Secondary outcomes will analyze changes in health behaviors, biometric data, and anthropometric measures using mixed-effects regression models. Qualitative data will undergo thematic analysis.

CONCLUSIONS

As envisioned and described in detail in this manuscript, this study will inform the development and implementation of reproducible, scalable teaching kitchen interventions. The protocol described here is intended to set the stage for future investigations to evaluate evidence for the impact of teaching kitchen interventions on dietary habits, physical activity, and overall health and well-being.

Umbrella review of social inequality in digital interventions targeting dietary and physical activity behaviors

Digital interventions are increasingly utilized as a lever to promote population health, yet not everyone may equally benefit from them. This umbrella review pooled the insights from available systematic and scoping reviews regarding potential social inequalities in digital intervention uptake, engagement and effectiveness, focusing on the promotion of weight-related behaviors (diet, physical activity, sedentary behavior) and weight loss (maintenance) in adults. Six databases were searched from 1970 to October 2023. Forty-six reviews were included, of which most focused on physical activity and intervention effectiveness. Age and gender/ sex differences were most frequently studied. Most reviews found digital interventions to be effective irrespective of age, while men benefitted more from digital interventions than women. Other inequality indicators (e.g., income, education) were rarely studied, despite them being potential causes of a digital divide. A more systematic and thorough exploration of inequalities in digital health is required to promote health for all.

Optimization of a Web-Based Self-Assessment Tool for Preconception Health in People of Reproductive Age in Australia: User Feedback and User-Experience Testing Study

Background

Good preconception health reduces the incidence of preventable morbidity and mortality for women, their babies, and future generations. In Australia, there is a need to increase health literacy and awareness about the importance of good preconception health. Digital health tools are a possible enabler to increase this awareness at a population level. The Healthy Conception Tool (HCT) is an existing web-based, preconception health self-assessment tool, that has been developed by academics and clinicians.

Objective

This study aims to optimize the HCT and to seek user feedback to increase the engagement and impact of the tool.

Methods

In-depth interviews were held with women and men aged 18-41 years, who spoke and read English and were residing in Australia. Interview transcripts were analyzed, and findings were used to inform an enhanced HCT prototype. This prototype underwent user-experience testing and feedback from users to inform a final round of design changes to the tool.

Results

A total of 20 women and 5 men were interviewed; all wanted a tool that was quick and easy to use with personalized results. Almost all participants were unfamiliar with the term "preconception care" and stated they would not have found this tool on the internet with its current title. User-experience testing with 6 women and 5 men identified 11 usability issues. These informed further changes to the tool's title, the information on how to use the tool, and the presentation of results.

Conclusions

Web-based self-assessment tools need to be easy to find and should communicate health messages effectively. End users' feedback informed changes to improve the tool's acceptability, engagement, and impact. We expect that the revised tool will have greater reach and prompt more people to prepare well for pregnancy.

Targeting Key Risk Factors for Cardiovascular Disease in At-Risk Individuals: Developing a Digital, Personalized, and Real-Time Intervention to Facilitate Smoking Cessation and Physical Activity

Health care is under pressure due to an aging population with an increasing prevalence of chronic diseases, including cardiovascular disease. Smoking and physical inactivity are 2 key preventable risk factors for cardiovascular disease. Yet, as with most health behaviors, they are difficult to change. In the interdisciplinary Perfect Fit project, scientists from different fields join forces to develop an evidence-based virtual coach (VC) that supports smokers in quitting smoking and increasing their physical activity. In this Viewpoint paper, intervention content, design, and implementation, as well as lessons learned, are presented to support other research groups working on similar projects. A total of 6 different approaches were used and combined to support the development of the Perfect Fit VC. The approaches used are (1) literature reviews, (2) empirical studies, (3) collaboration with end users, (4) content and technical development sprints, (5) interdisciplinary collaboration, and (6) iterative proof-of-concept implementation. The Perfect Fit intervention integrates evidence-based behavior change techniques with new techniques focused on identity change, big data science, sensor technology, and personalized real-time coaching. Intervention content of the virtual coaching matches the individual needs of the end users. Lessons learned include ways to optimally implement and tailor interactions with the VC (eg, clearly explain why the user is asked for input and tailor the timing and frequency of the intervention components). Concerning the development process, lessons learned include strategies for effective interdisciplinary collaboration and technical development (eg, finding a good balance between end users' wishes and legal possibilities). The Perfect Fit development process was collaborative, iterative, and challenging at times. Our experiences and lessons learned can inspire and benefit others. Advanced, evidence-based digital interventions, such as Perfect Fit, can contribute to a healthy society while alleviating health care burden.

Literature Searches in Medical Informatics Systematic Reviews: Suggested Approaches

This study explores database selection for systematic reviews in medical informatics, addressing challenges researchers face in maximizing relevant article retrieval. Systematic reviews from top medical informatics journals in 2021 were analyzed, divided into randomized control trials and non-randomized control trials groups. Four databases were evaluated based on Recall, Precision, and Unique references. Findings revealed that for randomized control trials, the best combination was PubMed, Embase, and Web of Science, while for the non-restricted group, recommended combination included PubMed, Embase, Web of Science, and Scopus, highlighting effective literature search strategies.

Comparative effects of behaviour change techniques using eHealth and mHealth in promoting dietary behaviour: protocol for a systematic review and component network meta-analysis

INTRODUCTION

Globally, it is estimated that dietary habits contribute to 22% of adult deaths and 15% of disability-adjusted life years, highlighting the critical role of dietary behaviour in public health. Despite the known benefits of healthy eating, many individuals find it challenging to change their diet for disease prevention. eHealth and mHealth interventions using behaviour change techniques (BCTs) have emerged as promising strategies to address this issue. However, the specific BCTs that are most effective in promoting dietary behaviour are not well established. This systematic review and component network meta-analysis (CNMA) aims to estimate the effect size of each BCT on fostering healthy eating.

METHODS AND ANALYSIS

We will include randomised controlled trials that assess the effects of eHealth and mHealth interventions on promoting changes in dietary behaviours among healthy adults. Studies with a minimum follow-up period of 3 weeks will be considered. Searches will be conducted in MEDLINE [PubMed], Embase [Dialogue], Cochrane Central Register of Controlled Trials, PsycInfo [Dialogue], ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform and the University Hospital Medical Information Network Clinical Trials Registry on 27 January 2024. Two independent reviewers will conduct title and abstract screening followed by a full-text review. Disagreements will be resolved through discussion or consultation with a third reviewer. The primary outcome is dietary behaviour, as measured by changes in the diet quality score and the intake of a specific food. Our data synthesis will apply a frequentist random-effects model for pairwise meta-analysis, network meta-analysis and an additive CNMA model to compute the effect size of each BCT. This methodological approach will reveal the positive and negative effects of each BCT and provide a ranking of these techniques, considering both direct and indirect evidence.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review because it uses existing published data. These results will be submitted for publication in a peer-reviewed journal. The current protocol was submitted to PROSPERO on 16 January 2024 (CRD 42024502217).

Frail Older Adults' Needs and Preferences for Mobile Health Exercise Interventions Guided by Nudge Theory: AQualitative Analysis

AIM

To explore frail older adults' preferences and needs regarding mobile health (mHealth) exercise interventions in China. Additionally, it sought to identify the nudge strategies necessary for initiating and sustaining exercise behaviours among frail older adults.

DESIGN

A qualitative study.

METHOD

The semi-structured interviews were conducted between April and May 2024 from two communities in Changsha, China. The data were analysed using a deductive framework analysis aligned to nudge theory, and an inductive thematic analysis to gather relevant needs and preferences.

RESULTS

This study involved 14 participants with pre-frailty or frailty, aged 60-82 years (median age of 64 years). While participants were generally receptive to new technologies, lower levels of health literacy and competing priorities often hindered their participation. Three primary functionality requirements were as follows. (1) Profession engagement: tailored exercise prescription, professional and timely feedback and guidance; (2) personalised knowledge encompassing pain management, successful cases and inspiration; (3) beneficial, tailored, dynamic, fragmented, challenging exercise courses. Participants showed positive attitudes towards simplification nudges, gamification nudges, social nudges, trustworthy nudges, reminder nudges, economic nudges, feedback nudges and pre-commitment nudges. Addressing privacy concerns was essential to build trust and acceptance among older adults.

CONCLUSION

These findings emphasised the importance of designing mHealth interventions that address frail older adults' specific needs and preferences while incorporating effective nudge strategies to promote engagement and adherence. Future researchers should explore wearables, ChatGPT language models, virtual coaching assistants, exercise snack to further optimise the experience and analyse the effects of nudges in mHealth exercise interventions among older adults.

IMPLICATION FOR THE PROFESSION AND/OR PATIENT CARE

Exercise systems or app development for frail older adults should meet three basic functionality and essential nudge strategies.

REPORTING METHOD

The consolidated criteria for reporting qualitative research (COREQ) guidelines were used for reporting.

PATIENT OR PUBLIC CONTRIBUTION

Older adults' engagement and interview data contribute a lot.

Assessing the Effectiveness of eHealth Interventions to Manage Multiple Lifestyle Risk Behaviors Among Older Adults: Systematic Review and Meta-Analysis

BACKGROUND

Developing adverse lifestyle behaviors increases the risk of a variety of chronic age-related diseases, including cardiovascular disease, obesity, and Alzheimer disease. There is limited evidence regarding the effectiveness of eHealth-based multiple health behavior change (MHBC) interventions to manage lifestyle risk behaviors.

OBJECTIVE

The purpose of this systematic evaluation was to assess the effectiveness of eHealth MHBC interventions in changing ≥2 major lifestyle risk behaviors in people aged ≥50 years.

METHODS

The literature search was conducted in 6 electronic databases-PubMed, Embase, Web of Science, Scopus, Cochrane Library, and SPORTDiscus-from inception to May 1, 2024. Eligible studies were randomized controlled trials of eHealth interventions targeting ≥2 of 6 behaviors of interest: alcohol use, smoking, diet, physical activity (PA), sedentary behavior, and sleep.

RESULTS

A total of 34 articles with 35 studies were included. eHealth-based MHBC interventions significantly increased smoking cessation rates (odds ratio 2.09, 95% CI 1.62-2.70; P<.001), fruit intake (standardized mean difference [SMD] 0.18, 95% CI 0.04-0.32; P=.01), vegetable intake (SMD 0.17, 95% CI 0.05-0.28; P=.003), self-reported total PA (SMD 0.22, 95% CI 0.02-0.43; P=.03), and objectively measured moderate to vigorous PA (SMD 0.25, 95% CI 0.09-0.41; P=.002); in addition, the interventions decreased fat intake (SMD -0.23, 95% CI -0.33 to -0.13; P<.001). No effects were observed for alcohol use, sedentary behavior, or sleep. A sensitivity analysis was conducted to test the robustness of the pooled results. Moreover, the certainty of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) framework.

CONCLUSIONS

eHealth-based MHBC interventions may be a promising strategy to increase PA, improve diet, and reduce smoking among older adults. However, the effect sizes were small. Further high-quality, older adult-oriented research is needed to develop eHealth interventions that can change multiple behaviors.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42023444418; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023444418.

Electronic Health Literacy Scale-Web3.0 for Older Adults with Noncommunicable Diseases: Validation Study

BACKGROUND

In the current digital era, eHealth literacy plays an indispensable role in health care and self-management among older adults with noncommunicable diseases (NCDs). Measuring eHealth literacy appropriately and accurately ensures the successful implementation and evaluation of pertinent research and interventions. However, existing eHealth literacy measures focus mainly on individuals' abilities of accessing and comprehending eHealth information (Web1.0), whereas the capabilities for web-based interaction (Web2.0) and using eHealth information (Web3.0) have not been adequately evaluated.

OBJECTIVE

This study aimed to examine the reliability, validity, and measurement invariance of the eHealth Literacy Scale-Web3.0 (eHLS-Web3.0) among older adults with NCDs.

METHODS

A total of 642 Chinese older adults with NCDs (mean age 65.78, SD 3.91 years; 55.8% female) were recruited in the baseline assessment, of whom 134 (mean age 65.63, SD 3.99 years; 58.2% female) completed the 1-month follow-up assessment. Baseline measures included the Chinese version of the 24-item 3D eHLS-Web3.0, the Chinese version of the 8-item unidimensional eHealth Literacy Scale (eHEALS), and demographic information. Follow-up measures included the 24-item eHLS-Web3.0 and accelerometer-measured physical activity and sedentary behavior. A series of statistical analyses, for example, Cronbach α, composite reliability coefficient (CR), confirmatory factor analysis (CFA), and multigroup CFA, were performed to examine the internal consistency and test-retest reliabilities, as well as the construct, concurrent, convergent, discriminant, and predictive validities, and the measurement invariance of the eHLS-Web3.0 across gender, education level, and residence.

RESULTS

Cronbach α and CR were within acceptable ranges of 0.89-0.94 and 0.90-0.97, respectively, indicating adequate internal consistency of the eHLS-Web3.0 and its subscales. The eHLS-Web3.0 also demonstrated cross-time stability, with baseline and follow-up measures showing a significant intraclass correlation of 0.81-0.91. The construct validity of the 3D structure model of the eHLS-Web3.0 was supported by confirmatory factor analyses. The eHLS-Web3.0 exhibited convergent validity with an average variance extracted value of 0.58 and a CR value of 0.97. Discriminant validity was supported by CFA results for a proposed 4-factor model integrating the 3 eHLS-Web3.0 subscales and eHEALS. The predictive validity of the eHLS-Web3.0 for health behaviors was supported by significant associations of the eHLS-Web3.0 with light physical activity (β=.36, P=.004), moderate to vigorous physical activity (β=.49, P<.001), and sedentary behavior (β=-.26, P=.002). Finally, the measurement invariance of the eHLS-Web3.0 across gender, education level, and residence was supported by the establishment of configural, metric, strong, and strict invariances.

CONCLUSIONS

The present study provides timely empirical evidence on the reliability, validity, and measurement invariance of the eHLS-Web3.0, suggesting that the 24-item 3D eHLS-Web3.0 is an appropriate and valid tool for measuring eHealth literacy among older adults with NCDs within the Web3.0 sphere.

Digital Peer-Supported App Intervention to Promote Physical Activity Among Community-Dwelling Older Adults: Nonrandomized Controlled Trial

BACKGROUND

The use of mobile apps has promoted physical activity levels. Recently, with an increasing number of older adults accessing the internet, app-based interventions may be feasible in older populations. Peer support-based interventions have become a common method for promoting health-related behavior change. To our knowledge, the feasibility of using digital peer support apps (DPSAs) to increase physical activity among older adults and its impact on physical activity and physical function have not been investigated.

OBJECTIVE

This study aims to assess the feasibility of using DPSAs in older adults and to assess changes in physical activity and physical function in DPSA users.

METHODS

We conducted a nonrandomized controlled trial of older adults aged ≥65 years. We recruited participants for 2 distinct 12-week programs designed to increase physical activity. Participants could choose between an intervention group (app program and exercise instruction) or a control group (exercise instruction only). DPSA creates a group chat for up to 5 people with a common goal, and participants anonymously post to each other in the group. Once a day, participants posted a set of their step counts, photos, and comments on a group chat box. The intervention group used the DPSA after receiving 2 face-to-face lectures on its use. The participants were characterized using questionnaires, accelerometers, and physical function assessments. The feasibility of the DPSA was assessed using retention and adherence rates. Physical activity was assessed using accelerometers to measure the daily step count, light intensity physical activity, moderate to vigorous intensity physical activity (MVPA), and sedentary behavior. Physical function was assessed using grip strength and the 30-second chair-stand test.

RESULTS

The participants in the intervention group were more frequent users of apps, were more familiar with information and communication technology, and had a higher baseline physical activity level. The retention and adherence rates for the DPSA intervention were 88% (36/41) and 87.7%, respectively, indicating good feasibility. Participants in the intervention group increased their step count by at least 1000 steps and their MVPA by at least 10 minutes using the DPSA. There was a significant difference in the interaction between groups and intervention time points in the daily step count and MVPA (step count, P=.04; duration of MVPA, P=.02). The DPSA increased physical activity, especially in older adults with low baseline physical activity levels.

CONCLUSIONS

The feasibility of DPSA was found to be good, with the intervention group showing increases in daily steps and MVPA. The effects of DPSA on step count, physical activity, and physical function in older adults with low baseline physical activity should be investigated using randomized controlled trials.

Effectiveness of Interventions for Changing More Than One Behavior at a Time to Manage Chronic Conditions: A Systematic Review and Meta-analysis

BACKGROUND

Health behaviors play a significant role in chronic disease management. Rather than being independent of one another, health behaviors often co-occur, suggesting that targeting more than one health behavior in an intervention has the potential to be more effective in promoting better health outcomes.

PURPOSE

We aimed to conduct a systematic review and meta-analysis of randomized trials of interventions that target more than one behavior to examine the effectiveness of multiple health behavior change interventions in patients with chronic conditions.

METHODS

Five electronic databases (Web of Science, PubMed, CINAHL, EMBASE, and Cochrane) were systematically searched in November 2023, and studies included in previous reviews were also consulted. We included randomized trials of interventions aiming to change more than one health behavior in individuals with chronic conditions. Two independent reviewers screened and extracted data, and used Cochrane's Risk of Bias 2 tool. Meta-analyses were conducted to estimate the effects of interventions on change in health behaviors. Results were presented as Cohen's d for continuous data, and risk ratio for dichotomous data.

RESULTS

Sixty-one studies were included spanning a range of chronic diseases: cardiovascular (k = 25), type 2 diabetes (k = 15), hypertension (k = 10), cancer (k = 7), one or more chronic conditions (k = 3), and multiple conditions (k = 1). Most interventions aimed to change more than one behavior simultaneously (rather than in sequence) and most targeted three particular behaviors at once: "physical activity, diet and smoking" (k = 20). Meta-analysis of 43 eligible studies showed for continuous data (k = 29) a small to substantial positive effect on behavior change for all health behaviors (d = 0.081-2.003) except for smoking (d = -0.019). For dichotomous data (k = 23) all analyses showed positive effects of targeting more than one behavior on all behaviors (RR = 1.026-2.247).

CONCLUSIONS

Targeting more than one behavior at a time is effective in chronic disease management and more research should be directed into developing the science of multiple behavior change.

Effective management of sedentary behavior among Indian university students: An empirical exploration into health-related behavior

BACKGROUND

The past few years have witnessed a notable rise in sedentary tendencies, unveiling a modern era of prolonged stillness and diminished physical engagement. This study sought to assess the feasibility of a digital health intervention (DHI) to reduce overall sedentary behavior among university students. The study also identifies distinct subgroups within Indian universities that exhibit a heightened propensity for engaging in unhealthy behaviors.

MATERIALS AND METHODS

The research design used was a quasi-experimental (pre-post) design. A total of 500 participants were selected using a simple randomized sampling method (250 belonging to the control group and 250 belonging to the experimental group). These participants actively engaged in the study for 2 weeks. The participants completed the Sedentary Behavior Questionnaire (SBQ) before the intervention to evaluate their level of sedentary behavior. To evaluate the impact of the intervention on subjectively measured sedentary behavior, statistical analyses were conducted using the paired-samples t-test and analysis of covariance (ANCOVA) with the post hoc Bonferroni test.

RESULTS

The findings demonstrated a significant t-value of sedentary behavior for the entire group, with t(249) = 4.88, P < .05. Furthermore, the F-value of 28.787 indicated a statistically significant difference in the sedentary behavior between the experimental and control groups. When considering female university students specifically, the t-value for sedentary behavior was significant at t(105) = 3.22, P < .05, and for male university students, the t-value for sedentary behavior was found to be significant at t(143) = 3.69, P < .05.

CONCLUSION

Smartphone-based health interventions targeting sedentary behavior reduction demonstrated promising outcomes in facilitating health behavior change among university students.

Can Digital Technologies Be Useful for Weight Loss in Individuals with Overweight or Obesity? A Systematic Review

Digital technologies have greatly developed and impacted several aspects of life, including health and lifestyle. Activity tracking, mobile applications, and devices may also provide messages and goals to motivate adopting healthy behaviors, namely physical activity and dietary changes. This review aimed to assess the effectiveness of digital resources in supporting behavior changes, and thus influencing weight loss, in people with overweight or obesity. A systematic review was conducted according to the PRISMA guidelines. The protocol was registered in PROSPERO (CRD42023403364). Randomized Controlled Trials published from the database's inception to 8 November 2023 and focused on digital-based technologies aimed at increasing physical activity for the purpose of weight loss, with or without changes in diet, were considered eligible. In total, 1762 studies were retrieved and 31 met the inclusion criteria. Although they differed in the type of technology used and in their design, two-thirds of the studies reported significantly greater weight loss among electronic device users than controls. Many of these studies reported tailored or specialist-guided interventions. The use of digital technologies may be useful to support weight-loss interventions for people with overweight or obesity. Personalized feedback can increase the effectiveness of new technologies in motivating behavior changes.

Effects of eHealth Interventions on 24-Hour Movement Behaviors Among Preschoolers: Systematic Review and Meta-Analysis

BACKGROUND

The high prevalence of unhealthy movement behaviors among young children remains a global public health issue. eHealth is considered a cost-effective approach that holds great promise for enhancing health and related behaviors. However, previous research on eHealth interventions aimed at promoting behavior change has primarily focused on adolescents and adults, leaving a limited body of evidence specifically pertaining to preschoolers.

OBJECTIVE

This review aims to examine the effectiveness of eHealth interventions in promoting 24-hour movement behaviors, specifically focusing on improving physical activity (PA) and sleep duration and reducing sedentary behavior among preschoolers. In addition, we assessed the moderating effects of various study characteristics on intervention effectiveness.

METHODS

We searched 6 electronic databases (PubMed, Ovid, SPORTDiscus, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials) for experimental studies with a randomization procedure that examined the effectiveness of eHealth interventions on 24-hour movement behaviors among preschoolers aged 2 to 6 years in February 2023. The study outcomes included PA, sleep duration, and sedentary time. A meta-analysis was conducted to assess the pooled effect using a random-effects model, and subgroup analyses were conducted to explore the potential effects of moderating factors such as intervention duration, intervention type, and risk of bias (ROB). The included studies underwent a rigorous ROB assessment using the Cochrane ROB tool. Moreover, the certainty of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) assessment.

RESULTS

Of the 7191 identified records, 19 (0.26%) were included in the systematic review. The meta-analysis comprised a sample of 2971 preschoolers, which was derived from 13 included studies. Compared with the control group, eHealth interventions significantly increased moderate to vigorous PA (Hedges g=0.16, 95% CI 0.03-0.30; P=.02) and total PA (Hedges g=0.37, 95% CI 0.02-0.72; P=.04). In addition, eHealth interventions significantly reduced sedentary time (Hedges g=-0.15, 95% CI -0.27 to -0.02; P=.02) and increased sleep duration (Hedges g=0.47, 95% CI 0.18-0.75; P=.002) immediately after the intervention. However, no significant moderating effects were observed for any of the variables assessed (P>.05). The quality of evidence was rated as "moderate" for moderate to vigorous intensity PA and sedentary time outcomes and "low" for sleep outcomes.

CONCLUSIONS

eHealth interventions may be a promising strategy to increase PA, improve sleep, and reduce sedentary time among preschoolers. To effectively promote healthy behaviors in early childhood, it is imperative for future studies to prioritize the development of rigorous comparative trials with larger sample sizes. In addition, researchers should thoroughly examine the effects of potential moderators. There is also a pressing need to comprehensively explore the long-term effects resulting from these interventions.

TRIAL REGISTRATION

PROSPERO CRD42022365003; http://tinyurl.com/3nnfdwh3.

The use of internet-based smartphone apps consistently improved consumers' healthy eating behaviors: a systematic review of randomized controlled trials

Introduction

Digital tools, such as mobile apps and the Internet, are being increasingly used to promote healthy eating habits. However, there has been inconsistent reporting on the effectiveness of smartphones and web-based apps in influencing dietary behaviors. Moreover, previous reviews have been limited in scope, either by focusing on a specific population group or by being outdated. Therefore, the purpose of this review is to investigate the impacts of smartphone- and web-based dietary interventions on promoting healthy eating behaviors worldwide.

Methods

A systematic literature search of randomized controlled trials was conducted using databases such as Google Scholar, PubMed, Global Health, Informit, Web of Science, and CINAHL (EBSCO). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to prepare the entire document. EndNote (version 20) was used for reference management. The risk of bias in the articles was assessed using the "Revised Cochrane Risk of Bias tool for randomized trials (RoB 2.0)" by the Cochrane Collaboration. Narrative synthesis, using text and tables, was used to present the results. The study was registered in PROSPERO under protocol number CRD42023464315.

Results

This review analyzed a total of 39 articles, which consisted of 25 smartphone-based apps and 14 web-based apps. The studies involved a total of 14,966 participants. Out of the 25 studies, 13 (52%) showed that offline-capable smartphone apps are successful in promoting healthier eating habits. The impact of smartphone apps on healthy adults has been inconsistently reported. However, studies have shown their effectiveness in chronically ill patients. Likewise, internet-based mobile apps, such as social media or nutrition-specific apps, have been found to effectively promote healthy eating behaviors. These findings were consistent across 14 studies, which included healthy adults, overweight or obese adults, chronically ill patients, and pregnant mothers.

Conclusion

Overall, the findings suggest that smartphone apps contribute to improving healthy eating behaviors. Both nutrition-specific and social media-based mobile apps consistently prove effective in promoting long-term healthy eating habits. Therefore, policymakers in the food system should consider harnessing the potential of internet-based mobile apps and social media platforms to foster sustainable healthy eating behaviors.

Long-term follow-up of web-based and group-based behavioural intervention in NAFLD in a real world clinical setting

BACKGROUND

The long-term results of web-based behavioural intervention in non-alcoholic fatty liver disease (NAFLD) have not been described in patients followed in specialised centres.

AIMS

To analyse the long-term effectiveness of web education compared with the results achieved by a group-based behavioural intervention in the same years 2012-2014.

METHODS

We followed 679 patients with NAFLD (web-based, n = 290; group-based, n = 389) for 5 years. Weight loss ≥10% was the primary outcome; secondary outcomes were attrition, changes in liver enzymes and in biomarkers of steatosis (Fatty liver Index) and fibrosis (Fibrosis-4 index).

RESULTS

The cohorts differed in age, education, working status and presence of diabetes. Attrition was higher in the web-based cohort (hazard ratio: 1.53; 95% CI: 1.24-1.88), but not different after adjustment for confounders. Among patients in active follow-up, 50% lost ≥5% of initial body weight and 19% lost ≥10%, without difference between cohorts. Alanine aminotransferase levels fell to within the normal range in 51% and 45% of web- and group-based cohorts, respectively. Fatty Liver Index declined progressively and, by year 5, it ruled out steatosis in 4.8%, whereas 24.9% were in the indeterminate range. Fibrosis-4 index increased in both cohorts, driven by age, but the prevalence of cases ruling-in advanced fibrosis remained very low (around 1%). Improvements in the class of both surrogate biomarkers were associated with ≥5% weight loss.

CONCLUSIONS

Although burdened by attrition, web-based behavioural intervention is feasible and effective in NAFLD, expanding the cohort involved in behavioural programs and reducing the risk of progressive disease.

Protocol of a mixed-methods evaluation of Perfect Fit: A personalized mHealth intervention with a virtual coach to promote smoking cessation and physical activity in adults

Objective

Adopting healthy behavior is vital for preventing chronic diseases. Mobile health (mHealth) interventions utilizing virtual coaches (i.e., artificial intelligence conversational agents) can offer scalable and cost-effective solutions. Additionally, targeting multiple unhealthy behaviors, like low physical activity and smoking, simultaneously seems beneficial. We developed Perfect Fit, an mHealth intervention with a virtual coach providing personalized feedback to simultaneously promote smoking cessation and physical activity. Through innovative methods (e.g., sensor technology) and iterative development involving end-users, we strive to overcome challenges encountered by mHealth interventions, such as shortage of evidence-based interventions and insufficient personalization. This paper outlines the content of Perfect Fit and the protocol for evaluating its feasibility, acceptability, and preliminary effectiveness, the role of participant characteristics, and the study's feasibility.

Methods

A single-arm, mixed-method, real-world evaluation study will be conducted in the Netherlands. We aim to recruit 100 adult daily smokers intending to quit within 6 weeks. The personalized intervention will last approximately 16 weeks. Primary outcomes include Perfect Fit's feasibility and acceptability. Secondary outcomes are preliminary effectiveness and study feasibility, and we will measure participant characteristics. Quantitative data will be collected through questionnaires administered at baseline, post-intervention and 2, 6, and 12 months post-intervention. Qualitative data will be gathered via semi-structured interviews post-intervention. Data analysis will involve descriptive analyses, generalized linear mixed models (quantitative) and the Framework Approach (qualitative), integrating quantitative and qualitative data during interpretation.

Conclusions

This study will provide novel insight into the potential of interventions like Perfect Fit, as a multiple health behavior change strategy. Findings will inform further intervention development and help identify methods to foster feasibility and acceptability. Successful mHealth interventions with virtual coaches will prevent chronic diseases and promote public health.

Effectiveness of holistic mobile health interventions on diet, and physical, and mental health outcomes: a systematic review and meta-analysis

Background

Good physical and mental health are essential for healthy ageing. Holistic mobile health (mHealth) interventions-including at least three components: physical activity, diet, and mental health-could support both physical and mental health and be scaled to the population level. This review aims to describe the characteristics of holistic mHealth interventions and their effects on related behavioural and health outcomes among adults from the general population.

Methods

In this systematic review and meta-analysis, we searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, Scopus, China National Knowledge Infrastructure, and Google Scholar (first 200 records). The initial search covered January 1, 2011, to April 13, 2022, and an updated search extended from April 13, 2022 to August 30, 2023. Randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs) were included if they (i) were delivered via mHealth technologies, (ii) included content on physical activity, diet, and mental health, and (iii) targeted adults (≥18 years old) from the general population or those at risk of non-communicable diseases (NCDs) or mental disorders. Studies were excluded if they targeted pregnant women (due to distinct physiological responses), individuals with pre-existing NCDs or mental disorders (to emphasise prevention), or primarily utilised web, email, or structured phone support (to focus on mobile technologies without exclusive human support). Data (summary data from published reports) extraction and risk-of-bias assessment were completed by two reviewers using a standard template and Cochrane risk-of-bias tools, respectively. Narrative syntheses were conducted for all studies, and random-effects models were used in the meta-analyses to estimate the pooled effect of interventions for outcomes with comparable data in the RCTs. The study was registered in PROSPERO, CRD42022315166.

Findings

After screening 5488 identified records, 34 studies (25 RCTs and 9 pre-post NRSIs) reported in 43 articles with 5691 participants (mean age 39 years, SD 12.5) were included. Most (91.2%, n = 31/34) were conducted in high-income countries. The median intervention duration was 3 months, and only 23.5% (n = 8/34) of studies reported follow-up data. Mobile applications, short-message services, and mobile device-compatible websites were the most common mHealth delivery modes; 47.1% (n = 16/34) studies used multiple mHealth delivery modes. Of 15 studies reporting on weight change, 9 showed significant reductions (6 targeted on individuals with overweight or obesity), and in 10 studies reporting perceived stress levels, 4 found significant reductions (all targeted on general adults). In the meta-analysis, holistic mHealth interventions were associated with significant weight loss (9 RCTs; mean difference -1.70 kg, 95% CI -2.45 to -0.95; I2 = 89.00%) and a significant reduction in perceived stress levels (6 RCTs; standardised mean difference [SMD] -0.32; 95% CI -0.52 to -0.12; I2 = 14.52%). There were no significant intervention effects on self-reported moderate-to-vigorous physical activity (5 RCTs; SMD 0.21; 95%CI -0.25 to 0.67; I2 = 74.28%) or diet quality scores (5 RCTs; SMD 0.21; 95%CI -0.47 to 0.65; I2 = 62.27%). All NRSIs were labelled as having a serious risk of bias overall; 56% (n = 14/25) of RCTs were classified as having some concerns, and the others as having a high risk of bias.

Interpretation

Findings from identified studies suggest that holistic mHealth interventions may aid reductions in weight and in perceived stress levels, with small to medium effect sizes. The observed effects on diet quality scores and self-reported moderate-to-vigorous physical activity were less clear and require more research. High-quality RCTs with longer follow-up durations are needed to provide more robust evidence. To promote population health, future research should focus on vulnerable populations and those in middle- and low-income countries. Optimal combinations of delivery modes and components to improve efficacy and sustain long-term effects should also be explored.

Funding

National Research Foundation, Prime Minister's Office, Singapore, under its Campus for Research Excellence and Technological Enterprise (CREATE) Programme and Physical Activity and Nutrition Determinants in Asia (PANDA) Research Programme.

Use of a mobile health patient engagement technology improves perioperative outcomes in gynecologic oncology patients

OBJECTIVE

To evaluate the impact of a mobile health patient engagement technology (PET) on postoperative outcomes in gynecologic oncology patients.

METHODS

All gynecologic oncology patients undergoing laparotomy on an enhanced recovery program (ERP) were approached from July 2019 to May 2021 to enroll in a PET, which can be accessed by computer, tablet, or smart phone. This platform provides enhanced pre- and postoperative patient education and remote patient monitoring. Patients who elected to participate were provided with targeted education based on their age and comorbidities and were asked to complete daily health checks during the postoperative period. Participants in the PET were compared to patients who opted out as well as to a historical cohort from prior to PET implementation. Patient and procedure-level factors were recorded. The primary outcomes were length of stay (LOS) and 30-day readmission rate. Analysis was performed using SPSS v.26.

RESULTS

682 women met inclusion criteria during the study time; 347 in the PET group and 335 in the control group. Demographic and other factors including race, BMI (kg/m2), Charlson Comorbidity Index (CCI), surgical complexity, and insurance status were not different between the PET and control group; however, patients in the PET cohort were slightly younger (55.0 yo vs. 57.2 yo; p = 0.04). Patients in the PET group had a significantly shorter LOS (2.9 days vs. 3.6 days; p < 0.01) and lower readmission rate (4.3% vs. 8.6%; p < 0.01) when compared with the control group.

CONCLUSIONS

Use of a PET in our gynecologic oncology patients decreased LOS by nearly one day despite an absence of differences in other demographic and surgical factors other than age. Furthermore, there was a 50% reduction in readmission rates in the PET group. The use of a PET allows for healthcare professionals to engage, evaluate, and treat patients in a way that improves perioperative care.

Benefits and Harms of Digital Health Interventions Promoting Physical Activity in People With Chronic Conditions: Systematic Review and Meta-Analysis

BACKGROUND

Digital health interventions for managing chronic conditions have great potential. However, the benefits and harms are still unclear.

OBJECTIVE

This systematic review and meta-analysis aimed to investigate the benefits and harms of digital health interventions in promoting physical activity in people with chronic conditions.

METHODS

We searched the MEDLINE, Embase, CINAHL, and Cochrane Central Register of Controlled Trials databases from inception to October 2022. Eligible randomized controlled trials were included if they used a digital component in physical activity promotion in adults with ≥1 of the following conditions: depression or anxiety, ischemic heart disease or heart failure, chronic obstructive pulmonary disease, knee or hip osteoarthritis, hypertension, or type 2 diabetes. The primary outcomes were objectively measured physical activity and physical function (eg, walk or step tests). We used a random effects model (restricted maximum likelihood) for meta-analyses and meta-regression analyses to assess the impact of study-level covariates. The risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and the certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

Of 14,078 hits, 130 randomized controlled trials were included. Compared with usual care or minimal intervention, digital health interventions increased objectively measured physical activity (end of intervention: standardized mean difference [SMD] 0.29, 95% CI 0.21-0.37; follow-up: SMD 0.17, 95% CI 0.04-0.31) and physical function (end of intervention: SMD 0.36, 95% CI 0.12-0.59; follow-up: SMD 0.29, 95% CI 0.01-0.57). The secondary outcomes also favored the digital health interventions for subjectively measured physical activity and physical function, depression, anxiety, and health-related quality of life at the end of the intervention but only subjectively measured physical activity at follow-up. The risk of nonserious adverse events, but not serious adverse events, was higher in the digital health interventions at the end of the intervention, but no difference was seen at follow-up.

CONCLUSIONS

Digital health interventions improved physical activity and physical function across various chronic conditions. Effects on depression, anxiety, and health-related quality of life were only observed at the end of the intervention. The risk of nonserious adverse events is present during the intervention, which should be addressed. Future studies should focus on better reporting, comparing the effects of different digital health solutions, and investigating how intervention effects are sustained beyond the end of the intervention.

TRIAL REGISTRATION

PROSPERO CRD42020189028; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=189028.

Effectiveness of a gamified digital intervention based on lifestyle modification (iGAME) in secondary prevention: a protocol for a randomised controlled trial

INTRODUCTION

Combating physical inactivity and reducing sitting time are one of the principal challenges proposed by public health systems. Gamification has been seen as an innovative, functional and motivating strategy to encourage patients to increase their physical activity (PA) and reduce sedentary lifestyles through behaviour change techniques (BCT). However, the effectiveness of these interventions is not usually studied before their use. The main objective of this study will be to analyse the effectiveness of a gamified mobile application (iGAME) developed in the context of promoting PA and reducing sitting time with the BCT approach, as an intervention of secondary prevention in sedentary patients.

METHODS AND ANALYSIS

A randomised clinical trial will be conducted among sedentary patients with one of these conditions: non-specific low back pain, cancer survivors and mild depression. The experimental group will receive a 12-week intervention based on a gamified mobile health application using BCT to promote PA and reduce sedentarism. Participants in the control group will be educated about the benefits of PA. The International Physical Activity Questionnaire will be considered the primary outcome. International Sedentary Assessment Tool, EuroQoL-5D, MEDRISK Instruments and consumption of Health System resources will be evaluated as secondary outcomes. Specific questionnaires will be administered depending on the clinical population. Outcomes will be assessed at baseline, at 6 weeks, at the end of the intervention (12 weeks), at 26 weeks and at 52 weeks.

ETHICS AND DISSEMINATION

The study has been approved by the Portal de Ética de la Investigación Biomédica de Andalucía Ethics Committee (RCT-iGAME 24092020). All participants will be informed about the purpose and content of the study and written informed consent will be completed. The results of this study will be published in a peer-reviewed journal and disseminated electronically and in print.

TRIAL REGISTRATION NUMBER

NCT04019119.

Perceptions and Experiences of Supplemental Nutrition Assistance Program (SNAP) Participants Related to Receiving Food and Nutrition-Related Text Messages Sent Agency-Wide: Findings from Focus Groups in San Diego County, California

We developed and sent a series of five monthly text messages promoting fruit and vegetable consumption to approximately 170,000 SNAP participants in San Diego County, California. The text messages, which were sent in English and Spanish, included links to a dedicated bilingual website offering additional information, including how to select, store, and prepare seasonal fruits and vegetables, health benefits of different fruits and vegetables, recipes, and tips to reduce food waste. To our knowledge, this represents the first instance of a SNAP agency providing nutrition information directly to SNAP participants. We conducted seven focus groups (four in English and three in Spanish) with a convenience sample of twenty-six text message recipients, to elicit their perceptions of this intervention, self-reported behavior changes, and recommendations for moving forward. Respondents reported overwhelmingly positive perceptions of this effort, including increased intake of fruits and vegetables, and trying new fruits and vegetables. Participants also reported improved perceptions of SNAP. Virtually all would like this effort to continue, and many would like to receive the messages more frequently than once a month. This effort represents a relatively low-cost approach that SNAP agencies can implement to provide SNAP participants with food and nutrition information that can help them to improve their diets, optimize their food dollars, and enhance their feelings of well-being related to participating in the program.

Development of "LvL UP 1.0": a smartphone-based, conversational agent-delivered holistic lifestyle intervention for the prevention of non-communicable diseases and common mental disorders

Background

Non-communicable diseases (NCDs) and common mental disorders (CMDs) are the leading causes of death and disability worldwide. Lifestyle interventions via mobile apps and conversational agents present themselves as low-cost, scalable solutions to prevent these conditions. This paper describes the rationale for, and development of, "LvL UP 1.0″, a smartphone-based lifestyle intervention aimed at preventing NCDs and CMDs.

Materials and Methods

A multidisciplinary team led the intervention design process of LvL UP 1.0, involving four phases: (i) preliminary research (stakeholder consultations, systematic market reviews), (ii) selecting intervention components and developing the conceptual model, (iii) whiteboarding and prototype design, and (iv) testing and refinement. The Multiphase Optimization Strategy and the UK Medical Research Council framework for developing and evaluating complex interventions were used to guide the intervention development.

Results

Preliminary research highlighted the importance of targeting holistic wellbeing (i.e., both physical and mental health). Accordingly, the first version of LvL UP features a scalable, smartphone-based, and conversational agent-delivered holistic lifestyle intervention built around three pillars: Move More (physical activity), Eat Well (nutrition and healthy eating), and Stress Less (emotional regulation and wellbeing). Intervention components include health literacy and psychoeducational coaching sessions, daily "Life Hacks" (healthy activity suggestions), breathing exercises, and journaling. In addition to the intervention components, formative research also stressed the need to introduce engagement-specific components to maximise uptake and long-term use. LvL UP includes a motivational interviewing and storytelling approach to deliver the coaching sessions, as well as progress feedback and gamification. Offline materials are also offered to allow users access to essential intervention content without needing a mobile device.

Conclusions

The development process of LvL UP 1.0 led to an evidence-based and user-informed smartphone-based intervention aimed at preventing NCDs and CMDs. LvL UP is designed to be a scalable, engaging, prevention-oriented, holistic intervention for adults at risk of NCDs and CMDs. A feasibility study, and subsequent optimisation and randomised-controlled trials are planned to further refine the intervention and establish effectiveness. The development process described here may prove helpful to other intervention developers.

Holistic mHealth interventions for the promotion of healthy ageing: protocol for a systematic review

INTRODUCTION

Maintaining physical and mental health is essential for healthy ageing. It can be supported by modifying lifestyle factors such as physical activity and diet. Poor mental health, in turn, contributes to the opposing effect. The promotion of healthy ageing may therefore benefit from holistic interventions integrating physical activity, diet and mental health. These interventions can be scaled up to the population level by using mobile technologies. However, systematic evidence regarding the characteristics and effectiveness of such holistic mHealth interventions remains limited. This paper presents a protocol for a systematic review that aims to provide an overview of the current state of the evidence for holistic mHealth interventions, including their characteristics and effects on behavioural and health outcomes in general adult populations .

METHODS AND ANALYSIS

We will conduct a comprehensive search for randomised controlled trials and non-randomised studies of interventions published between January 2011 and April 2022 in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, Scopus, China National Knowledge Infrastructure and Google Scholar (first 200 records). Eligible studies will be mHealth interventions targeting general adult populations with content on physical activity, diet and mental health. We will extract information on all relevant behavioural and health outcomes, as well as those related to intervention feasibility. Screening and data extraction processes will be carried out independently by two reviewers. Cochrane risk-of-bias tools will be used to assess risk of bias. We will provide a narrative overview of the findings from eligible studies. With sufficient data, a meta-analysis will be conducted.

ETHICS AND DISSEMINATION

Ethical approval is not required because this study is a systematic review based on published data. We intend to publish our findings in a peer-reviewed journal and present the study at international conferences.

PROSPERO REGISTRATION NUMBER

CRD42022315166.

Test-Retest Reliability and Internal Consistency of a Newly Developed Questionnaire to Assess Explanatory Variables of 24-h Movement Behaviors in Adults

A questionnaire on explanatory variables for each behavior of the 24-h movement behaviors (i.e., physical activity, sedentary behavior, sleep) was developed based on three levels of the socio-ecological model, i.e., the intrapersonal level, interpersonal level and the physical environmental level. Within these levels, different constructs were questioned, i.e., autonomous motivation, attitude, facilitators, internal behavioral control, self-efficacy, barriers, subjective norm, social modeling, social support, home environment, neighborhood, and work environment. The questionnaire was tested for test-retest reliability (i.e., intraclass correlation (ICC)) for each item and internal consistency for each construct (i.e., Cronbach's Alpha Coefficient) among a group of 35 healthy adults with a mean age of 42.9 (±16.1) years. The total questionnaire contained 266 items, consisting of 14 items on general information, 70 items on physical activity, 102 items on sedentary behavior, 45 items on sleep and 35 items on the physical environment. Seventy-one percent of the explanatory items showed moderate to excellent reliability (ICC between 0.50 and 0.90) and a majority of constructs had a good homogeneity among items (Cronbach's Alpha Coefficient ≥ 0.70). This newly developed and comprehensive questionnaire might be used as a tool to understand adults' 24-h movement behaviors.

Lifestyle Intervention in NAFLD: Long-Term Diabetes Incidence in Subjects Treated by Web- and Group-Based Programs

BACKGROUND

Behavioral programs are needed for prevention and treatment of NAFLD and the effectiveness of a web-based intervention (WBI) is similar to a standard group-based intervention (GBI) on liver disease biomarkers.

OBJECTIVE

We aimed to test the long-term effectiveness of both programs on diabetes incidence, a common outcome in NAFLD progression.

METHODS

546 NAFLD individuals (212 WBI, 334 GBI) were followed up to 60 months with regular 6- to 12-month hospital visits. The two cohorts differed in several socio-demographic and clinical data. In the course of the years, the average BMI similarly decreased in both cohorts, by 5% or more in 24.4% and by 10% or more in 16.5% of cases available at follow-up. After excluding 183 cases with diabetes at entry, diabetes was newly diagnosed in 48 cases during follow-up (31 (16.6% of cases without diabetes at entry) in the GBI cohort vs. 17 (9.7%) in WBI; p = 0.073). Time to diabetes was similar in the two cohorts (mean, 31 ± 18 months since enrollment). At multivariable regression analysis, incident diabetes was significantly associated with prediabetes (odds ratio (OR) 4.40; 95% confidence interval (CI) 1.97-9.81; p < 0.001), percent weight change (OR 0.57; 95% CI 0.41-0.79; p < 0.001) and higher education (OR 0.49; 95% CI 0.27-0.86; p = 0.014), with no effect of other baseline socio-demographic, behavioral and clinical data, and of the type of intervention. The importance of weight change on incident diabetes were confirmed in a sensitivity analysis limited to individuals who completed the follow-up.

CONCLUSION

In individuals with NAFLD, WBI is as effective as GBI on the pending long-term risk of diabetes, via similar results on weight change.

The Effect of an eHealth Coaching Program (Smarter Pregnancy) on Attitudes and Practices Toward Periconception Lifestyle Behaviors in Women Attempting Pregnancy: Prospective Study

BACKGROUND

Lifestyle behaviors during the periconception period contribute to achievement of a successful pregnancy. Assessment of attitudes and practices toward these modifiable behaviors can aid in identifying gaps in unhealthy lifestyle behaviors with impact on intervention effectiveness.

OBJECTIVE

This study investigates the effectiveness of coaching by the eHealth program Smarter Pregnancy during the periconception period on improvement of attitudes and practices toward fruit and vegetable intake and smoking in women attempting pregnancy through assisted reproductive technology (ART) or natural conception.

METHODS

Women attempting pregnancy through ART (n=1060) or natural conception (n=631) were selected during the periconception period. The intervention groups, conceived through ART or naturally, received Smarter Pregnancy coaching for 24 weeks, whereas the control group conceived through ART and did not receive coaching. Attitudes and practices at baseline and follow-up periods were obtained from self-administered online questionnaire provided by the program. Attitudes were assessed in women with unhealthy behaviors as their intention to increase their fruit and vegetable intake and to quit smoking using a yes/no question. Outcomes on practices, suggesting effectiveness, included daily fruit (pieces) and vegetable (grams) intake, and if women smoked (yes/no). Changes in attitudes and practices were compared at 12 and 24 weeks with baseline between the ART intervention and ART control groups, and within the intervention groups between ART and natural conception. Changes in practices at 12 and 24 weeks were also compared with baseline between women with negative attitude and positive attitude within the intervention groups: ART and natural conception. Analysis was performed using linear and logistic regression models adjusted for maternal confounders and baseline attitudes and practices.

RESULTS

The ART intervention group showed higher vegetable intake and lower odds for negative attitudes toward vegetable intake after 12 weeks (β_adj=25.72 g, P<.001; adjusted odds ratio [OR_adj] 0.24, P<.001) and 24 weeks of coaching (β_adj=23.84 g, P<.001; OR_adj 0.28, P<.001) compared with ART controls. No statistically significant effect was observed on attitudes and practices toward fruit intake (12 weeks: P=.16 and .08, respectively; 24 weeks: P=.16 and .08, respectively) and smoking behavior (12 weeks: P=.87; 24 weeks: P=.92). No difference was observed for the studied attitudes and practices between the ART intervention and natural conception intervention groups. Women with persistent negative attitude toward fruit and vegetable intake at week 12 showed lower fruit and vegetable intake at week 24 compared with women with positive attitude (β_adj=-.49, P<.001; β_adj=-30.07, P<.001, respectively).

CONCLUSIONS

The eHealth Smarter Pregnancy program may improve vegetable intake-related attitudes and practices in women undergoing ART treatment. Women with no intention to increase fruit and vegetable intake had less improvement in their intakes. Despite small changes, this study demonstrates again that Smarter Pregnancy can be used to improve vegetable intake, which can complemented by blended care that combines face-to-face and online care to also improve fruit intake and smoking behavior.

Effects of Mindfulness-Based Interventions on Promoting Athletic Performance and Related Factors among Athletes: A Systematic Review and Meta-Analysis of Randomized Controlled Trial

In recent years, mindfulness-based interventions (MBIs) have been widely applied in competition sports with respect to athletic performance and mental health promotion, whereas evidence of randomized controlled trials (RCTs) has not been well summarized. Therefore, this study aimed to systematically review and meta-analyze the existing evidence on the effects of MBIs on improving athletic performance, mindfulness level, mindfulness-related psychological components (e.g., acceptance, self-compassion, flow), and mental health (e.g., burnout, stress, psychological well-being) among athletes. Following the PRISMA guidelines, a literature search was implemented on five electronic databases (Web of Science, PubMed, Scopus, ProQuest, and ScienceDirect) and relevant review papers. The article selection, risk of bias assessment, and data extraction were performed by two investigators independently. The standardized mean difference (SMD) was calculated to evaluate the effects of interventions using the random effect model. Among the 1897 original hits, thirty-two eligible RCT studies were included in the systematic review, of which seven were involved in the meta-analysis. The results showed that MBIs were effective in promoting athletes' athletic performances (by narrative synthesis), mindfulness-level (n = 3; SMD = 0.50, 95% CI = [0.17, 0.83]; I² = 45%, p = 0.16), and mindfulness-related psychological components (n = 5; SMD = 0.81, 95% CI = [0.53, 1.10], I² = 77%, p =0.001), while no significant intervention effects were found on the mental health of athletes (n = 4; SMD = -0.03, 95% CI = [-0.35, 0.29], I² = 89%, p < 0.001). Our findings preliminarily support the potential effectiveness of MBIs, whereas more high-quality RCTs were needed in the future.

Effects of Face-to-Face and eHealth Blended Interventions on Physical Activity, Diet, and Weight-Related Outcomes among Adults: A Systematic Review and Meta-Analysis

An increasing number of studies are blending face-to-face interventions and electronic health (eHealth) interventions to jointly promote physical activity (PA) and diet among people. However, a comprehensive summary of these studies is lacking. This study aimed to synthesize the characteristics of blended interventions and meta-analyze the effectiveness of blended interventions in promoting PA, diet, and weight-related outcomes among adults. Following the PRISMA guidelines, PubMed, SPORTDiscus, PsycINFO, Embase, and Web of Science were systematically searched to identify eligible articles according to a series of inclusion criteria. The search was limited to English language literature and publication dates between January 2002 and July 2022. Effect sizes were calculated as standardized mean difference (SMD) for three intervention outcomes (physical activity, healthy diet, and weight-related). Random effect models were used to calculate the effect sizes. A sensitivity analysis and publication bias tests were conducted. Of the 1561 identified studies, 17 were eligible for the systematic review. Studies varied in participants, intervention characteristics, and outcome measures. A total of 14 studies were included in the meta-analyses. There was evidence of no significant publication bias. The meta-analyses indicated that the blended intervention could lead to a significant increase in walking steps (p < 0.001), total PA level (p = 0.01), and diet quality (p = 0.044), a significant decrease in energy intake (p = 0.004), weight (p < 0.001), BMI (p < 0.001), and waist circumferences (p = 0.008), but had no influence on more moderate-to-vigorous physical activity (MVPA) or fruit and vegetable intake among adults, compared with a control group. The study findings showed that blended interventions achieve preliminary success in promoting PA, diet, and weight-related outcomes among adults. Future studies could improve the blended intervention design to achieve better intervention effectiveness.

A Digital Lifestyle Coach (E-Supporter 1.0) to Support People With Type 2 Diabetes: Participatory Development Study

BACKGROUND

A healthy lifestyle, including regular physical activity and a healthy diet, is becoming increasingly important in the treatment of chronic diseases. eHealth interventions that incorporate behavior change techniques (BCTs) and dynamic tailoring strategies could effectively support a healthy lifestyle. E-Supporter 1.0 is an eCoach designed to support physical activity and a healthy diet in people with type 2 diabetes (T2D).

OBJECTIVE

This paper aimed to describe the systematic development of E-Supporter 1.0.

METHODS

Our systematic design process consisted of 3 phases. The definition phase included the selection of the target group and formulation of intervention objectives, and the identification of behavioral determinants based on which BCTs were selected to apply in the intervention. In the development phase, intervention content was developed by specifying tailoring variables, intervention options, and decision rules. In the last phase, E-Supporter 1.0 integrated in the Diameter app was evaluated using a usability test in 9 people with T2D to assess intervention usage and acceptability.

RESULTS

The main intervention objectives were to stimulate light to moderate-vigorous physical activities or adherence to the Dutch dietary guidelines in people with T2D. The selection of behavioral determinants was informed by the health action process approach and theories explaining behavior maintenance. BCTs were included to address relevant behavioral determinants (eg, action control, self-efficacy, and coping planning). Development of the intervention resulted in 3 types of intervention options, consisting of motivational messages, behavioral feedback, and tailor-made supportive exercises. On the basis of IF-THEN rules, intervention options could be tailored to, among others, type of behavioral goal and (barriers to) goal achievement. Data on these variables could be collected using app data, activity tracker data, and daily ecological momentary assessments. Usability testing revealed that user experiences were predominantly positive, despite some problems in the fixed delivery of content.

CONCLUSIONS

The systematic development approach resulted in a theory-based and dynamically tailored eCoach. Future work should focus on expanding intervention content to other chronic diseases and lifestyle behaviors, enhancing the degree of tailoring and evaluating intervention effects on acceptability, use, and cost-effectiveness.

Comparison of Motivational Short Interventions to Improve Smokers' Health Behavior (The COSMOS Study): A Pragmatic Cluster-Randomized Two-Arm Trial in General Practice

INTRODUCTION

Helping smokers to quit is an important task of general practitioners (GPs). However, achieving tobacco abstinence is difficult, and smokers who fail may still want to improve their health in other ways. Therefore, Swiss GPs developed a multithematic coaching concept that encourages health behavior changes beyond smoking cessation alone.

AIMS AND METHODS

To compare the effectiveness of such coaching with state-of-the-art smoking cessation counseling, we conducted a pragmatic cluster-randomized two-arm trial with 56 GPs in German-speaking Switzerland and 149 of their cigarette smoking patients. GPs were instructed in either multithematic health coaching or smoking cessation counseling. After 12 months, we compared their patients' improvements in cigarette consumption, body weight, physical inactivity, alcohol consumption, stress, unhealthy diet, and a health behavior of their own choice, using hierarchical logistic regression models and Fisher's exact and t tests.

RESULTS

Over 95% of all participants achieved clinically relevant improvements in at least one health behavior, with no difference between study arms (health coaching vs. smoking cessation counseling: aOR = 1.21, 95% CI = [0.03-50.76]; and aOR = 1.78, 95% CI = [0.51-6.25] after non-responder imputation). Rates of clinically relevant improvements in the individual health behaviors did not differ between study arms either (they were most frequent in physical activity, achieved by 3 out of 4 patients), nor did the extent of the improvements.

CONCLUSIONS

Multithematic health coaching and state-of-the art smoking cessation counseling were found to be comparable interventions, both in terms of smoking cessation success and, quite unexpectedly, their effects on other health behaviors.

IMPLICATIONS

The findings of our study suggest that in general practice, multithematic health coaching is an effective smoking cessation intervention, and conversely, monothematic smoking cessation counseling also achieves the beneficial effects of a multithematic health behavior intervention. This opens up the possibility for GPs to support their smoking patients in improving their health behavior in additional and more flexible ways.

The Effectiveness of E-Health Interventions Promoting Physical Activity and Reducing Sedentary Behavior in College Students: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Insufficient physical activity (PA) and excessive sedentary behavior (SB) are detrimental to physical and mental health. This systematic review and meta-analysis aimed to identify whether e-health interventions are effective for improving PA and SB in college students. Five electronic databases, including Medline, Web of Science, Embase, Cochrane Library, and ProQuest, were searched to collect relevant randomized controlled trials up to 22 June 2022. In total, 22 trials (including 31 effects) with 8333 samples were included in this meta-analysis. The results showed that e-health interventions significantly improved PA at post-intervention (SMD = 0.32, 95% CI: 0.19, 0.45, p < 0.001) compared with the control group, especially for total PA (SMD = 0.34, 95% CI: 0.10, 0.58, p = 0.005), moderate to vigorous PA (SMD = 0.17, 95% CI: 0.01, 0.32, p = 0.036), and steps (SMD = 0.75, 95% CI: 0.23, 1.28, p < 0.001. There were no significant effects for both PA at follow-up (SMD = 0.24, 95% CI: − 0.01, 0.49, p = 0.057) and SB (MD = −29.11, 95% CI: −70.55, 12.32, p = 0.17). The findings of subgroup analyses indicated that compared to the control group, interventions in the group of general participants (SMD = 0.45, 95% CI: 0.27, 0.63, p < 0.001), smartphone apps (SMD = 0.46, 95% CI: 0.19, 0.73, p = 0.001), and online (SMD = 0.23, 95% CI: 0.04, 0.43, p < 0.001) can significantly improve PA at post-intervention. Moreover, the intervention effects were significant across all groups of theory, region, instrument, duration, and female ratio. At follow-up, interventions in groups of developing region (SMD = 1.17, 95% CI: 0.73, 1.62, p < 0.001), objective instrument (SMD = 0.83, 95% CI: 0.23, 1.42, p = 0.007), duration ≤ 3-month (SMD = 1.06, 95% CI: 0.72, 1.39, p < 0.001), and all female (SMD = 0.79, 95% CI: 0.02, 1.56, p = 0.044) can significantly improve PA. The evidence of this meta-analysis shows that e-health interventions can be taken as promising strategies for promoting PA. The maintenance of PA improvement and the effect of interventions in reducing SB remain to be further studied. Educators and health practitioners should focus on creating multiple e-health interventions with individualized components.

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.

Co-Design of an eHealth Intervention to Reduce Cardiovascular Disease Risk in Male Taxi Drivers: ManGuard

Taxi driving, a male-dominated occupation, is associated with an increased risk of cardiovascular disease (CVD). The increased risk is linked to a high prevalence of modifiable CVD risk factors including overweight/obesity, poor nutrition, smoking, excessive alcohol consumption and physical inactivity. Behaviour change interventions may prove advantageous, yet little research has been conducted to reduce CVD risk in this population. The purpose of this study was to co-design an eHealth intervention, 'ManGuard', to reduce CVD risk in male taxi drivers. The IDEAS framework was utilised to guide the development of the eHealth intervention, with the Behaviour Change Wheel (BCW) incorporated throughout to ensure the intervention was underpinned by behaviour change theory. Development and refinement of ManGuard was guided by current literature, input from a multidisciplinary team, an online survey, a systematic review and meta-analysis, and focus groups (n = 3) with male taxi drivers. Physical inactivity was identified as the prime behavior to change in order to reduce CVD risk in male taxi drivers. Male taxi drivers indicated a preference for an eHealth intervention to be delivered using smartphone technology, with a simple design, providing concise, straightforward, and relatable content, and with the ability to track and monitor progress.

Mobile Digital Health Intervention to Promote Nutrition and Physical Activity Behaviors Among Long-term Unemployed in Rural Areas: Protocol for a Randomized Controlled Trial

BACKGROUND

Long-term unemployed have poor nutritional and physical activity statuses, and, therefore, special health promotion needs. Particularly in rural areas, however, they often do not have access to health promotion service. Thus, new promising strategies to improve the health of long-term unemployed are needed. Hence, a digital health intervention to promote nutritional and physical health behaviors was conceived, and the effectiveness of the intervention in combination with face-to-face sessions will be evaluated in a randomized controlled trial.

OBJECTIVE

The aim of this study is to elucidate the effectiveness of a mobile digital health intervention to promote the nutritional and physical activity behaviors of long-term unemployed in the rural areas of Germany.

METHODS

The 9-week intervention aims to promote nutritional or physical activity behavior by improving drinking habits, increasing the consumption of fruits, vegetables, and whole grains, increasing daily step count, strengthening muscles, and improving endurance. The intervention design is based on the transtheoretical model and is implemented in a mobile app using the MobileCoach open-source platform. The effectiveness of the intervention will be elucidated by a 9-week, 2-armed, parallel-designed trial. Therefore, long-term unemployed will be recruited by employees of the German social sector institutions and randomized either to receive information brochures; the digital intervention in the form of a mobile app; and 3 face-to-face sessions regarding technical support, healthy eating, and physical activity (n=100) or to receive a control treatment consisting of solely the hand over of information brochures (n=100). The effectiveness of the intervention will be assessed using questionnaires at baseline, after 9 weeks in face-to-face appointments, and after a 3-month follow-up period by postal contact. The use of the mobile app will be monitored, and qualitative interviews or focus groups with the participants will be conducted. Incentives of €50 (US $49.7) will be paid to the participants and are tied to the completion of the questionnaires and not to the use of the mobile app or progress in the intervention.

RESULTS

The effectiveness of the intervention in promoting the nutritional and physical activity behaviors of long-term unemployed participants will be elucidated. The adherence of the participants to and the acceptance and usability of the mobile device app will be evaluated. Recruitment started in March 2022, and the final publication of the results is expected in the first half of 2023.

CONCLUSIONS

Positive health-related changes made by the intervention would display the potency of digital health interventions to promote nutritional and physical activity behaviors among long-term unemployed in the rural areas of Germany, which would also contribute to an improved health status of the German population in general.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00024805; https://www.drks.de/DRKS00024805.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/40321.

Physical Inactivity and Food Insecurity Are Associated with Social Capital: A Large-Scale Population-Based Study in Tehran

Background. There are limited studies on food security, physical activity, and social capital in the Iranian population. This study aimed to evaluate the social capital’s associations with physical inactivity and food insecurity in a large-scale study in Iran, Urban HEART-2. Methods. This cross-sectional study was conducted in 22 districts of Tehran, the capital of Iran. Residents of Tehran who were 15 years or older were selected by a multi-stage, stratified, and random sampling method. Food insecurity and physical activity were evaluated using Household Food Security Scale and Global Physical Activity Questionnaire, respectively, and their associations with social capital were evaluated. Results. A total of 5030 individuals were included in this study, with 3139 (62.4%) males. The mean age of participants was 44.08 years (SD = 16.33, range = 15–90). Participation in social events (OR = 0.893, 95% CI = 0.819–0.974, $P$  = 0.011), social network (OR = 0.849, 95% CI = 0.786, $P$  < 0.001), and voluntary activities (OR = 0.865, 95% CI = 0.812–0.921, $P$  < 0.001) were all negatively associated with food insecurity. Also, voluntary activities (OR = 0.823, 95% CI = 0.776–0.872, $P$  < 0.001) and participation in the associations activities (OR = 0.665, 95% CI = 0.582–0.759, $P$  < 0.001) were negatively associated with physical inactivity. Conclusion. The prevalence of food insecurity and physical inactivity is relatively high among Tehran residents. As a factor affecting the physical activity and food security, social capital can be targeted in interventions to improve physical activity and food security among Iranians.

An eHealth intervention (ManGuard) to reduce cardiovascular disease risk in male taxi drivers: protocol for a feasibility randomised controlled trial

Background

Men are at higher risk then women of developing cardiovascular disease (CVD), and male taxi drivers are a particularly high-risk group because of their typically unhealthy behaviours, such as poor eating habits, smoking and sedentary lifestyle. However, only two studies of behavioural interventions targeting taxi drivers have been identified, one of which reported a high attrition rate. Therefore, an eHealth intervention co-designed by taxi drivers may prove more acceptable and effective. The aim of this study is to assess the feasibility an eHealth intervention (ManGuard) to reduce CVD risk in male taxi drivers.

Methods

A randomised wait-list controlled trial will be conducted with a sample of 30 male taxi drivers to establish feasibility, including recruitment, engagement, and retention rates. Program usability and participant satisfaction will be assessed by a survey completed by all participants at 3 months after allocation. Additionally, an in-depth qualitative process evaluation to explore acceptability of the intervention will be conducted with a subset of participants by semi-structured telephone interviews. Preliminary efficacy of ManGuard for improving key CVD-related outcomes will be assessed, including biomarkers (total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, and total/HDL cholesterol ratio), blood pressure, anthropometry (body mass index, body fat percentage, and waist circumference), physical activity (accelerometery, and self-report) and psychosocial status (health-related quality of life, self-efficacy, and social support). Outcomes will be assessed at baseline, 7 weeks, and 3 months after group allocation. The wait-list control group will be offered access to the intervention at the completion of data collection.

Discussion

eHealth interventions show potential for promoting behaviour change and reducing CVD risk in men, yet there remains a paucity of robust evidence pertaining to male taxi drivers, classified as a high-risk group. This study uses a randomised controlled trial to assess the feasibility of ManGuard for reducing CVD risk in male taxi drivers. It is envisaged that this study will inform a fully powered trial that will determine the effectiveness of eHealth interventions for this high risk and underserved population.

Trial registration

This trial has been registered prospectively on the ISRCTN registry on 5 January 2022, registration number ISRCTN29693943

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01163-4.

Psychosocial Determinants of Hand Hygiene, Facemask Wearing, and Physical Distancing During the COVID-19 Pandemic: A Systematic Review and Meta-analysis

BACKGROUND

Hand hygiene, facemask wearing, and physical distancing play a crucial role in the prevention of the COVID-19 pandemic. Identifying the key psychosocial determinants of these precautionary behaviors contributes to effective intervention and policymaking for COVID-19 and future pandemics.

PURPOSE

This study aimed to systematically review and meta-analyze available evidence on psychosocial determinants of the general population's practice of three precautionary behaviors, based on the Risk, Attitudes, Norms, Abilities, and Self-regulation (RANAS) framework.

METHODS

Literature was identified by searching seven databases and relevant review papers. Observational and experimental studies targeting the general population (≥18 years) published between January 2020 to September 2021 were included. Pooled effect sizes were calculated with the inverse-variance method using random-effects models.

RESULTS

A total of 51 studies (64 samples) were included in the qualitative synthesis, of which 30 studies (42 samples) were included in the meta-analysis. RANAS-based constructs including knowledge, pros attitudes, and perceived norms were identified as significant determinants of all three behaviors in the meta-analysis. Perceived susceptibility and cons attitudes showed no significant associations with any behaviors. Perceived severity, perceived control, self-efficacy, and behavioral intention were significantly associated with one or two behaviors. Country (western vs. eastern hemispheres) significantly moderated the effects of certain risk and ability factors.

CONCLUSIONS

More research is needed with respect to the intention-behavior relationship, self-regulatory and reflexive factors of precautionary behaviors, as well as the exploration of the potential moderating effect of sociodemographic factors.

Study protocol for the description and evaluation of the "Habit Coach" - a longitudinal multicenter mHealth intervention for healthy habit formation in health care professionals

BACKGROUND

The adoption of a healthy lifestyle plays a crucial role for the health and well-being of health care professionals. Previous e- and mHealth interventions relied on deliberative psychological processes (e.g., intention, planning) to target lifestyle changes, while revealing mixed efficacy. The additional potential of non-deliberative, automatic processes (i.e., habits) for behavior change has been understudied in interventions so far. The Habit Coach mHealth intervention combines deliberative and non-deliberative processes to support health care professionals in forming healthy physical activity, nutrition and mindfulness habits in daily life. The aim of this paper is to outline the study protocol including a detailed description of the mHealth intervention, evaluation plan, and study design. The purpose of this trial is to understand healthy habit formation in health care professionals over time.

METHODS

A one-arm, multicenter mHealth intervention study will be conducted. Behavioral and psychosocial predictors will be collected via within-app questionnaires across a 100-day period at baseline, post, as well as at weekly assessments. To understand habit formation across time, linear mixed models will be used.

DISCUSSION

This trial aims to unravel the role of motivational and volitional determinants for healthy habit formation across multiple health behaviors in health care professionals embedded in a mHealth intervention.

TRIAL REGISTRATION

This trial is registered in the German Clinical Trials Register, DRKS-ID DRKS00027156. Date of registration 17 November 2021.

What Intervention Elements Drive Weight Loss in Blended-Care Behavior Change Interventions? A Real-World Data Analysis with 25,706 Patients

BACKGROUND

Blended-care behavior change interventions (BBCI) are a combination of digital care and coaching by health care professionals (HCP), which are proven effective for weight loss. However, it remains unclear what specific elements of BBCI drive weight loss.

OBJECTIVES

This study aims to identify the distinct impact of HCP-elements (coaching) and digital elements (self-monitoring, self-management, and education) for weight loss in BBCI.

METHODS

Long-term data from 25,706 patients treated at a digital behavior change provider were analyzed retrospectively using a ridge regression model to predict weight loss at 3, 6, and 12 months.

RESULTS

Overall relative weight loss was -1.63 kg at 1 month, -3.61 kg at 3 months, -5.28 kg at 6 months, and -6.55 kg at 12 months. The four factors of BBCI analyzed here (coaching, self-monitoring, self-management, and education) predict weight loss with varying accuracy and degree. Coaching, self-monitoring, and self-management are positively correlated with weight losses at 3 and 6 months. Learn time (i.e., self-guided education) is clearly associated with a higher degree of weight loss. Number of appointments outside of app coaching with a dietitian (coach) was negatively associated with weight loss.

CONCLUSIONS

The results testify to the efficacy of BBCI for weight loss-with particular positive associations per time point-and add to a growing body of research that characterizes the distinct impact of intervention elements in real-world settings, aiming to inform the design of future interventions for weight management.

The Aim2Be mHealth Intervention for Children With Overweight or Obesity and Their Parents: Person-Centered Analyses to Uncover Digital Phenotypes

Background

Despite the growing number of mobile health (mHealth) interventions targeting childhood obesity, few studies have characterized user typologies derived from individuals’ patterns of interactions with specific app features (digital phenotypes).

Objective

This study aims to identify digital phenotypes among 214 parent-child dyads who used the Aim2Be mHealth app as part of a randomized controlled trial conducted between 2019 and 2020, and explores whether participants’ characteristics and health outcomes differed across phenotypes.

Methods

Latent class analysis was used to identify distinct parent and child phenotypes based on their use of the app’s behavioral, gamified, and social features over 3 months. Multinomial logistic regression models were used to assess whether the phenotypes differed by demographic characteristics. Covariate-adjusted mixed-effect models evaluated changes in BMI z scores (zBMI), diet, physical activity, and screen time across phenotypes.

Results

Among parents, 5 digital phenotypes were identified: socially engaged (35/214, 16.3%), independently engaged (18/214, 8.4%) (socially and independently engaged parents are those who used mainly the social or the behavioral features of the app, respectively), fully engaged (26/214, 12.1%), partially engaged (32/214, 15%), and unengaged (103/214, 48.1%) users. Married parents were more likely to be fully engaged than independently engaged (P=.02) or unengaged (P=.01) users. Socially engaged parents were older than fully engaged (P=.02) and unengaged (P=.01) parents. The latent class analysis revealed 4 phenotypes among children: fully engaged (32/214, 15%), partially engaged (61/214, 28.5%), dabblers (42/214, 19.6%), and unengaged (79/214, 36.9%) users. Fully engaged children were younger than dabblers (P=.04) and unengaged (P=.003) children. Dabblers lived in higher-income households than fully and partially engaged children (P=.03 and P=.047, respectively). Fully engaged children were more likely to have fully engaged (P<.001) and partially engaged (P<.001) parents than unengaged children. Compared with unengaged children, fully and partially engaged children had decreased total sugar (P=.006 and P=.004, respectively) and energy intake (P=.03 and P=.04, respectively) after 3 months of app use. Partially engaged children also had decreased sugary beverage intake compared with unengaged children (P=.03). Similarly, children with fully engaged parents had decreased zBMI, whereas children with unengaged parents had increased zBMI over time (P=.005). Finally, children with independently engaged parents had decreased caloric intake, whereas children with unengaged parents had increased caloric intake over time (P=.02).

Conclusions

Full parent-child engagement is critical for the success of mHealth interventions. Further research is needed to understand program design elements that can affect participants’ engagement in supporting behavior change.

Trial Registration

ClinicalTrials.gov NCT03651284; https://clinicaltrials.gov/ct2/show/NCT03651284

International Registered Report Identifier (IRRID)

RR2-10.1186/s13063-020-4080-2

A systematic review and meta-analysis on the preventive behaviors in response to the COVID-19 pandemic among children and adolescents

Purpose

The purpose of this review was to synthesize the empirical evidence of relevant studies related to preventive behaviors in response to the COVID-19 pandemic among children and adolescents. Further to this, we aimed to identify the demographic, psychological, and social and environmental correlates of such behaviors.

Methods

Following PRISMA guidelines, eligible literature was identified by searching seven databases (PsycINFO, PubMed, MEDLINE, EMBASE, Cochrane Library, PROSPERO registry platform, and ClinicalTrials.gov website) and reference list of included studies and relevant review papers from 1^st Jan 2020 to 28^th Feb 2021. The standardized mean difference and correlation coefficients r were extracted to estimate the effect sizes. Analyses were conducted using R software.

Results

Of the 35,271 original papers, 23 eligible studies were included in the qualitative synthesis and all these studies were of moderate-to-high quality, of which 17 studies were further included into the quantitative analysis. Children and adolescents (6–20 yrs.) showed a poorer practice of COVID-19 preventive behaviors compared to younger adults (21–59 yrs.) with a small-to-medium effect size (SMD = -.25, 95%CI = -.41 to -.09). For the demographic correlates, children and adolescents’ COVID-19 preventive practice was found to be significantly associated with gender (r = .14, 95%CI = .10 to .18), while not with age (r = -.02, 95%CI = -.14 to .10). Narratively, knowledge was found to be consistently and significantly correlated. For the psychological correlates, small-to-medium overall effects were identified for the association with attitudes (r = .26, 95%CI = .21 to .31) and perceived severity (r = .16, 95%CI = .01 to .30). For the family and social correlates, a non-significant association was identified between family economic status and COVID-19 preventive behaviors (r = .004, 95%CI = -.12 to .12).

Conclusions

Interventions and relevant policies of promoting children and adolescent’s preventive measures should be a priority. Further, empirical studies identifying the demographic, psychological, and family and social correlates of children and adolescents’ preventive behaviors are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13585-z.

A WeChat Mini Program-Based Intervention for Physical Activity, Fruit and Vegetable Consumption Among Chinese Cardiovascular Patients in Home-Based Rehabilitation: A Study Protocol

Background

Cardiac rehabilitation programs aim to avoid further progression and relapse of cardiovascular diseases (CVDs). Patients with CVDs undergoing rehabilitation often experience difficulties in integrating and transferring the learned health behaviors into their daily life after returning home. This includes regular physical activity (PA) and sufficient fruit and vegetable consumption (FVC). eHealth individualized interventions have shown to be effective in increasing PA and FVC in home settings. As WeChat is the most popular social media site in China, this should be used for the intervention. The aim of this study is to develop and examine a WeChat mini program-based intervention on PA and FVC promotion among Chinese cardiovascular patients in home-based rehabilitation.

Methods

The study will adopt a randomized controlled trial (RCT), comprising a WeChat mini program-based intervention group and a waiting-list control group. The intervention content will be designed based on the Health Action Process Approach (HAPA). One hundred fifty-eight outpatients will be recruited from the cardiac rehabilitation center of a hospital in southern China and randomly assigned to one of the two groups. During the 10-week duration of the intervention, participants will be invited to access a WeChat mini program comprising two Modules. Module 1 provides weekly learning sessions addressing PA and FVC simultaneously for 10 weeks. Module 2 provides a platform, where participants can review their progress with Module 1 at any time and attend incentive activities aiming at promoting engagement and retention. The outcome variables include PA (mins/week), FVC (portion/day), healthy lifestyle (the synthesis of PA and FVC), social-cognitive predictors of behavior change (risk perception, outcome expectancies, self-efficacy, intention, planning, social support, and action control) as well as health outcomes (Body mass index, depression, and quality of life). Data collection will be implemented at pre-test, post-test and a post-test after 3-month respectively.

Discussion

The current study will be significant to understand how such a cost-effective social media mini program-based intervention enables participants to adopt and maintain a healthy lifestyle. If it is effective, it will enrich home-based cardiac rehabilitation approaches which can in turn save the lives of patients as well as much monetary, time and other investments.

Trial Registration

The study was registered at ClinicalTrials.gov (Identifier: NCT03636724; Last update posted: July 28, 2020).

Health Behaviors of Austrian Secondary School Teachers and Principals at a Glance: First Results of the From Science 2 School Study Focusing on Sports Linked to Mixed, Vegetarian, and Vegan Diets

Lifestyle behaviors are key contributors to sustainable health and well-being over the lifespan. The analysis of health-related behaviors is crucial for understanding the state of health in different populations, especially teachers who play a critical role in establishing the lifelong health behaviors of their pupils. This multidisciplinary, nationwide study aimed to assess and compare lifestyle patterns of Austrian teachers and school principals at secondary levels I and II with a specific focus on physical activity and diet. A total number of 1350 teachers (1.5% of the eligible Austrian sample; 69.7% females; 37.7% from urban areas; mean age: 45.8 ± 11.4 years; mean BMI: 24.2 ± 4.0) completed a standardized online survey following an epidemiological approach. Across the total sample, 34.4% were overweight/obese with a greater prevalence of overweight/obesity in males than females (49.5% vs. 29.2%, p < 0.01) and rural vs. urban environments (35.9% vs. 31.3%). Most participants (89.3%) reported a mixed diet, while 7.9% and 2.9% were vegetarians and vegans, respectively. The average BMI of teachers with mixed diets (24.4 ± 4.0 kg/m2) was significantly higher than vegetarians (23.1 ± 3.2 kg/m2) and vegans (22.7 ± 4.3 kg/m2). Vegans reported a lower level of alcohol intake (p < 0.05) among dietary groups. There was no between-group difference in smoking (p > 0.05). The prevalence of engagement in regular physical activity was 88.7% for leisure-time sports/exercises and 29.2% for club sports. Compared with the previous reports on general populations, the present data suggest an acceptable overall health status among Austrian teachers.

The Effectiveness of Sequentially Delivered Web-Based Interventions on Promoting Physical Activity and Fruit-Vegetable Consumption Among Chinese College Students: Mixed Methods Study

Background

Web-based interventions for multiple health behavior change (MHBC) appear to be a promising approach to change unhealthy habits. Limited research has tested this assumption in promoting physical activity (PA) and fruit-vegetable consumption (FVC) among Chinese college students. Moreover, the timing of MHBC intervention delivery and the order of components need to be addressed.

Objective

This study aims to examine the effectiveness of 2 sequentially delivered 8-week web-based interventions on physical activity, FVC, and health-related outcomes (BMI, depression, and quality of life) and the differences in the intervention effects between the 2 sequential delivery patterns. The study also aims to explore participants’ experiences of participating in the health program.

Methods

We conducted a randomized controlled trial, in which 552 eligible college students (mean 19.99, SD 1.04 years, 322/552, 58.3% female) were randomly assigned to 1 of 3 groups: PA-first group (4 weeks of PA followed by 4 weeks of FVC intervention), FVC-first group (4 weeks of FVC followed by 4 weeks of PA intervention), and a control group (8 weeks of placebo treatment unrelated to PA and FVC). The treatment content of two intervention groups was designed based on the Health Action Process Approach (HAPA) framework. A total of four web-based assessments were conducted: at baseline (T1, n=565), after 4 weeks (T2, after the first behavior intervention, n=486), after 8 weeks (T3, after the second behavior intervention, n=420), and after 12 weeks (T4, 1-month postintervention follow-up, n=348). In addition, after the completion of the entire 8-week intervention, 18 participants (mean 19.56, SD 1.04 years, 10/18, 56% female) who completed the whole program were immediately invited to attend one-to-one and face-to-face semistructured interviews. The entire study was conducted during the fall semester of 2017.

Results

The quantitative data supported superior effects on physical activity, FVC, and BMI in the 2 sequential intervention groups compared with the control group. There were no significant differences in physical activity, FVC, and health-related outcomes between the 2 intervention groups after 8 weeks. The FVC-first group contributed to more maintenance of FVC compared with the PA-first group after 12 weeks. Four major themes with several subthemes were identified in the qualitative thematic analysis: PA and FVC behavior, health-related outcomes, correlates of behavior change, and contamination detection.

Conclusions

This study provides empirical evidence for the effectiveness of sequentially delivered, web-based MHBC interventions on PA and FVC among Chinese college students. The timing issue of MHBC intervention delivery was preliminarily addressed. Qualitative findings provide an in-depth understanding and supplement the quantitative findings. Overall, this study may contribute considerably to future web-based MHBC interventions.

Trial Registration

ClinicalTrials.gov NCT03627949; https://clinicaltrials.gov/ct2/show/NCT03627949

International Registered Report Identifier (IRRID)

RR2-10.1186/s12889-019-7438-1