Internet and mobile phone text messaging intervention for college smokers

The effectiveness of digital health technologies for reducing substance use among young people: a systematic review & meta-analysis

BACKGROUND

Substance use amongst young people poses developmental and clinical challenges, necessitating early detection and treatment. Considering the widespread use of technology in young people, delivering interventions digitally may help to reduce and monitor their substance use.

AIMS

We conducted a systematic review and two meta-analyses to assess the effectiveness of digital interventions for reducing substance use (alcohol, smoking, and other substances) among young people aged 10 to 24 years old.

METHOD

Embase, Global Health, Medline, PsychINFO, Web of Science and reference lists of relevant papers were searched in November 2020. Studies were included if they quantitatively evaluated the effectiveness of digital health technologies for treating substance use. A narrative synthesis and meta-analysis were conducted.

RESULTS

Forty-two studies were included in the systematic review and 18 in the meta-analyses. Digital interventions showed small, but statistically significant reductions in weekly alcohol consumption compared to controls (SMD= -0.12, 95% CI= -0.17 to -0.06, I2=0%), but no overall effect was seen on 30-day smoking abstinence (OR = 1.12, 95% CI = 0.70 to 1.80, I2=81%). The effectiveness of digital interventions for reducing substance use is generally weak, however, promising results such as reducing alcohol use were seen. Large-scale studies should investigate the viability of digital interventions, collect user feedback, and determine cost-effectiveness.

PRISMA/PROSPERO

This systematic review was conducted following Cochrane methodology PRISMA guidelines. The review was registered with PROSPERO in November 2020 (CRD42020218442).

A mobile health intervention for emerging adults with regular cannabis use: A micro-randomized pilot trial design protocol

BACKGROUND

Emerging adult (EA) cannabis use is associated with increased risk for health consequences. Just-in-time adaptive interventions (JITAIs) provide potential for preventing the escalation and consequences of cannabis use. Powered by mobile devices, JITAIs use decision rules that take the person's state and context as input, and output a recommended intervention (e.g., alternative activities, coping strategies). The mHealth literature on JITAIs is nascent, with additional research needed to identify what intervention content to deliver when and to whom.

METHODS

Herein we describe the protocol for a pilot study testing the feasibility and acceptability of a micro-randomized trial for optimizing MiWaves mobile intervention app for EAs (ages 18-25; target N = 120) with regular cannabis use (≥3 times per week). Micro-randomizations will be determined by a reinforcement learning algorithm that continually learns and improves the decision rules as participants experience the intervention. MiWaves will prompt participants to complete an in-app twice-daily survey over 30 days and participants will be micro-randomized twice daily to either: no message or a message [1 of 6 types varying in length (short, long) and interaction type (acknowledge message, acknowledge message + click additional resources, acknowledge message + fill in the blank/select an option)]. Participants recruited via social media will download the MiWaves app, and complete screening, baseline, weekly, post-intervention, and 2-month follow-up assessments. Primary outcomes include feasibility and acceptability, with additional exploratory behavioral outcomes.

CONCLUSION

This study represents a critical first step in developing an effective mHealth intervention for reducing cannabis use and associated harms in EAs.

Applying the Just-In-Time Adaptive Intervention Framework to the Development of Gambling Interventions

Just-In-Time Adaptive Interventions (JITAIs) are emerging "push" mHealth interventions that provide the right type, timing, and amount of support to address the dynamically-changing needs for each individual. Although JITAIs are well-suited to the delivery of interventions for the addictions, few are available to support gambling behaviour change. We therefore developed GamblingLess: In-The-Moment and Gambling Habit Hacker, two smartphone-delivered JITAIs that differ with respect to their target populations, theoretical underpinnings, and decision rules. We aim to describe the decisions, methods, and tools we used to design these two treatments, with a view to providing guidance to addiction researchers who wish to develop JITAIs in the future. Specifically, we describe how we applied a comprehensive, organising scientific framework to define the problem, define just-in-time in the context of the identified problem, and formulate the adaptation strategies. While JITAIs appear to be a promising design in addiction intervention science, we describe several key challenges that arose during development, particularly in relation to applying micro-randomised trials to their evaluation, and offer recommendations for future research. Issues including evaluation considerations, integrating on-demand intervention content, intervention optimisation, combining active and passive assessments, incorporating human facilitation, adding cost-effectiveness evaluations, and redevelopment as transdiagnostic interventions are discussed.

The Dosing of Mobile-Based Just-in-Time Adaptive Self-Management Prompts for Caregivers: Preliminary Findings From a Pilot Microrandomized Study

BACKGROUND

Caregivers of people with chronic illnesses often face negative stress-related health outcomes and are unavailable for traditional face-to-face interventions due to the intensity and constraints of their caregiver role. Just-in-time adaptive interventions (JITAIs) have emerged as a design framework that is particularly suited for interventional mobile health studies that deliver in-the-moment prompts that aim to promote healthy behavioral and psychological changes while minimizing user burden and expense. While JITAIs have the potential to improve caregivers' health-related quality of life (HRQOL), their effectiveness for caregivers remains poorly understood.

OBJECTIVE

The primary objective of this study is to evaluate the dose-response relationship of a fully automated JITAI-based self-management intervention involving personalized mobile app notifications targeted at decreasing the level of caregiver strain, anxiety, and depression. The secondary objective is to investigate whether the effectiveness of this mobile health intervention was moderated by the caregiver group. We also explored whether the effectiveness of this intervention was moderated by (1) previous HRQOL measures, (2) the number of weeks in the study, (3) step count, and (4) minutes of sleep.

METHODS

We examined 36 caregivers from 3 disease groups (10 from spinal cord injury, 11 from Huntington disease, and 25 from allogeneic hematopoietic cell transplantation) in the intervention arm of a larger randomized controlled trial (subjects in the other arm received no prompts from the mobile app) designed to examine the acceptability and feasibility of this intensive type of trial design. A series of multivariate linear models implementing a weighted and centered least squares estimator were used to assess the JITAI efficacy and effect.

RESULTS

We found preliminary support for a positive dose-response relationship between the number of administered JITAI messages and JITAI efficacy in improving caregiver strain, anxiety, and depression; while most of these associations did not meet conventional levels of significance, there was a significant association between high-frequency JITAI and caregiver strain. Specifically, administering 5-6 messages per week as opposed to no messages resulted in a significant decrease in the HRQOL score of caregiver strain with an estimate of -6.31 (95% CI -11.76 to -0.12; P=.046). In addition, we found that the caregiver groups and the participants' levels of depression in the previous week moderated JITAI efficacy.

CONCLUSIONS

This study provides preliminary evidence to support the effectiveness of the self-management JITAI and offers practical guidance for designing future personalized JITAI strategies for diverse caregiver groups.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04556591; https://clinicaltrials.gov/ct2/show/NCT04556591.

Barriers to and facilitators of a just-in-time adaptive intervention for respiratory illness in cerebral palsy: a qualitative study

OBJECTIVE

To understand caregiver, healthcare professional and national expert perspectives on implementation of a just-in-time adaptive intervention, RE-PACT (Respiratory Exacerbation-Plans for Action and Care Transitions) to prevent respiratory crises in severe cerebral palsy.

DESIGN

Qualitative research study.

SETTING

Paediatric complex care programmes at two academic medical institutions.

PARTICIPANTS

A total of n=4 focus groups were conducted with caregivers of children with severe cerebral palsy and chronic respiratory illness, n=4 with healthcare professionals, and n=1 with national experts.

METHODS

Participants viewed a video summarising RE-PACT, which includes action planning, mobile health surveillance of parent confidence to avoid hospitalisation and rapid clinical response at times of low confidence. Moderated discussion elicited challenges and benefits of RE-PACT's design, and inductive thematic analysis elicited implementation barriers and facilitators.

RESULTS

Of the 19 caregivers recruited, nearly half reported at least one hospitalisation for their child in the prior year. Healthcare professionals and national experts (n=26) included physicians, nurses, respiratory therapists, social workers and researchers. Four overarching themes and their barriers/facilitators emphasised the importance of design and interpersonal relationships balanced against health system infrastructure constraints. Intervention usefulness in crisis scenarios relies on designing action plans for intuitiveness and accuracy, and mobile health surveillance tools for integration into daily life. Trust, knowledge, empathy and adequate clinician capacity are essential components of clinical responder-caregiver relationships.

CONCLUSIONS

RE-PACT's identified barriers are addressable. Just-in-time adaptive interventions for cerebral palsy appear well-suited to address families' need to tailor intervention content to levels of experience, preference and competing demands.

Using a complexity science approach to evaluate the effectiveness of just-in-time adaptive interventions: A meta-analysis

Objective

Just-in-time adaptive interventions (JITAIs), which allow individuals to receive the right amount of tailored support at the right time and place, hold enormous potential for promoting behavior change. However, research on JITAIs' implementation and evaluation is still in its early stages, and more empirical evidence is needed. This meta-analysis took a complexity science approach to evaluate the effectiveness of JITAIs that promote healthy behaviors and assess whether key design principles can increase JITAIs' impacts.

Methods

We searched five databases for English-language papers. Study eligibility required that interventions objectively measured health outcomes, had a control condition or pre-post-test design, and were conducted in the real-world setting. We included randomized and non-randomized trials. Data extraction encompassed interventions' features, methodologies, theoretical foundations, and delivery modes. RoB 2 and ROBINS-I were used to assess risk of bias.

Results

The final analysis included 21 effect sizes with 592 participants. All included studies used pre- and post-test design. A three-level random meta-analytic model revealed a medium effect of JITAIs on objective behavior change (g = 0.77 (95% confidence interval (CI); 0.32 to 1.22), p < 0.001). The summary effect was robust to bias. Moderator analysis indicated that design principles, such as theoretical foundations, targeted behaviors, and passive or active assessments, did not moderate JITAIs' effects. Passive assessments were more likely than a combination of passive and active assessments to relate to higher intervention retention rates.

Conclusions

This review demonstrated some evidence for the efficacy of JITAIs. However, high-quality randomized trials and data on non-adherence are needed.

Improving outcomes for care partners of persons with traumatic brain injury: Protocol for a randomized control trial of a just-in-time-adaptive self-management intervention

Informal family care partners of persons with traumatic brain injury (TBI) often experience intense stress resulting from their caregiver role. As such, there is a need for low burden, and easy to engage in interventions to improve health-related quality of life (HRQOL) for these care partners. This study is designed to evaluate the effectiveness of a personalized just-in-time adaptive intervention (JITAI) aimed at improving the HRQOL of care partners. Participants are randomized either to a control group, where they wear the Fitbit® and provide daily reports of HRQOL over a six-month (180 day) period (without the personalized feedback), or the JITAI group, where they wear the Fitbit®, provide daily reports of HRQOL and receive personalized self-management pushes for 6 months. 240 participants will be enrolled (n = 120 control group; n = 120 JITAI group). Outcomes are collected at baseline, 1-, 2-, 3-, 4-, 5- & 6-months, as well as 3- and 6-months post intervention. We hypothesize that the care partners who receive the intervention (JITAI group) will show improvements in caregiver strain (primary outcome) and mental health (depression and anxiety) after the 6-month (180 day) home monitoring period. Participant recruitment for this study started in November 2020. Data collection efforts should be completed by spring 2025; results are expected by winter 2025. At the conclusion of this randomized control trial, we will be able to identify care partners at greatest risk for negative physical and mental health outcomes, and will have demonstrated the efficacy of this JITAI intervention to improve HRQOL for these care partners. Trial registration: ClinicalTrial.gov NCT04570930; https://clinicaltrials.gov/ct2/show/NCT04570930.

An App-Based Just-in-Time Adaptive Self-management Intervention for Care Partners (CareQOL): Protocol for a Pilot Trial

BACKGROUND

Care partners (ie, informal family caregivers) of individuals with health problems face considerable physical and emotional stress, often with a substantial negative impact on the health-related quality of life (HRQOL) of both care partners and care recipients. Given that these individuals are often overwhelmed by their caregiving responsibilities, low-burden self-management interventions are needed to support care partners to ensure better patient outcomes.

OBJECTIVE

The primary objective of this study is to describe an intensive data collection protocol that involves the delivery of a personalized just-in-time adaptive intervention that incorporates passive mobile sensor data feedback (sleep and activity data from a Fitbit [Fitbit LLC]) and real time self-reporting of HRQOL via a study-specific app called CareQOL (University of Michigan) to provide personalized feedback via app alerts.

METHODS

Participants from 3 diverse care partner groups will be enrolled (care partners of persons with spinal cord injury, care partners of persons with Huntington disease, and care partners of persons with hematopoietic cell transplantation). Participants will be randomized to either a control group, where they will wear the Fitbit and provide daily reports of HRQOL over a 3-month (ie, 90 days) period (without personalized feedback), or the just-in-time adaptive intervention group, where they will wear the Fitbit, provide daily reports of HRQOL, and receive personalized push notifications for 3 months. At the end of the study, participants will complete a feasibility and acceptability questionnaire, and metrics regarding adherence and attrition will be calculated.

RESULTS

This trial opened for recruitment in November 2020. Data collection was completed in June 2021, and the primary results are expected to be published in 2022.

CONCLUSIONS

This trial will determine the feasibility and acceptability of an intensive app-based intervention in 3 distinct care partner groups: care partners for persons with a chronic condition that was caused by a traumatic event (ie, spinal cord injury); care partners for persons with a progressive, fatal neurodegenerative disease (ie, Huntington disease); and care partners for persons with episodic cancer conditions that require intense, prolonged inpatient and outpatient treatment (persons with hematopoietic cell transplantation).

TRIAL REGISTRATION

ClinicalTrials.gov NCT04556591; https://clinicaltrials.gov/ct2/show/NCT04556591.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/32842.

Multiple lifestyle behaviour mHealth intervention targeting Swedish college and university students: protocol for the Buddy randomised factorial trial

Introduction

The time during which many attend college or university is an important period for developing health behaviours, with potentially major implications for future health. Therefore, it is concerning that many Swedish students excessively consume alcohol, have unhealthy diets, are not physical active and smoke. The potential of digital interventions which integrate support for change of all of these behaviours is largely unexplored, as are the dismantled effects of the individual components that make up digital lifestyle behaviour interventions.

Methods and analysis

A factorial randomised trial (six factors with two levels each) will be employed to estimate the effects of the components of a novel mHealth multiple lifestyle intervention on alcohol consumption, diet, physical activity and smoking among Swedish college and university students. A Bayesian group sequential design will be employed to periodically make decisions to continue or stop recruitment, with simulations suggesting that between 1500 and 2500 participants will be required. Multilevel regression models will be used to analyse behavioural outcomes collected at 2 and 4 months postrandomisation.

Ethics and dissemination

The study was approved by the Swedish Ethical Review Authority on 2020-12-15 (Dnr 2020-05496). The main concern is the opportunity cost if the intervention is found to only have small effects. However, considering the lack of a generally available evidence-based multiple lifestyle behaviour support to university and college students, this risk was deemed acceptable given the potential benefits from the study.

Recruitment will begin in March 2021, and it is expected that recruitment will last no more than 24 months. A final data set will, therefore, be available in July 2023, and findings will be reported no later than December 2023.

Trial registration number

ISRCTN23310640; Pre-results.

Mobile Text Messaging for Tobacco Risk Communication Among Young Adult Community College Students: Randomized Trial of Project Debunk

BACKGROUND

The use of new and emerging tobacco products (NETPs) and conventional tobacco products (CTPs) has been linked to several alarming medical conditions among young adults (YAs). Considering that 96% of YAs own mobile phones, SMS text messaging may be an effective strategy for tobacco risk communication.

OBJECTIVE

Project Debunk is a community-based randomized trial aiming to identify specific types of messages that effectively improve perceived NETP and CTP risk among YAs in community colleges.

METHODS

With YAs recruited offline from 3 campuses at the Houston Community College (September 2016 to July 2017), we conducted a 6-month randomized trial with 8 arms based on the combination of 3 message categories: framing (gain-framed vs loss-framed), depth (simple vs complex), and appeal (emotional vs rational). Participants received fully automated web-based SMS text messages in two 30-day campaigns (2 messages per day). We conducted repeated-measures mixed-effect models stratified by message type received, predicting perceived CTP and NETP risks. Owing to multiple testing with 7 models, an association was deemed significant for P<.007 (.05 divided by 7).

RESULTS

A total of 636 participants completed the baseline survey, were randomized to 1 of 8 conditions (between 73 and 86 participants per condition), and received messages from both campaigns. By the 2-month post campaign 2 assessment point, 70.1% (446/636) completed all outcome measures. By the end of both campaigns, participants had a significant increase in perceived NETP risk over time (P<.001); however, participants had a marginal increase in perceived CTP risk (P=.008). Separately for each group, there was a significant increase in perceived NETP risk among participants who received rational messages (P=.005), those who received emotional messages (P=.006), those who received simple messages (P=.003), and those who received gain-framed messages (P=.003).

CONCLUSIONS

In this trial, YAs had an increase in perceived NETP risk. However, with stratification, we observed a significant increase in perceived NETP risk upon exposure to rational, emotional, simple, and gain-framed messages. In addition, YAs generally had an increase in perceived CTP risk and presented nonsignificant but observable improvement upon exposure to emotional, complex, and loss-framed messages. With the results of this study, researchers and practitioners implementing mobile health programs may take advantage of our tailored messages through larger technology-based programs such as smartphone apps and social media campaigns.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03457480; https://clinicaltrials.gov/ct2/show/NCT03457480.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/10977.

The effectiveness of technology-based interventions for smoking cessation: An umbrella review and quality assessment of systematic reviews

ISSUES

With the advancement and rapid increase in the public's interest in utilisation of Internet and mobile phones, technology-based interventions are being implemented across a range of health conditions to improve patient outcomes. The aim of this review was to summarise findings from systematic reviews that evaluated the effectiveness of technology-based smoking cessation interventions and to critically appraise their methodological qualities.

APPROACH

An umbrella review was conducted using studies identified from a comprehensive literature search of six databases and grey literature. All included systematic reviews were checked for eligibility criteria and quality using the Assessment of Multiple Systematic Reviews tool. The level of evidence for each intervention category was assessed, citation matrices were generated and corrected covered area was calculated.

KEY FINDINGS

Five systematic reviews with a total of 212 randomised controlled trials and 237 760 participants were included. Fourteen intervention approaches were identified and classified into three categories: stand-alone web-based; stand-alone mobile phone-based and multicomponent interventions. Incorporating web and/or mobile-based interventions with face-to-face approach improved the rate of smoking cessation. However, there was no consistent evidence regarding the effectiveness of stand-alone Internet or mobile-based interventions.

IMPLICATIONS

Policymakers are recommended to develop strategies that enable health professionals to integrate these approaches with face-to-face smoking cessation support. Health professionals are recommended to be trained and equipped for online and mobile-based interventions.

CONCLUSION

Adding technology-based intervention to face-to-face smoking cessation support improves smoking cessation. Further research is needed to evaluate stand-alone web-based and mobile phone-based interventions.

Detecting Receptivity for mHealth Interventions in the Natural Environment

Just-In-Time Adaptive Intervention (JITAI) is an emerging technique with great potential to support health behavior by providing the right type and amount of support at the right time. A crucial aspect of JITAIs is properly timing the delivery of interventions, to ensure that a user is receptive and ready to process and use the support provided. Some prior works have explored the association of context and some user-specific traits on receptivity, and have built post-study machine-learning models to detect receptivity. For effective intervention delivery, however, a JITAI system needs to make in-the-moment decisions about a user's receptivity. To this end, we conducted a study in which we deployed machine-learning models to detect receptivity in the natural environment, i.e., in free-living conditions. We leveraged prior work regarding receptivity to JITAIs and deployed a chatbot-based digital coach - Ally - that provided physical-activity interventions and motivated participants to achieve their step goals. We extended the original Ally app to include two types of machine-learning model that used contextual information about a person to predict when a person is receptive: a static model that was built before the study started and remained constant for all participants and an adaptive model that continuously learned the receptivity of individual participants and updated itself as the study progressed. For comparison, we included a control model that sent intervention messages at random times. The app randomly selected a delivery model for each intervention message. We observed that the machine-learning models led up to a 40% improvement in receptivity as compared to the control model. Further, we evaluated the temporal dynamics of the different models and observed that receptivity to messages from the adaptive model increased over the course of the study.

2021 ISHNE/HRS/EHRA/APHRS collaborative statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

2021 ISHNE/ HRS/ EHRA/ APHRS collaborative statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/ Heart Rhythm Society/ European Heart Rhythm Association/ Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

2021 ISHNE / HRS / EHRA / APHRS Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology / Heart Rhythm Society / European Heart Rhythm Association / Asia Pacific Heart Rhythm Society

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology / Heart Rhythm Society / European Heart Rhythm Association / Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

2021 ISHNE/HRS/EHRA/APHRS Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

2021 ISHNE/HRS/EHRA/APHRS Expert Collaborative Statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia-Pacific Heart Rhythm Society describes the current status of mobile health technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mobile health. The promises of predictive analytics but also operational challenges in embedding mobile health into routine clinical care are explored.

Developing an Adaptive Mobile Intervention to Address Risky Substance Use Among Adolescents and Emerging Adults: Usability Study

BACKGROUND

Substance use among adolescents and emerging adults continues to be an important public health problem associated with morbidity and mortality. Mobile health (mHealth) provides a promising approach to deliver just-in-time adaptive interventions (JITAIs) to prevent escalation of use and substance use-related consequences.

OBJECTIVE

This pilot study aims to describe the iterative development and initial feasibility and acceptability testing of an mHealth smartphone app, called MiSARA, designed to reduce escalation in substance use.

METHODS

We used social media advertisements to recruit youth (n=39; aged 16-24 years, who screened positive for past-month binge drinking or recreational cannabis use) with a waiver of parental consent. Participants used the MiSARA app for 30 days, with feasibility and acceptability data reported at a 1-month follow-up. We present descriptive data regarding behavior changes over time.

RESULTS

The results show that most participants (31/39, 79%) somewhat liked the app at least, with most (29/39, 74%) rating MiSARA as 3 or more stars (out of 5). Almost all participants were comfortable with self-reporting sensitive information within the app (36/39, 92%); however, most participants also desired more interactivity (27/39, 69%). In addition, participants' substance use declined over time, and those reporting using the app more often reported less substance use at the 1-month follow-up than those who reported using the app less often.

CONCLUSIONS

The findings suggest that the MiSARA app is a promising platform for JITAI delivery, with future trials needed to optimize the timing and dose of messages and determine efficacy.

Microrandomized Trial Design for Evaluating Just-in-Time Adaptive Interventions Through Mobile Health Technologies for Cardiovascular Disease

Smartphone and wearable device use is rising broadly and can be leveraged for chronic disease management. Just-in-time adaptive interventions promise to deliver personalized, dynamic interventions directly to patients through use of push notifications from mobile devices. Although just-in-time adaptive interventions are a powerful tool for shaping health behavior, their application to cardiovascular disease management has been limited as they can be challenging to design. Herein, we provide a general overview and conceptual framework for microrandomized trials, a novel experimental study design that can be used to optimize just-in-time adaptive interventions. Microrandomized trials leverage mobile devices to sequentially randomize participants to types or levels of an intervention to determine the effectiveness of an intervention and time-varying moderators of those effects. Microrandomized trials are an efficient study design that can be used to determine which intervention components to include in just-in-time adaptive interventions and to optimize their decision rules while maintaining the strength of causal inference associated with traditional randomized controlled trials.

Korean American Smokers' Perspectives on Mobile Smoking Cessation Applications

Introduction:

The primary purpose of this research is to investigate the adoption process of mobile smoking cessation apps for Korean American smokers with the eventual purpose of proposing a new combined model of smartphone smoking cessation adoption.

Methods:

From September 2018 to March 2019, a total of 227 Korean American smokers responded to surveys regarding the effectiveness of mobile applications for smoking cessation. A path analysis was used to analyze the predictors of adopting and using smoking cessation applications available via smartphones.

Results:

Perceived benefits and self-efficacy were important factors for influencing the perceived usefulness of a smoking cessation mobile app. Moreover, the perceived usefulness of a smoking cessation mobile app was also positively related to intention to use a smoking cessation mobile app.

Conclusion:

Although mobile smoking cessation apps can help many individuals quit smoking, most Korean American smokers are not current users of smoking cessation mobile apps. Therefore, there is a strong need to use strategic evidence-based communication interventions for promoting the widespread adoption of smoking cessation applications.

Just-in-the-Moment Adaptive Interventions (JITAI): A Meta-Analytical Review

A just-in-time, adaptive intervention (JITAI) is an emerging type of intervention that provides tailored support at the exact time of need. It does so using enabling new technologies (e.g., mobile phones, sensors) that capture the changing states of individuals. Extracting effect sizes of primary outcomes produced by 33 empirical studies that used JITAIs, we found moderate to large effect sizes of JITAI treatments compared to (1) waitlist-control conditions (k = 9), Hedges's g = 1.65 and (2) non-JITAI treatments (k = 21), g = 0.89. Also, participants of JITAI interventions showed significant changes (k = 13) in the positive direction (g = 0.79). A series of sensitivity tests suggested that those effects persist. Those effects also persist despite differences in the behaviors of interests (e.g., blood glucose control, recovering alcoholics), duration of the treatments, and participants' age. Two aspects of tailoring, namely: (1) tailoring to what (i.e., both people's previous behavioral patterns and their current need states; with these effects additive) and (2) approach to tailoring (i.e., both using a human agent and an algorithm to decide tailored feedback; with these effects additive), are significantly associated with greater JITAI efficacy.

mHealth for pediatric chronic pain: state of the art and future directions

INTRODUCTION

Chronic pain conditions are common among children and engender cascading effects across social, emotional, and behavioral domains for the child and family. Mobile health (mHealth) describes the practice of delivering healthcare via mobile devices and may be an ideal solution to increase access and reach of evidence-based behavioral health interventions.

AREAS COVERED

The aim of this narrative review is to present a state-of-the-art overview of evidence-based mHealth efforts within the field of pediatric chronic pain and consider new and promising directions for study. Given the nascent nature of the field, published mHealth interventions in all stages of development are discussed. Literature was identified through a non-systematic search in PubMed and Google Scholar, and a review of reference lists of papers that were identified as particularly relevant or foundational (within and outside of the chronic pain literature).

EXPERT OPINION

mHealth is a promising interventional modality with early evidence suggesting it is primed to enhance behavioral health delivery and patient outcomes. There are many exciting future directions to be explored including drawing inspiration from digital health technology to generate new ways of thinking about the optimal treatment of pediatric chronic pain.

Perceived usefulness of receiving a potential smoking cessation intervention via mobile phones among smokers in Indonesia

Background: The use of technology to support healthcare in Indonesia holds new promise in light of decreasing costs of owning mobile devices and ease of access to internet. However, it is necessary to assess end-user perceptions regarding mobile health interventions prior to its implementation. This would throw light on the acceptability of mobile phone communication in bringing about behavioral changes among the target Indonesian population. The aim of this study was to explore the perceived usefulness of receiving a potential smoking cessation intervention via mobile phones. Methods: This is an exploratory cross-sectional study involving current and former adult tobacco smokers residing in Indonesia. Online advertisement and snowballing were used to recruit respondents. Data was collected using a web-based survey over a period of 4 weeks. Those willing to participate signed an online consent and were subsequently directed to the online questionnaire that obtained demographics, tobacco usage patterns, perceived usefulness of a mobile phone smoking cessation application and its design. Results: A total of 161 people who smoked tobacco responded to the online survey. The mean age of the participants was 29.4. Of the 123 respondents, 102 were men. Prior experience with using a mobile phone for health communication (OR 3.6, P=0.014) and those willing to quit smoking (OR 5.1, P=0.043) were likely to perceive a mobile phone smoking cessation intervention as useful. A smartphone application was preferred over text messages, media messages or interactive voice response technology. Content consisting of motivational messages highlighting the methods and benefits of quitting smoking were requested. Conclusion: People who smoke in Indonesia perceived receiving a potential smoking cessation intervention via mobile phones as useful. A multi-component, personalized smartphone application was the desired intervention technique. Such an intervention developed and implemented within a public health program could help address the tobacco epidemic in Indonesia.

A Systematic Review of Recent Methodological Approaches for Using Ecological Momentary Assessment to Examine Outcomes in U.S. Based HIV Research

PURPOSE OF REVIEW

In recent years, researchers have been adopting and using ecological momentary assessment (EMA) methods via technology devices for real-time measurement of exposures and outcomes in HIV research. To assess and critically evaluate how EMA methods are currently being used in HIV research, we systematically reviewed recent published literature (October 2017-October 2019) and searched select conference databases for 2018 and 2019.

RECENT FINDINGS

Our searches identified 8 published articles that used EMA via smartphone app, a handheld Personal Digital Assistant, and web-based survey programs for real-time measurement of HIV-related exposures and outcomes in behavioral research. Overall trends include use of EMA and technology devices to address substance use, HIV primary prevention (e.g., condom use and preexposure prophylaxis), and HIV treatment (medication adherence). This review supports the use of EMA methods in HIV research and recommends that researchers use EMA methods to measure psychosocial factors and social contexts and with Black and Latinx samples of gay and bisexual men, transgender women, and cisgendered women to reflect current HIV disparities in the U.S.A.

Virtual Reality Smartphone-Based Intervention for Smoking Cessation: Pilot Randomized Controlled Trial on Initial Clinical Efficacy and Adherence

BACKGROUND

Obstacles to current tobacco cessation programs include limited access and adherence to effective interventions. Digital interventions offer a great opportunity to overcome these difficulties, yet virtual reality has not been used as a remote and self-administered tool to help increase adherence and effectiveness of digital interventions for tobacco cessation.

OBJECTIVE

This study aimed to evaluate participant adherence and smoking cessation outcomes in a pilot randomized controlled trial of the digital intervention Mindcotine (MindCotine Inc) using a self-administered treatment of virtual reality combined with mindfulness.

METHODS

A sample of 120 participants was recruited in the city of Buenos Aires, Argentina (mean age 43.20 years, SD 9.50; 57/120, 47.5% female). Participants were randomly assigned to a treatment group (TG), which received a self-assisted 21-day program based on virtual reality mindful exposure therapy (VR-MET) sessions, daily surveys, and online peer-to-peer support moderated by psychologists, or a control group (CG), which received the online version of the smoking cessation manual from the Argentine Ministry of Health. Follow-up assessments were conducted by online surveys at postintervention and 90-day follow-up. The primary outcome was self-reported abstinence at postintervention, with missing data assumed as still smoking. Secondary outcomes included sustained abstinence at 90-day follow-up, adherence to the program, and readiness to quit.

RESULTS

Follow-up rates at day 1 were 93% (56/60) for the TG and 100% (60/60) for the CG. At postintervention, the TG reported 23% (14/60) abstinence on that day compared with 5% (3/60) in the CG. This difference was statistically significant (χ²₁=8.3; P=.004). The TG reported sustained abstinence of 33% (20/60) at 90 days. Since only 20% (12/60) of participants in the CG completed the 90-day follow-up, we did not conduct a statistical comparison between groups at this follow-up time point. Among participants still smoking at postintervention, the TG was significantly more ready to quit compared to the CG (TG: mean 7.71, SD 0.13; CG: mean 7.16, SD 0.13; P=.005). A total of 41% (23/56) of participants completed the treatment in the time frame recommended by the program.

CONCLUSIONS

Results provide initial support for participant adherence to and efficacy of Mindcotine and warrant testing the intervention in a fully powered randomized trial. However, feasibility of trial follow-up assessment procedures for control group participants needs to be improved. Further research is needed on the impact of VR-MET on long-term outcomes.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN50586181; http://www.isrctn.com/ISRCTN50586181.

Toward a unifying theory of dysregulated behaviors

Dysregulated behaviors, defined as active behaviors that have short-term benefits but cause serious recurrent long-term distress or impairment to the individual and/or those around them, include behaviors such as suicidal and nonsuicidal self-injury, aggression, and substance use. These behaviors are common and costly to the individual, their friends and family, and society. Despite similar etiological models and interventions, dysregulated behaviors have largely been studied in isolation from one another. The goals of this paper were to a) define dysregulated behaviors as a coherent class of behaviors, b) review the prevalence and consequences of dysregulated behaviors, c) outline how dysregulated behaviors fit into current models of psychopathology, and d) describe the key questions to be addressed by future research in this area. It is argued that integrating across theories of discrete dysregulated behaviors can help provide aid in the development of etiological models, which in turn can improve prevention and intervention for dysregulated behaviors.

Microrandomized trials for promoting engagement in mobile health data collection: Adolescent/young adult oral chemotherapy adherence as an example

Long-term engagement with mobile health (mHealth) apps can provide critical data for improving empirical models for real-time health behaviors. To learn how to improve and maintain mHealth engagement, micro-randomized trials (MRTs) can be used to optimize different engagement strategies. In MRTs, participants are sequentially randomized, often hundreds or thousands of times, to different engagement strategies or treatments. The data gathered are then used to decide which treatment is optimal in which context. In this paper, we discuss an example MRT for youth with cancer, where we randomize different engagement strategies to improve self-reports on factors related to medication adherence. MRTs, moreover, can go beyond improving engagement, and we reference other MRTs to address substance abuse, sedentary behavior, and so on.

Exploring the State-of-Receptivity for mHealth Interventions

Recent advancements in sensing techniques for mHealth applications have led to successful development and deployments of several mHealth intervention designs, including Just-In-Time Adaptive Interventions (JITAI). JITAIs show great potential because they aim to provide the right type and amount of support, at the right time. Timing the delivery of a JITAI such as the user is receptive and available to engage with the intervention is crucial for a JITAI to succeed. Although previous research has extensively explored the role of context in users' responsiveness towards generic phone notifications, it has not been thoroughly explored for actual mHealth interventions. In this work, we explore the factors affecting users' receptivity towards JITAIs. To this end, we conducted a study with 189 participants, over a period of 6 weeks, where participants received interventions to improve their physical activity levels. The interventions were delivered by a chatbot-based digital coach - Ally - which was available on Android and iOS platforms. We define several metrics to gauge receptivity towards the interventions, and found that (1) several participant-specific characteristics (age, personality, and device type) show significant associations with the overall participant receptivity over the course of the study, and that (2) several contextual factors (day/time, phone battery, phone interaction, physical activity, and location), show significant associations with the participant receptivity, in-the-moment. Further, we explore the relationship between the effectiveness of the intervention and receptivity towards those interventions; based on our analyses, we speculate that being receptive to interventions helped participants achieve physical activity goals, which in turn motivated participants to be more receptive to future interventions. Finally, we build machine-learning models to detect receptivity, with up to a 77% increase in F1 score over a biased random classifier.

Just-in-Time Adaptive Interventions (JITAIs) in Mobile Health: Key Components and Design Principles for Ongoing Health Behavior Support

Background

The just-in-time adaptive intervention (JITAI) is an intervention design aiming to provide the right type/amount of support, at the right time, by adapting to an individual's changing internal and contextual state. The availability of increasingly powerful mobile and sensing technologies underpins the use of JITAIs to support health behavior, as in such a setting an individual's state can change rapidly, unexpectedly, and in his/her natural environment.

Purpose

Despite the increasing use and appeal of JITAIs, a major gap exists between the growing technological capabilities for delivering JITAIs and research on the development and evaluation of these interventions. Many JITAIs have been developed with minimal use of empirical evidence, theory, or accepted treatment guidelines. Here, we take an essential first step towards bridging this gap.

Methods

Building on health behavior theories and the extant literature on JITAIs, we clarify the scientific motivation for JITAIs, define their fundamental components, and highlight design principles related to these components. Examples of JITAIs from various domains of health behavior research are used for illustration.

Conclusions

As we enter a new era of technological capacity for delivering JITAIs, it is critical that researchers develop sophisticated and nuanced health behavior theories capable of guiding the construction of such interventions. Particular attention has to be given to better understanding the implications of providing timely and ecologically sound support for intervention adherence and retention.

Mobile phone text messaging and app-based interventions for smoking cessation

BACKGROUND

Mobile phone-based smoking cessation support (mCessation) offers the opportunity to provide behavioural support to those who cannot or do not want face-to-face support. In addition, mCessation can be automated and therefore provided affordably even in resource-poor settings. This is an update of a Cochrane Review first published in 2006, and previously updated in 2009 and 2012.

OBJECTIVES

To determine whether mobile phone-based smoking cessation interventions increase smoking cessation rates in people who smoke.

SEARCH METHODS

For this update, we searched the Cochrane Tobacco Addiction Group's Specialised Register, along with clinicaltrials.gov and the ICTRP. The date of the most recent searches was 29 October 2018.

SELECTION CRITERIA

Participants were smokers of any age. Eligible interventions were those testing any type of predominantly mobile phone-based programme (such as text messages (or smartphone app) for smoking cessation. We included randomised controlled trials with smoking cessation outcomes reported at at least six-month follow-up.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures described in the Cochrane Handbook for Systematic Reviews of Interventions. We performed both study eligibility checks and data extraction in duplicate. We performed meta-analyses of the most stringent measures of abstinence at six months' follow-up or longer, using a Mantel-Haenszel random-effects method, pooling studies with similar interventions and similar comparators to calculate risk ratios (RR) and their corresponding 95% confidence intervals (CI). We conducted analyses including all randomised (with dropouts counted as still smoking) and complete cases only.

MAIN RESULTS

This review includes 26 studies (33,849 participants). Overall, we judged 13 studies to be at low risk of bias, three at high risk, and the remainder at unclear risk. Settings and recruitment procedures varied across studies, but most studies were conducted in high-income countries. There was moderate-certainty evidence, limited by inconsistency, that automated text messaging interventions were more effective than minimal smoking cessation support (RR 1.54, 95% CI 1.19 to 2.00; I² = 71%; 13 studies, 14,133 participants). There was also moderate-certainty evidence, limited by imprecision, that text messaging added to other smoking cessation interventions was more effective than the other smoking cessation interventions alone (RR 1.59, 95% CI 1.09 to 2.33; I² = 0%, 4 studies, 997 participants). Two studies comparing text messaging with other smoking cessation interventions, and three studies comparing high- and low-intensity messaging, did not show significant differences between groups (RR 0.92 95% CI 0.61 to 1.40; I² = 27%; 2 studies, 2238 participants; and RR 1.00, 95% CI 0.95 to 1.06; I² = 0%, 3 studies, 12,985 participants, respectively) but confidence intervals were wide in the former comparison. Five studies compared a smoking cessation smartphone app with lower-intensity smoking cessation support (either a lower-intensity app or non-app minimal support). We pooled the evidence and deemed it to be of very low certainty due to inconsistency and serious imprecision. It provided no evidence that smartphone apps improved the likelihood of smoking cessation (RR 1.00, 95% CI 0.66 to 1.52; I² = 59%; 5 studies, 3079 participants). Other smartphone apps tested differed from the apps included in the analysis, as two used contingency management and one combined text messaging with an app, and so we did not pool them. Using complete case data as opposed to using data from all participants randomised did not substantially alter the findings.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that automated text message-based smoking cessation interventions result in greater quit rates than minimal smoking cessation support. There is moderate-certainty evidence of the benefit of text messaging interventions in addition to other smoking cessation support in comparison with that smoking cessation support alone. The evidence comparing smartphone apps with less intensive support was of very low certainty, and more randomised controlled trials are needed to test these interventions.

What Do Smokers Want in A Smartphone-Based Cessation Application?

Background

Fueled by rapid technological advances over the past decade, there is growing interest in the use of smartphones to aid in smoking cessation. Hundreds of applications have been developed for this purpose, but little is known about how these applications are accessed and used by smokers or what features smokers believe would be most useful.

Purpose

The present study sought to understand the prevalence of smartphone ownership and patterns of use among smokers as well as the perceived utility of various smartphone application features for smoking cessation that are currently in development or already available.

Methods

Daily cigarette smokers (n = 224) reported on smartphone ownership, their patterns of smartphone usage, and perceived utility of features. Features were ranked according to perceived utility and differences in both perceived utility and general smartphone use patterns were examined as a function of demographic and smoking-related variables.

Results

Most smokers (80.4%) own a smartphone, but experience with smoking cessation applications is extremely rare (6.1%). Ownership and patterns of usage differed as a function of demographic and smoking-related variables. Overall, gain-framed features were rated as most useful, while loss-framed and interpersonal features were rated as least useful.

Conclusions

Mobile health interventions have the potential to reach a large number of smokers but are currently underutilized. Additional effort is needed to ensure parity in treatment access. Gain-framed messages may be especially useful for engaging smokers, even if other features ultimately drive treatment effects.

Implications

This study describes patterns of smartphone usage among smokers and identifies the smartphone application features smokers believe would be most useful during a quit attempt. Findings indicate which subgroups of smokers are most likely to be reached with mobile health interventions and suggests that inclusion of specific features may be helpful for engaging smokers in the smoking cessation process.

Mobile messaging and smartphone apps for patient communication and engagement in spine surgery

Mobile health (mHealth) applications are rapidly becoming increasingly available to patients. These interventions utilize simple mobile messaging (SMS) and software applications on mobile devices for a variety of purposes. In the surgical population mHealth applications have shown promise in increasing medication and protocol adherence, monitoring patients after surgery, and helping modify behaviors associated with poor surgical outcomes. There is a paucity of spine specific applications at this time. Further development and study of efficacy of spine specific mHealth applications is needed.

Perceived usefulness of receiving a potential smoking cessation intervention via mobile phones among smokers in Indonesia

Background: The use of technology to support healthcare in Indonesia holds new promise in light of decreasing costs of owning mobile devices and ease of access to internet. However, it is necessary to assess end-user perceptions regarding mobile health interventions prior to its implementation. This would throw light on the acceptability of mobile phone communication in bringing about behavioural changes among the target Indonesian population. The aim of this study was to explore the perceived usefulness of receiving a potential smoking cessation intervention via mobile phones. Methods: This is an exploratory cross-sectional study involving current and former adult tobacco smokers residing in Indonesia. Online advertisement and snowballing were used to recruit respondents. Data was collected using a web-based survey over a period of 4 weeks. Those willing to participate signed an online consent and were subsequently directed to the online questionnaire that obtained demographics, tobacco usage patterns, perceived usefulness of a mobile phone smoking cessation application and its design. Results: A total of 161 people who smoked tobacco responded to the online survey. The mean age of the participants was 29.4. Of the 123 respondents, 102 were men. Prior experience with using a mobile phone for health communication (OR 3.6, P=0.014) and those willing to quit smoking (OR 5.1, P=0.043) were likely to perceive a mobile phone smoking cessation intervention as useful. A smartphone application was preferred over text messages, media messages or interactive voice response technology. Content comprising of motivational messages highlighting the methods and benefits of quitting smoking were requested. Conclusion: People who smoke in Indonesia perceived receiving a potential smoking cessation intervention via mobile phones as useful. A multi-component, personalized smartphone application was the desired intervention technique. Such an intervention developed and implemented within a public health program could help address the tobacco epidemic in Indonesia.

Mobile Intervention for Individuals With Psychosis, Dual Disorders, and Their Common Comorbidities: A Literature Review

Over 50% of people diagnosed with a severe mental illness, such as schizophrenia or bipolar disorder, will meet criteria for a substance use disorder in their lifetime. This dual disorder often starts during youth and leads to significant societal costs, including lower employability rates, more hospitalizations, and higher risk of homelessness and of suicide attempts when compared to those with a serious mental illness without substance misuse. Moreover, many individuals presenting with comorbid disorders also present with other psychological difficulties as well, such as personality disorders or anxiety and depression, also known as complex comorbid disorders. Transdiagnostic treatments that focus on core difficulties found in people with complex dual disorders, such as emotional regulation, are direly needed. Emotional regulation skills can help reduce distress related to psychotic symptoms and maintain abstinence in substance use disorders. New technologies in the field of communications have developed considerably over the past decade and have the potential to improve access to such treatments, a major problem in many health care settings. As such, this paper aims at: presenting core difficulties present in many individuals with dual disorders, reviewing the scientific literature pertaining to the use of mobile applications in mental health and addictions, and presenting the development and potential of a new application for emotional regulation for people with dual disorders.

Mobile Phone-Based Smoking-Cessation Intervention for Patients Undergoing Elective Surgery: Protocol for a Randomized Controlled Trial

Background

Several large studies have shown that the risk of cardiovascular, respiratory, and wound-healing complications (including death) within 30 days of surgery is greater for smokers than for nonsmokers. However, there is evidence that even short-term perioperative smoking cessation may reduce postoperative morbidity. Over the past few years, it has become more evident that short message service (SMS)–based interventions can help individuals quit smoking.

Objective

The overall aim of this project is to fill the knowledge gap on whether an SMS-based smoking-cessation intervention can be effective in helping patients stop smoking perioperatively. The aim of this trial is to evaluate the effectiveness of an SMS-based intervention on smoking behavior of patients undergoing elective surgery.

Methods

A two-arm parallel-group randomized controlled trial will be conducted at 20 surgical departments in southeast Sweden. Smokers undergoing elective surgery who own a mobile phone will be included. Power calculations indicate that it will be necessary to randomize 434 participants. One group will be given access to a novel 12-week SMS program, which includes daily SMS messages with behavior change–enforcing text content and hyperlinks to interactive modules, while the other group will not be given access to the intervention. Both groups will have access to the surgical departments’ current routine for smoking cessation prior to surgery. Primary outcome measures, prolonged abstinence, and point prevalence of smoking cessation will be measured through questionnaires at 3, 6, and 12 months after randomization. Logistic regression models adjusted using baseline characteristics will be explored to identify potential effects of the intervention.

Results

Recruitment started in late October 2018 and is expected to last for a maximum of 30 months. The first results are expected to be available approximately 3 months after the final date of recruitment.

Conclusions

Owing to the structural problems and scarcity of time and resources, patients at most Swedish surgical departments are simply instructed to quit smoking, and perhaps, referred to a primary health care clinic. An SMS-based smoking-cessation aid can be effective in helping individuals quit smoking and is a very simple and time-efficient tool for surgical departments to use.

Trial Registration

ISRCTN Registry ISRCTN33869008; http://www.isrctn.com/ISRCTN33869008

International Registered Report Identifier (IRRID)

PRR1-10.2196/12511

Proactive text messaging (GetReady2Quit) and nicotine replacement therapy to promote smoking cessation among smokers in primary care: A pilot randomized trial protocol

INTRODUCTION

Most smokers see a physician each year, but few use any assistance when they try to quit. Text messaging programs improve smoking cessation in community and school settings; however, their efficacy in a primary care setting is unclear. The current trial assesses the feasibility and preliminary clinical outcomes of text messaging and mailed nicotine replacement therapy (NRT) among smokers in primary care.

METHODS

In this single-center pilot randomized trial, eligible smokers in primary care are offered brief advice by phone and randomly assigned to one of four interventions: (1) Brief advice only, (2) text messages targeted to primary care patients and tailored to quit readiness, (3) a 2-week supply of nicotine patches and/or lozenges (NRT), and (4) both text messaging and NRT. Randomization is stratified by practice and intention to quit. The text messages (up to 5/day) encourage those not ready to quit to practice a quit attempt, assist those with a quit date through a quit attempt, and promote NRT use. The 2-week supply of NRT is mailed to patients' homes.

RESULTS

Feasibility outcomes include recruitment rates, study retention, and treatment adherence. Clinical outcomes are assessed at 1, 2, 6, and 12-weeks post-enrollment. The primary outcome is ≥1self-reported quit attempt(s). Secondary clinical outcomes include self-reported past 7- and 30-day abstinence, days not smoked, NRT adherence, and exhaled carbon monoxide.

CONCLUSIONS

This pilot assesses text messaging plus NRT, as a proactively offered intervention for smoking cessation support in smokers receiving primary care and will inform full-scale randomized trial planning.

TRIAL REGISTRATION

ClinicalTrials.govNCT03174158.

Mobile technology use and mHealth text message preferences: an examination of gender, racial, and ethnic differences among emerging adult college students

BACKGROUND

Mobile health (mHealth) interventions are a potentially feasible way of targeting emerging adult college students' physical and mental health concerns, decreasing health-risk, and augmenting health promoting behaviors. However, there is limited evidence attesting to advantageous ways of designing mHealth treatments in a manner that is apt to be well-received by emerging adult college students at large, and gender, racial, and ethnic subgroups in particular. To address these research gaps, this exploratory study examined general trends, and gender (male, female), racial (White, Black), and ethnic (Latino, non-Latino) differences, in emerging adult college students' mobile technology ownership and phone plan characteristics, technology use behaviors, and mHealth text message preferences.

METHODS

Participants included 1,371 college students aged 18 to 25 (20.54±1.80) years. Between July 2015 and April 2016, students from three universities in the Mid-Atlantic United States completed an online survey assessing technology use. Descriptive statistics and chi-square tests were run to answer primary study questions.

RESULTS

Results suggest that students frequently engage with mobile devices and inherent features. Overall, nearly all (99.5%) students owned smartphones, 89.5% had long-term phone contracts, 94.6% had unlimited texting, and 38.6% reported having unlimited data plans. Further, 96.8% reported texting, 92.0% accessing email, 97.3% accessing the internet, and 97.2% using apps on their mobile devices at least once per day. When asked about the types of text messages they would prefer to receive in the context of mHealth interventions, most students preferred messages that did not contain textese, were longer vs. shorter, contained a single vs. multiple exclamation marks, had a smiley face emoticon, used capitalization for emphatic purposes, contained a statement vs. a question, were polite in tone, and were non-directive. There was also multiple gender, racial, and ethnic group differences in mobile device ownership and plan attributes, usage patterns, and text message preferences.

CONCLUSIONS

The present research provides evidence that smartphones are commonly used by college students and may be a feasible platform for health intervention delivery among diverse student groups. mHealth interventions could use the present results to inform the design of future mHealth interventions and, in turn, increase the acceptability, usability, and efficacy of such treatments for college students at large and diverse student groups in particular.

Mobile Phone Text Messaging for Tobacco Risk Communication Among Young Adult Community College Students: Protocol and Baseline Overview for a Randomized Controlled Trial

Background

Community-college students are at high risk for tobacco use. Because the use of mobile phone text messaging is nearly ubiquitous today, short message service (SMS) may be an effective strategy for tobacco risk communication in this population. Little is known, however, concerning the message structure significantly influencing perceived tobacco risk.

Objective

We aim to outline the rationale and design of Project Debunk, a randomized trial comparing the effects of different SMS text message structures.

Methods

We conducted a 6-month randomized trial comparing 8 arms, based on the combination of the 3 message structures delivered to young adults in a 2×2×2 study design: framing (gain-framed or loss-framed), depth (simple or complex), and appeal (emotional or rational). Participants were invited to participate from 3 community colleges in Houston from September 2016 to July 2017. Participants were randomized to 1 arm and received text messages in 2 separate campaigns. Each campaign consisted of 2 text messages per day for 30 days. Perceived tobacco risk was assessed at baseline, 2 months after the first campaign, and 2 months after the second campaign. We assessed the perceived risk of using conventional products (eg, combustible cigarettes) and new and emerging products (eg, electronic cigarettes). The validity of message structures was assessed weekly for each campaign. A 1-week follow-up assessment was also conducted to understand immediate reactions from participants.

Results

We completed data collection for the baseline survey on a rolling basis during this time and assessed the validity of the message structure after 1 week of SMS text messages. For the entire sample (N=636), the average age was 20.92 years (SD 2.52), about two-thirds were male (430/636, 67.6%), and most were black or African American (259/636, 40.7%) or white (236/636, 37.1%). After 1 week of receiving text messages, the following was noted: (a) loss-framed messages were more likely to be perceived as presenting a loss than gain-framed messages (F_7,522=13.13, P<.001), (b) complex messages were perceived to be more complex than simple messages (F_7,520=2.04, P=.05), and (c) emotional messages were perceived to be more emotionally involving than rational messages (F_7,520=6.46, P<.001).

Conclusions

This study confirms that the recruitment, randomization, and message composition have been successfully implemented. Further analyses will identify specific types of messages that are more effective than others in increasing the perceived risk of tobacco use. If our results suggest that any of the 8 specific message structures are more effective for helping young adults understand tobacco risk, this would provide evidence to include such messages as part of a larger technology-based campaign such as mobile phone apps, entertainment-based campaigns, and social media.

Trial Registration

ClinicalTrials.gov NCT03457480; https://clinicaltrials.gov/ct2/show/NCT03457480 (Archived by WebCite at http://www.webcitation.org/6ykd4IIap)

Registered Report Identifier

RR1-10.2196/10977

Peer-Based Social Media Features in Behavior Change Interventions: Systematic Review

Background

Incorporating social media features into digital behavior change interventions (DBCIs) has the potential to contribute positively to their success. However, the lack of clear design principles to describe and guide the use of these features in behavioral interventions limits cross-study comparisons of their uses and effects.

Objective

The aim of this study was to provide a systematic review of DBCIs targeting modifiable behavioral risk factors that have included social media features as part of their intervention infrastructure. A taxonomy of social media features is presented to inform the development, description, and evaluation of behavioral interventions.

Methods

Search terms were used in 8 databases to identify DBCIs that incorporated social media features and targeted tobacco smoking, diet and nutrition, physical activities, or alcohol consumption. The screening and review process was performed by 2 independent researchers.

Results

A total of 5264 articles were screened, and 143 articles describing a total of 134 studies were retained for full review. The majority of studies (70%) reported positive outcomes, followed by 28% finding no effects with regard to their respective objectives and hypothesis, and 2% of the studies found that their interventions had negative outcomes. Few studies reported on the association between the inclusion of social media features and intervention effect. A taxonomy of social media features used in behavioral interventions has been presented with 36 social media features organized under 7 high-level categories. The taxonomy has been used to guide the analysis of this review.

Conclusions

Although social media features are commonly included in DBCIs, there is an acute lack of information with respect to their effect on outcomes and a lack of clear guidance to inform the selection process based on the features’ suitability for the different behaviors. The proposed taxonomy along with the set of recommendations included in this review will support future research aimed at isolating and reporting the effects of social media features on DBCIs, cross-study comparisons, and evaluations.

HealthyhornsTXT: A Text-Messaging Program to Promote College Student Health and Wellness

Objective: Text-messaging interventions positively affect health behaviors, but their use on college campuses has been limited. Text messaging serves as a relatively affordable way to communicate with large audiences and is one of the preferred modes of communication for young adults. This study examined the feasibility and acceptability of a campus-wide, health text–messaging program. Participants: The subscriber pool consisted of approximately 6,000 undergraduate students from a large, southern university. From that pool, 1,095 participants (64% female; 41% White) completed a posttest survey. Method: Text messages covered a range of health topics and information about campus resources. Research was conducted from August through December 2015. Process data were collected throughout the semester; participants’ attitudes were assessed via an online survey at the program’s conclusion. Results: Students demonstrated engagement with the messages throughout the semester as evidenced by replies to text-back keywords and clicks on website links embedded within messages. Messages about sleep, stress management, and hydration were considered most relevant. The majority of participants (61%) reported increased awareness regarding their health. Conclusions: Text-messaging interventions are a feasible strategy to improve college student health.

Feasibility of a proactive text messaging intervention for smokers in community health centers

Background

Few smokers receive evidence-based cessation services during primary care visits.

Objective

We aimed to assess the feasibility of a proactive text messaging program for primary care patients who smoke.

Methods

We used electronic health records to identify smokers who had a mobile phone number listed from two community health centers in Massachusetts. Between March 2014 and June 2015, patients were screened by their primary care physician and then sent a proactive text message inviting them to enroll by texting back. Patients who opted in were asked about their readiness to quit. The text message program included messages from the QuitNowTXT library and novel content for smokers who were not ready to quit.

Results

Among 949 eligible smokers, 88 (9.3%) enrolled after receiving a single proactive text message. Compared with those who did not enroll, enrollees were more often female (54/88, 61% vs 413/861, 48.0%, P=.02), but otherwise did not differ in age, race, insurance status, or comorbidities. In all, 28% (19/67) of enrollees reported they were not ready to quit in the next 30 days, 61% (41/67) were ready to quit, and 11% (7/67) already quit. The median time in the program was 9 days (interquartile range 2-32 days). Of current smokers, 25% (15/60) sent one or more keyword requests to the server. These did not differ by readiness to quit.

Conclusions

A proactively delivered text messaging program targeting primary care patients who smoke was feasible and engaged both smokers ready to quit and those not ready to quit. This method shows promise as part of a population health model for addressing tobacco use outside of the primary care office.

Development of a Just-in-Time Adaptive Intervention for Smoking Cessation Among Korean American Emerging Adults

PURPOSE

Cigarette smoking is a preventable risk factor that contributes to unnecessary lung cancer burden among Korean Americans and there is limited research on effective smoking cessation strategies for this population. Smartphone-based smoking cessation apps that leverage just-in-time adaptive interventions (JITAIs) hold promise for smokers attempting to quit. However, little is known about how to develop and tailor a smoking cessation JITAI for Korean American emerging adult (KAEA) smokers.

METHOD

This paper documents the development process of MyQuit USC according to design guidelines for JITAI. Our development process builds on findings from a prior ecological momentary assessment study by using qualitative research methods. Semi-structured interviews and a focus group were conducted to inform which intervention options to offer and the decision rules that dictate their delivery.

RESULTS

Qualitative findings highlighted that (1) smoking episodes are highly context-driven and that (2) KAEA smokers believe they need personalized cessation strategies tailored to different contexts. Thus, MyQuit USC operates via decision rules that guide the delivery of personalized implementation intentions, which are contingent on dynamic factors, to be delivered "just in time" at user-scheduled, high-risk smoking situations.

CONCLUSION

Through an iterative design process, informed by quantitative and qualitative formative research, we developed a smoking cessation JITAI tailored specifically for KAEA smokers. Further testing is under way to optimize future versions of the app with the most effective intervention strategies and decision rules. MyQuit USC has the potential to provide cessation support in real-world settings, when KAEAs need them the most.

Content Analysis of Smartphone Apps for Smoking Cessation in China: Empirical Study

Background

With 360 million smokers, China consumes more cigarettes than any other country in the world. Given that 620 million Chinese own smartphones, smartphone apps for smoking cessation are increasingly used in China to help smokers quit.

Objective

This study analyzed and evaluated the contents of all smoking cessation apps (iOS and Android) available in China, applying the China Clinical Smoking Cessation Guideline (CCSCG; identical to the US Clinical Practice Guideline for Treating Tobacco Use and Dependence) as a framework for analysis.

Methods

We conducted a content analysis of Chinese Android and iOS smoking cessation apps (N=64) designed to assist users in quitting smoking. Each app was independently coded by two raters for its approach to smoking cessation and adherence to the CCSCG. We also recorded the features of smoking cessation apps (eg, release date, size, frequency of downloads, user ratings, type, quality scores by raters, and designers). Linear regression was used to test predictors of popularity and user-rated quality.

Results

Chinese smoking cessation apps have low levels of adherence to guidelines, with an average score of 11.1 for Android and 14.6 for iOS apps on a scale of 0 to 46. There was no significant association between popularity, user rating, and the characteristics of apps. However, there was a positive relationship between popularity, user rating, and adherence score.

Conclusions

Chinese apps for smoking cessation have low levels of adherence to standard clinical practice guidelines. New apps need be developed and existing apps be revised following evidence-based principles in China.

A Systematic Review of the mHealth Interventions to Prevent Alcohol and Substance Abuse

Substance abuse in young adults is a public health issue with costs to the individual and society. There is mounting evidence that the increased uses of mHealth approaches have promise as a way to facilitate reductions in substance use. This systematic review evaluated the recent body of research on mHealth-based interventions for substance use, with aims of (a) examining the functionality and effectiveness of these interventions, (b) evaluating the available research on the effectiveness of these interventions for substance use, and (c) evaluating the design, methodology, results, theoretical grounding, limitations, and implications of each study. We identified eligible studies by searching electronic databases using Boolean methods. The reviewed studies (N = 12) indicated that that a wide range of Internet-based, text messaging, and smartphone application interventions have been developed to address substance use. Interventions had an assortment of features; participants in each study highlighted the ease and convenience of the interventions; and the majority of studies provided support for the efficacy of mHealth in reducing substance use. Mobile technology is a promising tool for reducing substance use and warrants further development. Future practice including the use of mHealth interventions can be an integral part of reducing substance use.

Preventive Health Behavior Change Text Message Interventions: A Meta-analysis

CONTEXT

Existing evidence shows that text message interventions can produce short-term health behavior change. However, understanding is limited regarding intervention characteristics moderating this effect or the long-term effectiveness of text message interventions on behavior change after contact stops.

EVIDENCE ACQUISITION

MEDLINE, PubMed Central, ERIC, PsycINFO, and Web of Science were searched for articles published between April 2008 and December 2014 that evaluated an intervention targeting preventive health behaviors, delivered primarily by text message.

EVIDENCE SYNTHESIS

Intervention development and design characteristics and research outcomes were evaluated for 51 studies. Thirty-five studies were included in a meta-analysis (conducted in 2015) examining overall effect size and moderators of effect size. The overall pooled effect of interventions was d=0.24 (95% CI=0.16, 0.32, p<0.001) using outcome data collected most proximal to intervention cessation. Seven studies collected data following a no-intervention maintenance period and showed a small but significant pooled maintenance effect (d=0.17, 95% CI=0.03, 0.31, p=0.017, k=7). Few variables significantly moderated intervention efficacy. Interventions that did not use a theoretic basis, used supplementary intervention components, and had a duration of 6-12 months were most effective. The specific behavior being targeted was not associated with differences in efficacy nor was tailoring, targeting, or personalization of text message content.

CONCLUSIONS

Text message interventions are capable of producing positive change in preventive health behaviors. Preliminary evidence indicates that these effects can be maintained after the intervention stops. The moderator analysis findings are at odds with previous research, suggesting a need to examine moderators at the behavior-specific level.

An Integrated Framework for Disseminating Health Information to Students in Zimbabwe

University students in Zimbabwe lack immediate access to accurate health information. There is lack of explicit and integrated structures for disseminating health information to students in Zimbabwe. Informed by the salutogenic theory of health, the study assessed the health information needs of students and evaluated existing health information dissemination methods at National University of Science and Technology (NUST), Zimbabwe, in developing a framework for disseminating health information. A case study strategy was used to gather data within the pragmatic paradigm of grounded constructivism. The findings reveal that students need health information on a wide range of health topics and prefer mobile electronic media, workshops, qualified health professionals and peers for their health needs. There are significant gaps between the strategies that are being used by NUST to disseminate health information and the health information needs of the students. Therefore, this paper proposes a needs-based, integrated information dissemination framework for promoting health amongst students. The proposed framework emphasizes utilization of synchronous information and communication technologies, the need for integration of activities, a viable policy, health information literacy training and the use of a mix of persuasion techniques as an effective health promotion strategy.

E-mental health preferences of Veterans with and without probable posttraumatic stress disorder

Mental health care practices supported by electronic communication, referred to as e-mental health, offer ways to increase access to mental health resources. In recent years, e-mental health interventions using clinical video teleconferencing, Internet-based interventions, social networking sites, and telephones have emerged as viable, cost-effective methods to augment traditional service delivery. Whereas some research evaluates attitudes about e-mental health, few studies have assessed interest in using these approaches in a contemporary sample of U.S. Veterans. This study sought to understand willingness to use e-mental health in a diverse group of Veterans residing in Hawaii. Mailed surveys were completed by 600 Operation Iraqi Freedom/Operation Enduring Freedom Veterans and National Guard members. Results suggest that overall willingness to use e-mental health ranged from 32.2% to 56.7% depending on modality type. Importantly, Veterans who screened positive for posttraumatic stress disorder (PTSD) were significantly less likely to report willingness to use each e-mental health modality than their peers without PTSD, despite their greater desire for mental health services. These results suggest that despite solutions to logistical barriers afforded via e-mental health services, certain barriers to mental health care may persist, especially among Veterans who screen positive for PTSD.

Advances in Motivational Interviewing for Pediatric Obesity: Results of the Brief Motivational Interviewing to Reduce Body Mass Index Trial and Future Directions

Rates of childhood obesity in the United States remain at historic highs. The pediatric primary care office represents an important yet underused setting to intervene with families. One factor contributing to underuse of the primary care setting is lack of effective available interventions. One evidence-based method to help engage and motivate patients is motivational interviewing, a client-centered and goal-oriented style of counseling used extensively to increase autonomous motivation and modify health behaviors. This article summarizes the methods and results from a large trial implemented in primary care pediatric office and concludes with recommendations for improving the intervention and increasing its dissemination.

Text2Quit: an analysis of participant engagement in the mobile smoking cessation program

BACKGROUND

Text2Quit, an interactive text-messaging program aimed at smoking cessation, has been shown to increase quit rates, but engagement has not been thoroughly explored. Understanding the program features associated with engagement and behavior change is integral for effective program design.

OBJECTIVES

This study explored participants' interaction with the Text2Quit text-messaging program and associations between engagement and smoking cessation.

METHODS

The study included the 262 participants who received the Text2Quit intervention. Self-reported engagement measures, primarily usage of Text2Quit keywords and survey responses, were collected through computer records of participant use. Demographic variables and self-reported smoking abstinence were recorded in surveys at baseline and 6-month assessment.

RESULTS

The majority of participants (73%) maintained their subscription during the 6-month intervention. On average, participants received 210.51 text messages, 23.75 emails, and logged into the web portal 1.94 times. Being female was predictive of engagement with the program (β = 15.39). Program engagement, measured by the keyword PLEDGE (p = .002) and the Smokefree Status at 7 Days survey (p < .001) were associated with 6-month abstinence; use of keywords SMOKED (p < .001), RELAPSE (p = .007), and STOP (p = .023) were inversely related to abstinence. While abstainers (N = 83, 31%) stayed enrolled longer and engaged with the program more frequently, program "dose" was not predictive of smoking cessation.

CONCLUSIONS

Using interactive tools such as pledges and reporting on smoking status were predictive of cessation. Further study of program features is required to understand how to optimally design text messaging programs.