Motherhood and drinking: The relative importance of mental health and psychosocial factors on maternal alcohol misuse during the postpartum period

OBJECTIVE

Being a mother of a young child may be protective against alcohol misuse for some, but not all, women. This is the first paper to identify the mental health and psychosocial correlates of alcohol misuse among postpartum mothers.

METHODS

Mothers with a child under 12-months (n=319) were recruited via social media to complete a cross-sectional online survey. Two hierarchical logistic regressions examined unique factors associated with heavy episodic drinking and hazardous alcohol use, including sociodemographic, mental ill-health, and psychosocial factors.

RESULTS

On average, mothers drank alcohol at low levels (4 drinking days, 9 standard drinks in the past month). One in 10 (11.6%) reported heavy episodic drinking during this time and 1 in 12 (8.5%) were drinking at hazardous or greater levels. In the final models, older age and more severe postpartum anxiety were associated with higher likelihood of hazardous drinking (OR=1.37, OR=1.09, respectively), while breastfeeding was associated with lower odds of heavy episodic drinking (OR=0.29). Greater perceived social support was associated with lower odds of heavy episodic (OR=0.56) and hazardous drinking (OR=0.39), while higher coping-with-anxiety and social drinking motives were associated with greater odds of both forms of alcohol misuse (ORs=3.51-10.40). Conformity drinking motives (e.g., drinking to avoid social rejection) were negatively associated with heavy episodic drinking (OR=0.24).

CONCLUSIONS

Maternal anxiety, coping-with-anxiety and social drinking motives, and reduced social support are important factors associated with postpartum alcohol misuse. These modifiable factors are potential targets for screening and intervention for mothers who may need additional support and preventative care.

The Health4Life e-health intervention for modifying lifestyle risk behaviours of adolescents: secondary outcomes of a cluster randomised controlled trial

OBJECTIVES

To investigate the effectiveness of a school-based multiple health behaviour change e-health intervention for modifying risk factors for chronic disease (secondary outcomes).

STUDY DESIGN

Cluster randomised controlled trial.

SETTING, PARTICIPANTS

Students (at baseline [2019]: year 7, 11-14 years old) at 71 Australian public, independent, and Catholic schools.

INTERVENTION

Health4Life: an e-health school-based multiple health behaviour change intervention for reducing increases in the six major behavioural risk factors for chronic disease: physical inactivity, poor diet, excessive recreational screen time, poor sleep, and use of alcohol and tobacco. It comprises six online video modules during health education class and a smartphone app.

MAIN OUTCOME MEASURES

Comparison of Health4Life and usual health education with respect to their impact on changes in twelve secondary outcomes related to the six behavioural risk factors, assessed in surveys at baseline, immediately after the intervention, and 12 and 24 months after the intervention: binge drinking, discretionary food consumption risk, inadequate fruit and vegetable intake, difficulty falling asleep, and light physical activity frequency (categorical); tobacco smoking frequency, alcohol drinking frequency, alcohol-related harm, daytime sleepiness, and time spent watching television and using electronic devices (continuous).

RESULTS

A total of 6640 year 7 students completed the baseline survey (Health4Life: 3610; control: 3030); 6454 (97.2%) completed at least one follow-up survey, 5698 (85.8%) two or more follow-up surveys. Health4Life was not statistically more effective than usual school health education for influencing changes in any of the twelve outcomes over 24 months; for example: fruit intake inadequate: odds ratio [OR], 1.08 (95% confidence interval [CI], 0.57-2.05); vegetable intake inadequate: OR, 0.97 (95% CI, 0.64-1.47); increased light physical activity: OR, 1.00 (95% CI, 0.72-1.38); tobacco use frequency: relative difference, 0.03 (95% CI, -0.58 to 0.64) days per 30 days; alcohol use frequency: relative difference, -0.34 (95% CI, -1.16 to 0.49) days per 30 days; device use time: relative difference, -0.07 (95% CI, -0.29 to 0.16) hours per day.

CONCLUSIONS

Health4Life was not more effective than usual school year 7 health education for modifying adolescent risk factors for chronic disease. Future e-health multiple health behaviour change intervention research should examine the timing and length of the intervention, as well as increasing the number of engagement strategies (eg, goal setting) during the intervention.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12619000431123 (prospective).

'The convenience is a double-edged sword': Qualitative interviews with people who use online alcohol delivery services

INTRODUCTION

The past decade has seen a shift towards online purchasing and home delivery of alcohol, with this trend accelerated due to the COVID-19 pandemic. However, research in this area is limited. This study aims to explore how and why people use online alcohol delivery services.

METHODS

Semi-structured qualitative interviews (mean = 12.5 min; range = 7-19.5 min) with a convenience sample of 40 Australians ≥18 years who purchase alcohol online for delivery at least once per month. Reflexive thematic analysis was used to analyse and report the data.

RESULTS

Three themes were generated. (i) The convenience is a 'double-edged sword': almost all participants expressed that they use alcohol delivery services because they reduce difficulty in obtaining alcohol by saving time or energy/effort; however, for some this could lead them to purchase and consume more alcohol than they otherwise would have. (ii) Cost savings motivate online purchases: some participants expressed that they could access alcohol more cheaply online than in-store due to promotions, cost-comparisons and the ability to shop at low-cost outlets. (iii) Initiating or increasing use during the COVID-19 pandemic: for some people continued or increased use had been maintained as they had grown accustomed to the convenience or changed shopping habits.

DISCUSSION AND CONCLUSION

Participants purchased alcohol online for home delivery primarily for convenience; however, for some the convenience could lead them to purchase and consume more alcohol than they otherwise would have. Targeted improvements to the regulation of these services are needed to minimise the risks they may pose for alcohol harm.

Potential Mediators of a School-Based Digital Intervention Targeting Six Lifestyle Risk Behaviours in a Cluster Randomised Controlled Trial of Australian Adolescents

Lifestyle risk behaviours-physical inactivity, poor diet, poor sleep, recreational screen time, and alcohol and tobacco use-collectively known as the "Big 6" emerge during adolescence and significantly contribute to chronic disease development into adulthood. To address this issue, the Health4Life program targeted the Big 6 risk behaviours simultaneously via a co-designed eHealth school-based multiple health behaviour change (MHBC) intervention. This study used multiple causal mediation analysis to investigate some potential mediators of Health4Life's effects on the Big 6 primary outcomes from a cluster randomised controlled trial of Health4Life among Australian school children. Mediators of knowledge, behavioural intentions, self-efficacy, and self-control were assessed. The results revealed a complex pattern of mediation effects across different outcomes. Whilst there was a direct effect of the intervention on reducing moderate-to-vigorous physical activity risk, the impact on sleep duration appeared to occur indirectly through the hypothesised mediators. Conversely, for alcohol and tobacco use, both direct and indirect effects were observed in opposite directions cancelling out the total effect (competitive partial mediation). The intervention's effects on alcohol and tobacco use highlighted complexities, suggesting the involvement of additional undetected mediators. However, little evidence supported mediation for screen time and sugar-sweetened beverage intake risk. These findings emphasise the need for tailored approaches when addressing different risk behaviours and designing effective interventions to target multiple health risk behaviours. The trial was pre-registered with the Australian and New Zealand Clinical Trials Registry: ACTRN12619000431123.

"What Do I Say? How Do I Say it?" Twitter as a Knowledge Dissemination Tool for Mental Health Research

This study aims to generate evidence-based guidelines for researchers regarding how to effectively disseminate mental health research via Twitter. Three hundred mental health research Tweets posted from September 2018 to September 2019 were sampled from two large Australian organizations. Twenty-seven predictor variables were coded for each Tweet across five thematic categories: messaging; research area; mental health area; external networks; and media features. Regression analyses were conducted to determine associations with engagement outcomes of Favourites, Retweets, and Comments. Less than half (n = 10) of predictor variables passed validity tests. Notably, conclusions could not reliably be drawn on whether a Tweet featured evidence-based information. Tweets were significantly more likely to be Retweeted if they contained a hyperlink or multimedia. Tweets were significantly more likely to receive comments if they focused on a specific population group. These associations remain significant when controlling for organization. These findings indicate that researchers may be able to maximize engagement on Twitter by highlighting the population groups that the research applies to and enriching Tweets with multimedia content. In addition, care should be taken to ensure users can infer which messages are evidence-based. Guidelines and an accompanying resource are proposed.

Can we use ChatGPT for Mental Health and Substance Use Education? Examining Its Quality and Potential Harms

BACKGROUND

The use of generative artificial intelligence, more specifically large language models (LLMs), is proliferating, and as such, it is vital to consider both the value and potential harms of its use in medical education. Their efficiency in a variety of writing styles makes LLMs, such as ChatGPT, attractive for tailoring educational materials. However, this technology can feature biases and misinformation, which can be particularly harmful in medical education settings, such as mental health and substance use education. This viewpoint investigates if ChatGPT is sufficient for 2 common health education functions in the field of mental health and substance use: (1) answering users' direct queries and (2) aiding in the development of quality consumer educational health materials.

OBJECTIVE

This viewpoint includes a case study to provide insight into the accessibility, biases, and quality of ChatGPT's query responses and educational health materials. We aim to provide guidance for the general public and health educators wishing to utilize LLMs.

METHODS

We collected real world queries from 2 large-scale mental health and substance use portals and engineered a variety of prompts to use on GPT-4 Pro with the Bing BETA internet browsing plug-in. The outputs were evaluated with tools from the Sydney Health Literacy Lab to determine the accessibility, the adherence to Mindframe communication guidelines to identify biases, and author assessments on quality, including tailoring to audiences, duty of care disclaimers, and evidence-based internet references.

RESULTS

GPT-4's outputs had good face validity, but upon detailed analysis were substandard in comparison to expert-developed materials. Without engineered prompting, the reading level, adherence to communication guidelines, and use of evidence-based websites were poor. Therefore, all outputs still required cautious human editing and oversight.

CONCLUSIONS

GPT-4 is currently not reliable enough for direct-consumer queries, but educators and researchers can use it for creating educational materials with caution. Materials created with LLMs should disclose the use of generative artificial intelligence and be evaluated on their efficacy with the target audience.

Predictive Value of Day of Treatment SPECT/CT Radiomics in Lobar Y90 Radioembolization of Hepatocellular Carcinoma: A Pilot Study

PURPOSE/OBJECTIVE(S)

Transarterial Radioembolization (TARE) with Yttrium-90 (Y90) microspheres is a well-tolerated liver-directed therapy for patients with inoperable hepatocellular carcinoma (HCC). Y90 TARE uses pretreatment and post-treatment single photon emission computed tomography (SPECT)/CT for assessment of microsphere biodistribution within tumor. Patients who develop disease progression (PD) after lobar TARE have poor overall survival (OS). Conventional radiography can require several months follow-up to assess tumor response per modified RECIST (mRECIST), resulting in treatment delays for patients with PD. Predictive models capable of identifying patients at high risk for PD could prompt close surveillance and rapid initiation of salvage therapies, enhancing disease control (DC). Predictive models in various cancers have incorporated radiomics, an analytic technique that extracts digital patterns from medical imaging. We hypothesized that radiomics of immediate post-treatment SPECT/CT can predict objective response (OR) to Y90 TARE.

MATERIALS/METHODS

A total of 38 lobar TARE treatments were assessed retrospectively. For all treatments, the prescribed dose was 120 Gy. SPECT/CT obtained immediately after TARE underwent radiomics analysis. A total of 75 features related to gray-level (GL) co-occurrence matrices (COM), dependency matrices (DM), run length matrices (RLM), zone size matrices (ZSM), and neighborhood difference matrices (NDM) were examined and balanced between cohorts with and without OR by aid of Gaussian noise up-sampling. Top features were chosen for a weighted k-nearest neighbors (KNN) classifier based on rank as determined by the RELIEF-F algorithm. Performance of the developed classifier was evaluated by receiver operating characteristic (ROC) curve analysis.

RESULTS

Most patients (76%) were Child-Pugh A cirrhotic, while Barcelona Clinic Liver Cancer (BCLC) stage was evenly distributed A to C. On radiographic review, 22 treatments (58%) achieved OR. The selected top features consisted of two from CT (GLNDM-based coarseness; GLDM-based small dependence low gray level emphasis) and two from SPECT (GLNDM-based coarseness; GLZSM-based zone entropy). The weighted KNN classifier built using the selected features demonstrated a relatively strong power for predicting OR, with a ROC area under curve (AUC) of 0.83.

CONCLUSION

In lobar TARE Y90 of inoperable HCC, a predictive model using texture features extracted from day of treatment SPECT/CT distinguished responders from non-responders with high accuracy. Limitations of this study include its retrospective nature and the absence of toxicity analysis. These findings suggest that predictive modeling incorporating SPECT/CT radiomics could enhance the therapeutic ratio for vulnerable HCC patients and merits further investigation in prospective clinical trials of Y90 TARE.

Evaluating a Peer-Support Mobile App for Mental Health and Substance Use Among Adolescents Over 12 Months During the COVID-19 Pandemic: Randomized Controlled Trial

BACKGROUND

Although it is well known that adolescents frequently turn to their friends for support around mental health and substance use problems, there are currently no evidence-based digital programs to support them to do this.

OBJECTIVE

The aim of this study was to evaluate the efficacy of the Mind your Mate program, a digital peer-support program, in improving mental health symptoms, reducing the uptake of substance use, and increasing help seeking. The Mind your Mate program consists of a 40-minute web-based classroom lesson and a companion smartphone mobile app. The active control group received school-based health education as usual.

METHODS

A cluster randomized controlled trial was conducted with 12 secondary schools and 166 students (mean age 15.3, SD 0.41 years; 72/166, 43.4% female; and 133/166, 80.1% born in Australia). Participants completed self-reported questionnaires assessing symptoms of mental health (depression, anxiety, and psychological distress), substance use (alcohol and other drug use), and help-seeking measures at baseline and at 6-month and 12-month follow-ups.

RESULTS

Students who received the Mind your Mate program had greater reductions in depressive symptoms over a 12-month period than controls (b=-1.86, 95% CI -3.73 to 0.02; Cohen d=-0.31). Anxiety symptoms decreased among students in the intervention group; however, these reductions did not meet statistical significance thresholds. No differences were observed in relation to psychological distress or help-seeking.

CONCLUSIONS

Small to moderate reductions in depression symptoms were observed among students allocated to receive the Mind your Mate intervention. Although the current results are encouraging, there is a need to continue to refine, develop, and evaluate innovative applied approaches for the prevention of mental disorders in real-world settings.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000753954; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12620000753954.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/26796.

24-month outcomes of an eHealth universal program for students and parents to prevent adolescent alcohol use: A cluster randomized controlled trial in schools

Background

Parents play a critical role in delaying adolescent initiation of alcohol and other drug use. However, the majority of prevention programs focus on adolescents only. This study tested the acceptability and effectiveness of an eHealth universal program for students and parents to prevent adolescent alcohol use.

Methods

A cluster randomized controlled trial (RCT) was conducted between 2018 and 2020 with students from one grade level (aged 12-14 years) from 12 Australian secondary schools randomly allocated to the intervention or control conditions. Students accessed a web-based program in class and parents accessed the program online at their convenience. Data were collected via online questionnaires from students (N = 572) and parents (N = 78) at baseline, and 12- and 24- months post baseline. Multilevel, mixed effects regression models were used to analyse student data.

Findings

More students in the control group reported having at least one standard alcoholic drink and engaging in heavy episodic drinking in the previous 12 months at both 12- and 24-month follow up compared to students in the intervention, however, these differences were not statistically significant. Students in the intervention group reported greater increases in alcohol-related knowledge, compared to the control students. Qualitative data from parents indicated that they found the program useful, however, the number of parents who enrolled in the research study (13.9 %) was low. Parent engagement increased following implementation of an interactive parent/adolescent homework task.

Conclusions

Small sample size, low prevalence of alcohol use and parental engagement, and relatively short follow-up period may have contributed to lack of observed intervention effect, other than on alcohol-related knowledge. Parents who engaged with the program found it useful, however, implementation strategies that encourage parent-child interaction and communication may increase parent engagement for future programs.

Prevalence and correlates of addictive eating behaviours in a large cohort of Australian adolescents

OBJECTIVE

Research shows highly palatable foods can elicit addictive eating behaviours or 'food addiction'. Early adolescence is theorised to be a vulnerable period for the onset of addictive eating behaviours, yet minimal research has examined this. This study explored the prevalence and correlates of addictive eating behaviours in a large early adolescent sample.

METHODS

6640 Australian adolescents (Mage = 12.7 ± 0.5, 49%F) completed an online survey. Addictive eating was measured with the Child Yale Food Addiction Scale (YFAS-C). Negative-binomial generalised linear models examined associations between addictive eating symptoms and high psychological distress, energy drink consumption, sugar-sweetened beverage (SSB) consumption, alcohol use, and cigarette use.

RESULTS

Mean YFAS-C symptom criteria count was 1.36 ± 1.47 (of 7). 18.3% of participants met 3+ symptoms, 7.5% endorsed impairment and 5.3% met the diagnostic threshold for food addiction. All examined behavioural and mental health variables were significantly associated with addictive eating symptoms. Effects were largest for high psychological distress and cigarette use; with those exhibiting high psychological distress meeting 0.65 more criteria (95%CI = 0.58-0.72, p < 0.001) and those who smoked a cigarette meeting 0.51 more criteria (95%CI = 0.26-0.76, p < 0.001). High psychological distress and consumption of SSB and energy drinks remained significant when modelling all predictors together.

CONCLUSION

In this large adolescent study, addictive eating symptoms were common. Further research should establish directionality and causal mechanisms behind the association between mental ill-health, alcohol and tobacco use, and addictive eating behaviours. Cross-disciplinary prevention initiatives that address shared underlying risk factors for addictive eating and mental ill-health may offer efficient yet substantial public health benefits.

Cross-sectional survey of a convenience sample of Australians who use alcohol home delivery services

INTRODUCTION

Online alcohol purchasing and home delivery has increased in recent years, accelerated by the onset of the coronavirus disease 2019 pandemic. This article aims to investigate the purchasing and drinking behaviour of Australians who use online alcohol delivery services.

METHOD

A cross-sectional self-report survey with a convenience sample of 1158 Australians ≥18 years (49.3% female) who used an online alcohol delivery service in the past 3 months, recruited through paid social media advertisements from September to November 2021. Quota sampling was used to obtain a sample with age and gender strata proportional to the Australian adult population. Descriptive statistics were generated and logistic regression used to explore variables that predict hazardous/harmful drinking (Alcohol Use Disorders Identification Test score ≥8).

RESULTS

One-in-five (20.1%, 95% confidence interval [CI] 17.8-22.5) participants had used an alcohol delivery service to extend a home drinking session because they had run out of alcohol and wanted to continue drinking and, of these, one-third (33.9%, 95% CI 27.9-40.4) indicated that if the service was not available they would have stopped drinking. Using delivery services in this way was associated with six times higher odds of drinking at hazardous/harmful levels (odds ratio 6.26, 95% CI 3.78-10.36). Participants ≤25 years were significantly more likely to report never having their identification verified when receiving their alcohol delivery at the door compared with purchasing takeaway alcohol in-person at a bottle shop (p < 0.001, McNemar).

DISCUSSION AND CONCLUSION

Given the risks associated with alcohol delivery, regulation of these services should be improved to meet the same standards as bricks-and-mortar bottle shops.

Study protocol of the Our Futures Vaping Trial: a cluster randomised controlled trial of a school-based eHealth intervention to prevent e-cigarette use among adolescents

BACKGROUND

Effective and scalable prevention approaches are urgently needed to address the rapidly increasing rates of e-cigarette use among adolescents. School-based eHealth interventions can be an efficient, effective, and economical approach, yet there are none targeting e-cigarettes within Australia. This paper describes the protocol of the OurFutures Vaping Trial which aims to evaluate the efficacy and cost-effectiveness of the first school-based eHealth intervention targeting e-cigarettes in Australia.

METHODS

A two-arm cluster randomised controlled trial will be conducted among Year 7 and 8 students (aged 12-14 years) in 42 secondary schools across New South Wales, Western Australia and Queensland, Australia. Using stratified block randomisation, schools will be assigned to either the OurFutures Vaping Program intervention group or an active control group (health education as usual). The intervention consists of four web-based cartoon lessons and accompanying activities delivered during health education over a four-week period. Whilst primarily focused on e-cigarette use, the program simultaneously addresses tobacco cigarette use. Students will complete online self-report surveys at baseline, post-intervention, 6-, 12-, 24-, and 36-months after baseline. The primary outcome is the uptake of e-cigarette use at 12-month follow-up. Secondary outcomes include the uptake of tobacco smoking, frequency/quantity of e-cigarettes use and tobacco smoking, intentions to use e-cigarettes/tobacco cigarettes, knowledge about e-cigarettes/tobacco cigarettes, motives and attitudes relating to e-cigarettes, self-efficacy to resist peer pressure and refuse e-cigarettes, mental health, quality of life, and resource utilisation. Generalized mixed effects regression will investigate whether receiving the intervention reduces the likelihood of primary and secondary outcomes. Cost-effectiveness and the effect on primary and secondary outcomes will also be examined over the longer-term.

DISCUSSION

If effective, the intervention will be readily accessible to schools via the OurFutures platform and has the potential to make substantial health and economic impact. Without such intervention, young Australians will be the first generation to use nicotine at higher rates than previous generations, thereby undoing decades of effective tobacco control.

TRIAL REGISTRATION

The trial has been prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12623000022662; date registered: 10/01/2023).

Health4Life eHealth intervention to modify multiple lifestyle risk behaviours among adolescent students in Australia: a cluster-randomised controlled trial

BACKGROUND

Lifestyle risk behaviours are prevalent among adolescents and commonly co-occur, but current intervention approaches tend to focus on single risk behaviours. This study aimed to evaluate the efficacy of the eHealth intervention Health4Life in modifying six key lifestyle risk behaviours (ie, alcohol use, tobacco smoking, recreational screen time, physical inactivity, poor diet, and poor sleep, known as the Big 6) among adolescents.

METHODS

We conducted a cluster-randomised controlled trial in secondary schools that had a minimum of 30 year 7 students, in three Australian states. A biostatistician randomly allocated schools (1:1) to Health4Life (a six-module, web-based programme and accompanying smartphone app) or an active control group (usual health education) with the Blockrand function in R, stratified by site and school gender composition. All students aged 11-13 years who were fluent in English and attended participating schools were eligible. Teachers, students, and researchers were not masked to allocation. Primary outcomes were alcohol use, tobacco use, recreational screen time, moderate to vigorous physical activity (MVPA), sugar-sweetened beverage intake, and sleep duration at 24 months, measured by self-report surveys, and analysed in all students who were eligible at baseline. Latent growth models estimated between-group change over time. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619000431123).

FINDINGS

Between April 1, 2019, and Sept 27, 2019, we recruited 85 schools (9280 students), of which 71 schools with 6640 eligible students (36 schools [3610 students] assigned to the intervention and 35 [3030 students] to the control) completed the baseline survey. 14 schools were excluded from the final analysis or withdrew, mostly due to a lack of time. We found no between-group differences for alcohol use (odds ratio 1·24, 95% CI 0·58-2·64), smoking (1·68, 0·76-3·72), screen time (0·79, 0·59-1·06), MVPA (0·82, 0·62-1·09), sugar-sweetened beverage intake (1·02, 0·82-1·26), or sleep (0·91, 0·72-1·14) at 24 months. No adverse events were reported during this trial.

INTERPRETATION

Health4Life was not effective in modifying risk behaviours. Our results provide new knowledge about eHealth multiple health behaviour change interventions. However, further research is needed to improve efficacy.

FUNDING

Paul Ramsay Foundation, the Australian National Health and Medical Research Council, the Australian Government Department of Health and Aged Care, and the US National Institutes of Health.

Parent-based interventions to improve multiple lifestyle risk behaviors among adolescents: A systematic review and meta-analysis

Lifestyle risk behaviors often co-occur and are prevalent among adolescents. Parent-based interventions addressing risk behaviors concurrently have the potential to improve youth and parent outcomes. This systematic review evaluated the efficacy of parent-based interventions targeting multiple lifestyle risk behaviors among adolescents and parents. MEDLINE (Ovid), Embase (Ovid), PsycInfo (Ovid), Scopus, CINAHL, the Cochrane Database of Systematic Reviews (CDSR) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from 2010-May 2021. Eligible studies were randomised controlled trials (RCTs) of parent-based interventions addressing 2+ risk behaviors: alcohol use, smoking, poor diet, physical inactivity, sedentary behaviors, and poor sleep. Studies directly targeting parents, and that assessed adolescent outcomes (11-18 years) were eligible. Where possible, random-effects meta-analysis was conducted. From 11,975 identified records, 46 publications of 36 RCTs (n = 28,322 youth, n = 7385 parents) were eligible. Parent-based interventions were associated with improved adolescent moderate-to-vigorous physical activity (MVPA) [Odds Ratio (OR) = 1.82, 95% CI = 1.18, 2.81; p = 0.007], and reduced screen time (SMD = -0.39, 95% CI = -0.62, -0.16, p = 0.0009) and discretionary food intake (SMD = -0.18; 95% CI = -0.30, -0.06; p = 0.002) compared to controls. However, there was some evidence that interventions increased the odds of ever using tobacco in the medium-term (OR = 1.47, 95% CI = 0.99, 2.18, p = 0.06) and of past month tobacco use in the long-term (OR = 1.46, 95% CI = 1.12, 1.90; p = 0.005). Overall, the quality of evidence was moderate. Parent-based interventions targeting multiple risk behaviors improved adolescent MVPA, and reduced screen time discretionary food intake. Further research is needed to address sleep problems and increase intervention efficacy, particularly for alcohol and tobacco use.

School-based preventive interventions targeting e-cigarette use among adolescents: a systematic review protocol

INTRODUCTION

Electronic cigarette (e-cigarette) use has drastically increased in recent years, particularly among adolescents. This poses several acute and chronic harms to young people, including poisonings, burns, serious lung injury and-where nicotine e-liquid is used-the potential to impact healthy brain development and precipitate future nicotine addiction. School-based prevention programmes have the potential to address this growing public health concern by reaching large numbers of young people during a critical period for intervention; however, the efficacy of such interventions has not been systematically explored. This systematic review aims to determine the existence and efficacy of school-based preventive interventions targeting e-cigarette use.

METHODS AND ANALYSIS

A systematic search of MEDLINE, Embase, PsycINFO, Scopus, CINAHL, Cochrane Database of Systematic Reviews and international clinical trials registries will be conducted from 2000 to April 2022 to identify eligible studies (randomised controlled trials, cluster randomised controlled trials and quasiexperimental studies) evaluating school-based interventions to prevent e-cigarette use among adolescents. Two reviewers will independently screen title, abstract and full text of all studies for eligibility. Both reviewers will independently extract the data and assess the risk of bias. Any discrepancies will be resolved by a third reviewer. Results will be summarised in a narrative synthesis and data will be meta-analysed if appropriate. Heterogeneity in findings will be assessed narratively, and using the I² statistic (where meta-analysis is feasible), meta-regression will be used to explore potential factors associated with programme efficacy, where data permit.

ETHICS AND DISSEMINATION

This research is conducted on published work and does not require ethics approval. The findings will be published in a peer-reviewed journal and used to guide the development of new school-based e-cigarette preventive interventions.

TRIAL REGISTRATION NUMBER

CRD42022323352.

Measurement properties of smartphone approaches to assess physical activity in healthy young people: A systematic review (Preprint)

Background

Physical inactivity is a preventable risk factor for several chronic diseases and one of the driving forces behind the growing global burden of disease. Recent evidence has shown that interventions using mobile smartphone apps can promote a significant increase in physical activity (PA) levels. However, the accuracy and reliability of using apps is unknown.

Objective

The aim of our review was to determine the accuracy and reliability of using mobile apps to measure PA levels in young people. We conducted a systematic review guided by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).

Methods

Studies published from 2007 to 2020 were sourced from 8 databases—Ovid MEDLINE, Embase (Elsevier), Cochrane Library (Wiley), PsychINFO (EBSCOhost), CINAHL (EBSCOhost), Web of Science (Clarivate), SPORTDiscus (EBSCOhost), and IEEE Xplore Digital Library database. Studies were conducted in young people aged 10-24 years and without chronic illnesses, who evaluated a mobile app’s ability to measure PA. Primary outcomes included validity, reliability, and responsiveness of the measurement approach. Duplicate screening was conducted for eligibility, data extraction, and assessing the risk of bias. Results were reported as a systematic review. The main physical activity measures evaluated for each study were the following: total PA time (min/day or min/week), total moderate to vigorous PA per week, daily step count, intensity measure (heart rate), and frequency measure (days per week).

Results

Of the 149 identified studies, 5 met the inclusion criteria (322 participants, 176 female; mean age 14, SD 3 years). A total of 3 studies measured criterion validity and compared PA measured via apps against PA measured via an Actigraph accelerometer. The 2 studies that reported on construct validity identified a significant difference between self-reported PA and the objective measure. Only 1 of the 5 apps examined was available to the public, and although this app was highly accepted by young people, the app recorded PA to be significantly different to participants’ self-reported PA.

Conclusions

Overall, few studies assess the reliability, validity, and responsiveness of mobile apps to measure PA in healthy young people, with studies typically only reporting on one measurement property. Of the 3 studies that measured validity, all concluded that mobile phones were acceptable and valid tools. More research is needed into the validity and reliability of smartphone apps to measure PA levels in this population as well as in populations with other characteristics, including other age groups and those with chronic diseases.

Trial Registration

PROSPERO CRD42019122242; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=122242

You've got mail: Drinks are on sale! A study to assess volume and content of direct marketing received from online alcohol retailers in Australia

BACKGROUND

Customers of online alcohol retailers are exposed to marketing displayed on alcohol retailers' websites and may also receive direct marketing via email and text message once contact details are provided in an online sale. To date, this direct marketing activity from online alcohol retailers has not been studied. This study aims to document the quantity and content of marketing material received by customers of online alcohol retailers in Australia, and whether the material complies with relevant regulation.

METHODS

A cross-sectional study of direct marketing from the 100 most popular online alcohol retailers in Australia. Marketing material received via email and text message was collected for three-months from March to June 2021. Email and text messages were coded for 17 variables in four categories: primary purpose of the communication; compliance with relevant regulations; marketing themes and practices used; and offers, promotions, and discounts.

RESULTS

We received 1496 emails from 85 of the 100 retailers. Of the retailers who sent emails, the number sent varied widely (Mdn=8; IQR=2-21). Seven retailers sent a total of 18 text messages. The primary purpose of most emails (67.4%) was to advertise a special or offer a discount. Almost all emails (98.6%) complied with spam legislation to include an unsubscribe link, but around half (46.5%) of emails from retailers in jurisdictions where the inclusion of a liquor license number is mandatory, failed to include one. The most common marketing theme was to link specific times or events to drinking (18.8%). Almost half (48.5%) of emails advertised free or discounted delivery for purchasing over a specified threshold.

CONCLUSION

Most online alcohol retailers in Australia are engaging in direct marketing to their customers via email. More research is needed to understand how these emails may influence purchasing and consumption.

Measurement Properties of Smartphone Approaches to Assess Diet, Alcohol Use, and Tobacco Use: Systematic Review

Background

Poor diet, alcohol use, and tobacco smoking have been identified as strong determinants of chronic diseases, such as cardiovascular disease, diabetes, and cancer. Smartphones have the potential to provide a real-time, pervasive, unobtrusive, and cost-effective way to measure these health behaviors and deliver instant feedback to users. Despite this, the validity of using smartphones to measure these behaviors is largely unknown.

Objective

The aim of our review is to identify existing smartphone-based approaches to measure these health behaviors and critically appraise the quality of their measurement properties.

Methods

We conducted a systematic search of the Ovid MEDLINE, Embase (Elsevier), Cochrane Library (Wiley), PsycINFO (EBSCOhost), CINAHL (EBSCOHost), Web of Science (Clarivate), SPORTDiscus (EBSCOhost), and IEEE Xplore Digital Library databases in March 2020. Articles that were written in English; reported measuring diet, alcohol use, or tobacco use via a smartphone; and reported on at least one measurement property (eg, validity, reliability, and responsiveness) were eligible. The methodological quality of the included studies was assessed using the Consensus-Based Standards for the Selection of Health Measurement Instruments Risk of Bias checklist. Outcomes were summarized in a narrative synthesis. This systematic review was registered with PROSPERO, identifier CRD42019122242.

Results

Of 12,261 records, 72 studies describing the measurement properties of smartphone-based approaches to measure diet (48/72, 67%), alcohol use (16/72, 22%), and tobacco use (8/72, 11%) were identified and included in this review. Across the health behaviors, 18 different measurement techniques were used in smartphones. The measurement properties most commonly examined were construct validity, measurement error, and criterion validity. The results varied by behavior and measurement approach, and the methodological quality of the studies varied widely. Most studies investigating the measurement of diet and alcohol received very good or adequate methodological quality ratings, that is, 73% (35/48) and 69% (11/16), respectively, whereas only 13% (1/8) investigating the measurement of tobacco use received a very good or adequate rating.

Conclusions

This review is the first to provide evidence regarding the different types of smartphone-based approaches currently used to measure key behavioral risk factors for chronic diseases (diet, alcohol use, and tobacco use) and the quality of their measurement properties. A total of 19 measurement techniques were identified, most of which assessed dietary behaviors (48/72, 67%). Some evidence exists to support the reliability and validity of using smartphones to assess these behaviors; however, the results varied by behavior and measurement approach. The methodological quality of the included studies also varied. Overall, more high-quality studies validating smartphone-based approaches against criterion measures are needed. Further research investigating the use of smartphones to assess alcohol and tobacco use and objective measurement approaches is also needed.

International Registered Report Identifier (IRRID)

RR2-https://doi.org/10.1186/s13643-020-01375-w

436Food addiction, mental health and substance-use during a transition period: Data from 6,700 Australian 12/13-year-olds

Background

Early adolescence is a challenging transition period where mental ill-health and experimentation with alcohol and tobacco often increases. Some foods and eating behaviours can be addictive in a way that is comparable to addictive substances. Few studies have examined the prevalence of food addiction in young people, and none have measured it with mental ill-health and substance-use.

Methods

6,700 Year 7 students across NSW, WA and QLD completed the baseline questionnaire for “Health4Life” (Mage=12.7±0.5, 49%F). The prevalence of, and associations between, food addiction (YFAS-C), anxiety (PROMIS-A), depression (PHQ-A), psychological distress (K6), discretionary food/drink intake (SPANS) and alcohol and tobacco use were examined.

Results

Respondents who met diagnostic criteria for food addiction (5.2%, n = 272) were significantly more likely to screen positively for anxiety (X23=315.4, P &lt; 0.001), probable major depression (X21=299.9, P &lt; 0.001) and psychological distress at levels of serious mental illness (X21=238.885, P &lt; 0.001). They were also significantly more likely to have consumed a full standard drink and smoked tobacco in the past 6-months (X21=53.8, P &lt; 0.001 and X21=29.7, P &lt; 0.001, respectively) and to consume high amounts of sugar-sweetened beverages (X21=15.2, P &lt; 0.001), discretionary foods (X22=26.4, P &lt; 0.001) and energy drinks (X25=28.4, P &lt; 0.001). Relative risks ranged 1.29-4.35.

Conclusions

Findings suggest a strong link between food addiction, substance use, discretionary food and drink consumption and mental ill-health in early adolescence. Further analysis will model multivariable relationships whilst controlling for affluence, BMI and gender.

Key messages

Links between food addiction, substance use and mental ill-health are found in the largest sample of adolescents screened for these variables worldwide.

195The Health4Life Initiative: An eHealth intervention targeting multiple lifestyle risk behaviours among Australian adolescents

Background

Physical inactivity, poor diet, sedentary recreational screen time, poor sleep, alcohol use and smoking (the “Big 6”) are key lifestyle risk factors for chronic disease. The Big 6 typically emerge during adolescence, co-occur and continue into adulthood. To improve short- and long-term health, early and effective prevention is critical.

Methods

A cluster randomised controlled trial (ACTRN12619000431123) is being conducted in 71 schools across NSW, QLD and WA. Schools are randomised to the Health4life intervention or health education as usual. The intervention has three components: 1) An online, school-based program delivered to all Year 7 students; 2) An accompanying smartphone application (all students); 3) Booster content, delivered to at-risk students in Years 8 and 9. Students complete questionnaires on five occasions over three years.

Results

Preliminary analyses including 6716 students (49% female) indicated that 22% of participants met national guidelines for physical activity, 27% reported drinking 2+ cups of sugar-sweetened beverages/week, 3% had consumed a standard alcoholic drink in the prior 6 months, 2% had tried smoking, 86% engaged in excessive recreational screen time, and 32% had inadequate sleep. The final dataset will be analysed for the conference.

Conclusions

Many Australian adolescents are engaging in lifestyle behaviours that put them at risk of chronic disease. Effective and scalable preventive interventions that simultaneously target these behaviours are needed.

Key messages

This is the first trial of an eHealth intervention to concurrently target the Big 6 among adolescents. Health4Life has the potential to improve physical and mental health in adolescence and beyond.

Factors Predicting Trial Engagement, Treatment Satisfaction, and Health-Related Quality of Life During a Web-Based Treatment and Social Networking Trial for Binge Drinking and Depression in Young Adults: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Mental health and alcohol use problems are among the most common causes of disease burden in young Australians, frequently co-occur (comorbidity), and lead to significant lifetime burden. However, comorbidities remain significantly underdetected and undertreated in health settings. Digital mental health tools designed to identify at-risk individuals, encourage help-seeking, or deliver treatment for comorbidity have the potential to address this service gap. However, despite a strong body of evidence that digital mental health programs provide an effective treatment option for a range of mental health and alcohol use problems in young adults, research shows that uptake rates can be low. Thus, it is important to understand the factors that influence treatment satisfaction and quality-of-life outcomes for young adults who access e-mental health interventions for comorbidity.

OBJECTIVE

In this study, we seek to understand the factors that influence treatment satisfaction and quality-of-life outcomes for young adults who access e-mental health interventions for comorbid alcohol and mood disorders. The aim is to determine the importance of personality (ie, Big Five personality traits and intervention attitudes), affective factors (ie, depression, anxiety, and stress levels), and baseline alcohol consumption in predicting intervention trial engagement at sign-up, satisfaction with the online tool, and quality of life at the end of the iTreAD (Internet Treatment for Alcohol and Depression) trial.

METHODS

Australian adults (N=411) aged between 18 and 30 years who screened positive for depression and alcohol use problems signed up for the iTreAD project between August 2014 and October 2015. During registration, participants provided information about their personality, current affective state, alcohol use, treatment expectations, and basic demographic information. Subsequent follow-up surveys were used to gauge the ongoing trial engagement. The last follow-up questionnaire, completed at 64 weeks, assessed participants' satisfaction with web-based treatment and quality-of-life outcomes.

RESULTS

Multiple linear regression analyses were used to assess the relative influence of predictor variables on trial engagement, treatment satisfaction, and quality-of-life outcomes. The analyses revealed that the overall predictive effects of personality and affective factors were 20% or lower. Neuroticism constituted a unique predictor of engagement with the iTreAD study in that neuroticism facilitated the return of web-based self-assessments during the study. The return of incentivized follow-up assessments predicted treatment satisfaction, and state-based depression predicted variance in quality-of-life reports at study completion.

CONCLUSIONS

Our findings suggest that traditional predictors of engagement observed in face-to-face research may not be easily transferable to digital health interventions, particularly those aimed at comorbid mental health concerns and alcohol misuse among young adults. More research is needed to identify what determines engagement in this population to optimally design and execute digital intervention studies with multiple treatment aims.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN): 12614000310662; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365137&isReview=true.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-015-2365-2.

Therapeutic alliance in psychological treatment for depression and alcohol use comorbidity: The client's perspective

This qualitative study explored the treatment experience and the therapeutic relationship of participants receiving an integrated psychological treatment for comorbid alcohol use problems and depressive disorders. Semistructured interviews targeting experience of therapy and the relationship with the therapist were carried out with seven participants. Transcripts were analyzed using Interpretive Phenomenological Analysis to reveal major themes. Four major themes were identified. "Nature of the relationship" describes the importance of the client's perception of the therapeutic relationship experienced, "Confidence in therapy" and "Acknowledgment of experience" address components assisting the development of a positive alliance, and "Meeting unmet needs for connection" illustrates the importance of a positive therapeutic relationship for this population. Participants thought that clinicians would benefit from a good understanding of the role the alliance relationship plays within comorbidity treatment, of the need this relationship meets for this population, and the importance of engendering confidence in therapy and recognizing client perspectives.

A Multiple Health Behavior Change, Self-Monitoring Mobile App for Adolescents: Development and Usability Study of the Health4Life App

Background

The link between chronic diseases and the Big 6 lifestyle risk behaviors (ie, poor diet, physical inactivity, smoking, alcohol use, sedentary recreational screen time, and poor sleep) is well established. It is critical to target these lifestyle risk behaviors, as they often co-occur and emerge in adolescence. Smartphones have become an integral part of everyday life, and many adolescents already use mobile apps to monitor their lifestyle behaviors and improve their health. Smartphones may be a valuable platform for engaging adolescents with interventions to prevent key chronic disease risk behaviors.

Objective

The aim of this paper is to describe the development, usability, and acceptability of the Health4Life app, a self-monitoring smartphone app for adolescents that concurrently targets the Big 6 lifestyle behaviors.

Methods

The development of the Health4Life app was an iterative process conducted in collaboration with adolescents and experts. The development process consisted of three stages: scoping the literature; end user consultations, which included a web-based survey (N=815; mean age 13.89, SD 0.89 years) and a focus group (N=12) among adolescents; and app development and beta testing. Following this development work, 232 adolescents were asked to rate the usability and acceptability of the app.

Results

The process resulted in a self-monitoring smartphone app that allows adolescent users to track and set goals for the Big 6 health behaviors, using in-app rewards and notifications to enhance engagement. The overall adolescent feedback was positive in terms of user-friendly design, content, relevance, and helpfulness. Commonly identified areas for improvement were to increase interactive features and display recorded health behaviors differently to improve interpretability.

Conclusions

The Health4Life app is a co-designed, self-monitoring smartphone app for adolescents that concurrently targets the Big 6 lifestyle behaviors. Adolescents rated the app as highly acceptable and usable. The app has the potential to efficiently and effectively modify important risk factors for chronic disease among young people and is currently being evaluated in a world-first trial of 6640 secondary school students in 71 schools across Australia.

Behavioral medicine challenges in the shadow of a global pandemic

Health behavior researchers should refocus and retool as it becomes increasingly clear that the challenges of the COVID-19 pandemic surpass the direct effects of COVID-19 and include unique, drastic, and ubiquitous consequences for health behavior. The circumstances of the pandemic have created a natural experiment, allowing researchers focusing on a wide range of health behaviors and populations with the opportunity to use previously collected and future data to study: (a) changes in health behavior prepandemic and postpandemic, (b) health behavior prevalence and needs amidst the pandemic, and (c) the effects of the pandemic on short- and long-term health behavior. Our field is particularly challenged as we attempt to consider biopsychosocial, political, and environmental factors that affect health and health behavior. These realities, while daunting, should call us to action to refocus and retool our research, prevention, and intervention efforts.

Clustering of Six Key Risk Behaviors for Chronic Disease among Adolescent Females

Chronic diseases are the leading cause of disability and mortality globally. In Australia, females are at heightened risk. This research explored the prevalence, patterns, and correlates of six key risk behaviors (physical inactivity, poor diet, recreational screen time, inadequate sleep, alcohol use, and smoking) among adolescent females and whether knowledge of health guidelines was associated with adherence. Adolescent females completed an anonymous online questionnaire (N = 687; Mage = 13.82). Logistic regression assessed the association between knowledge and adherence. A Latent Class Analysis (LCA) and three-step procedure identified risk behavior clusters and their correlates. Despite positive health self-ratings (77% good/very good), most participants reported insufficient moderate-to-vigorous physical activity (MVPA; 89%), vegetable intake (89%), and excessive screen time (63%). Knowledge of guidelines was associated with adherence for MVPA, vegetable intake, sleep, and alcohol abstinence. Three classes emerged: "moderate risk" (76%), "relatively active, healthy eaters" (19%), and "excessive screen users" (5%). These risk-behavior clusters were associated with perceived value of academic achievement and physical wellbeing. Adolescent females commonly perceive they are in good health, despite engaging in unhealthy behaviors. Public health interventions should utilize effective behavior change strategies, adopt a multiple health behavior change approach (MHBC), and be tailored to specific risk profiles and values among females.

Meal delivery and public health nutrition: a comparison study in three international cities

Background

The food environment has been recognized as a dominant driver of public health nutrition. Although planning mechanisms are increasingly being triggered to help control the proliferation of fast food outlets, the recent upsurge in meal delivery options has reshaped the food environment. Currently, we lack insight in the breath of meal delivery options. Therefore, this study sought to examine between-city differences and within-city socio-economic differences in the number of online meal delivery options and meal types.

Methods

A cross-sectional study was conducted in three international cities. Across 10 sampled addresses in Chicago (USA), Amsterdam (The Netherlands) and Melbourne (Australia), meal delivery options provided by a major international meal delivery company were sampled. Bonferroni adjusted Chi2-tests were conducted to assess between-city - and within-city socio-economic differences.

Results

Across the 10 sampled addresses in each city, there were 1668 delivery options in Chicago, 1496 in Amsterdam and 1159 in Melbourne. In total, 10220 keywords (representing 148 different meal types) were recorded across all delivery options. In Amsterdam and Melbourne, a greater number of options was available for the addresses in the least disadvantaged neighborhoods. Among all cities, sandwiches (14.6%), burgers (14.4%), and pizza (13.4%) were most commonly advertised. In contrast, salads (7.8%) and 'healthy' options (5.5.%) were less frequent offered for delivery.

Conclusions

Meals available for delivery did not favor a healthy diet, and healthy options were less often advertised then unhealthier ones. Currently, meal delivery platforms appear to operate in a largely unregulated environment continued growth is likely in the near future. It is vital that public health professionals and policy makers become aware of this online component of the food environment and its potential consequences for public health nutrition.

Key messages

Most commonly advertised meals for delivery do not favor a healthy diet, and healthy options were less often advertised then unhealthier ones. It is vital that public health professionals and policy makers become aware of the online component of the food environment and its potential consequences for public health nutrition.

A Web-Based Intervention to Prevent Multiple Chronic Disease Risk Factors Among Adolescents: Co-Design and User Testing of the Health4Life School-Based Program

BACKGROUND

Chronic diseases are the leading cause of death worldwide. Addressing key lifestyle risk factors during adolescence is critical for improving physical and mental health outcomes and reducing chronic disease risk. Schools are ideal intervention settings, and electronic health (eHealth) interventions afford several advantages, including increased student engagement, scalability, and sustainability. Although lifestyle risk behaviors tend to co-occur, few school-based eHealth interventions have targeted multiple behaviors concurrently.

OBJECTIVE

This study aims to summarize the co-design and user testing of the Health4Life school-based program, a web-based cartoon intervention developed to concurrently prevent 6 key lifestyle risk factors for chronic disease among secondary school students: alcohol use, smoking, poor diet, physical inactivity, sedentary recreational screen time, and poor sleep (the Big 6).

METHODS

The development of the Health4Life program was conducted over 18 months in collaboration with students, teachers, and researchers with expertise relevant to the Big 6. The iterative process involved (1) scoping of evidence and systematic literature review; (2) consultation with adolescents (N=815) via a cross-sectional web-based survey to identify knowledge gaps, attitudes, barriers, and facilitators in relation to the Big 6; (3) content and web development; and (4) user testing of the web-based program with students (n=41) and teachers (n=8) to evaluate its acceptability, relevance, and appeal to the target audience.

RESULTS

The co-design process resulted in a six-module, evidence-informed program that uses interactive cartoon storylines and web-based delivery to engage students. Student and teacher feedback collected during user testing was positive in terms of acceptability and relevance. Commonly identified areas for improvement concerned the length of modules, age appropriateness of language and alcohol storyline, the need for character backstories and links to syllabus information, and feasibility of implementation. Modifications were made to address these issues.

CONCLUSIONS

The Health4Life school-based program is the first universal, web-based program to concurrently address 6 important chronic disease risk factors among secondary school students. By adopting a multiple health behavior change approach, it has the potential to efficiently modify the Big 6 risk factors within one program and to equip young people with the skills and knowledge needed to achieve and maintain good physical and mental health throughout adolescence and into adulthood.

Study protocol of the Health4Life initiative: a cluster randomised controlled trial of an eHealth school-based program targeting multiple lifestyle risk behaviours among young Australians

INTRODUCTION

Lifestyle risk behaviours, including alcohol use, smoking, poor diet, physical inactivity, poor sleep (duration and/or quality) and sedentary recreational screen time ('the Big 6'), are strong determinants of chronic disease. These behaviours often emerge during adolescence and co-occur. School-based interventions have the potential to address risk factors prior to the onset of disease, yet few eHealth school-based interventions target multiple behaviours concurrently. This paper describes the protocol of the Health4Life Initiative, an eHealth school-based intervention that concurrently addresses the Big 6 risk behaviours among secondary school students.

METHODS AND ANALYSIS

A multisite cluster randomised controlled trial will be conducted among year 7 students (11-13 years old) from 72 Australian schools. Stratified block randomisation will be used to assign schools to either the Health4Life intervention or an active control (health education as usual). Health4Life consists of (1) six web-based cartoon modules and accompanying activities delivered during health education (once per week for 6 weeks), and a smartphone application (universal prevention), and (2) additional app content, for students engaging in two or more risk behaviours when they are in years 8 and 9 (selective prevention). Students will complete online self-report questionnaires at baseline, post intervention, and 12, 24 and 36 months after baseline. Primary outcomes are consumption of sugar-sweetened beverages, moderate-to-vigorous physical activity, sleep duration, sedentary recreational screen time and uptake of alcohol and tobacco use.

ETHICS AND DISSEMINATION

This study has been approved by the University of Sydney (2018/882), NSW Department of Education (SERAP no. 2019006), University of Queensland (2019000037), Curtin University (HRE2019-0083) and relevant Catholic school committees. Results will be presented to schools and findings disseminated via peer-reviewed journals and scientific conferences. This will be the first evaluation of an eHealth intervention, spanning both universal and selective prevention, to simultaneously target six key lifestyle risk factors among adolescents.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12619000431123), 18 March 2019.

Measurement properties of smartphone approaches to assess key lifestyle behaviours: protocol of a systematic review

BACKGROUND

Six core behavioural risk factors (poor diet, physical activity, sedentary behaviour, alcohol misuse, smoking and unhealthy sleep patterns) have been identified as strong determinants of chronic disease, such as cardiovascular disease, diabetes and cancers. Smartphones have the potential to provide a real-time, pervasive, unobtrusive and cost-effective way to measure health behaviours and deliver instant feedback to users. Despite this, validity of using smartphones to measure these six key behaviours is largely unknown. The proposed systematic review aims to address this gap by identifying existing smartphone-based approaches to measure these health behaviours and critically appraising, comparing and summarizing the quality of their measurement properties.

METHODS

A systematic search of the Ovid MEDLINE, Embase (Elsevier), Cochrane Library (Wiley), PsychINFO (EBSCOhost), CINAHL (EBSCOHost), Web of Science (Clarivate), SPORTDiscus (EBSCOhost) and IEEE Xplore Digital Library databases will be conducted from January 2007 to March 2020. Eligible studies will be those written in English that measure at least one of the six health behaviours of interest via a smartphone and report on at least one measurement property. The primary outcomes will be validity, reliability and/or responsiveness of these measurement approaches. A secondary outcome will be the feasibility (e.g. user burden, usability and cost) of identified approaches. No restrictions will be placed on the participant population or study design. Two reviewers will independently screen studies for eligibility, extract data and assess the risk of bias. The study methodological quality (or bias) will be appraised using an appropriate tool. Our results will be described in a narrative synthesis. If feasible, random effects meta-analysis will be conducted where appropriate.

DISCUSSION

The results from this review will provide important information about the types of smartphone-based approaches currently available to measure the core behavioural risk factors for chronic disease and the quality of their measurement properties. It will allow recommendations on the most suitable and effective measures of these lifestyle behaviours using smartphones. Valid and reliable measurement of these behaviours and risk factor opens the door to targeted and real-time delivery of health behaviour interventions, providing unprecedented opportunities to offset the trajectory toward chronic disease.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42019122242.

Smartphone apps for managing alcohol consumption: a literature review

Background

Smartphone applications (apps) designed to assist users to reduce hazardous and harmful alcohol consumption show potential as an inexpensive alternative to traditional brief intervention in primary care. The aim of this paper is to provide an overview of the literature on alcohol reduction apps and the availability of evidenced-based apps on top commercial app stores.

Methods

We reviewed literature through to December 2019 using the databases PubMed, MEDLINE, PsycINFO and Google Scholar and keyword search terms smartphone/mobile/phone AND application/app AND alcohol. Articles were included if the primary intervention was a smartphone app and the study measured participant changes in frequency or volume of alcohol consumption.

Results

21 relevant articles were identified that evaluated 19 unique smartphone apps. Of the 19 unique apps, seven were designed for use among youth and 12 in adult populations. The available evidence for the efficacy of alcohol reduction apps among youth is inconclusive, with results from these evaluations not showing a clear benefit in reducing alcohol consumption compared to control groups. The results of apps designed for adult populations appears more promising, but results are still mixed. Of the 19 alcohol reduction apps that have been evaluated only eight of these are currently publicly available in commercial app stores. Of these eight apps, only four were demonstrated in the literature to assist with reducing alcohol consumption.

Conclusion

The evidence for alcohol reduction apps is promising but inconclusive. Few apps that have been evaluated in the scientific literature are currently available for download in commercial app stores.

Stakeholder perspectives on evidence for digital mental health interventions: Implications for accreditation systems

Background

Digital mental health interventions can be effective for treating mental health problems, but uptake by consumers and clinicians is not optimal. The lack of an accreditation pathway for digital mental health interventions is a barrier to their uptake among clinicians and consumers. However, there are a number of factors that may contribute to whether a digital intervention is suitable for recommendation to the public. The aim of this study was to identify the types of evidence that would support the accreditation of digital interventions.

Method

An expert workshop was convened, including researcher, clinician, consumer (people with lived experience of a mental health condition) and policymaker representatives.

Results

Existing methods for assessing the evidence for digital mental health interventions were discussed by the stakeholders present at the workshop. Empirical evidence from randomised controlled trials was identified as a key component for evaluating digital interventions. However, information on the safety of users, data security, user ratings, and fidelity to clinical guidelines, along with data from routine care including adherence, engagement and clinical outcomes, were also identified as important considerations when evaluating an intervention. There are considerable challenges in weighing the evidence for a digital mental health intervention.

Conclusions

Empirical evidence should be the cornerstone of any accreditation system to identify appropriate digital mental health interventions. However, robust accreditation systems should also account for program and user safety, user engagement and experience, and fidelity to clinical treatment guidelines.

Lifestyle risk indices in adolescence and their relationships to adolescent disease burden: findings from an Australian national survey

Background

The current study investigates the extent to which an adolescent-specific lifestyle risk factor index predicts indicators of the leading causes of adolescent morbidity and mortality.

Methods

Data came from 13 to 17 year-old respondents from the 2013–2014 nationally representative Australian Child and Adolescent Survey of Mental Health and Wellbeing (n = 2314). Indicators of adolescent disease burden included Major Depressive Disorder, psychological distress, self-harm and suicide attempt. Risk factors included risky alcohol use, drug use, unprotected sex, smoking, BMI and sleep duration. The extent to which these risk factors co-occurred were investigated using tetrachoric correlations. Several risk indices were then constructed based on these risk factors. Receiver Operating Characteristic curves determined the precision with which these indices predicted the leading causes of adolescent disease burden.

Results

Risky alcohol use, drug use, smoking, unprotected sex, and sleep were all highly clustered lifestyle risk factors, whereas BMI was not. A risk index comprising risky alcohol use, drug use, unprotected sex and sleep duration predicted the disease burden outcomes with the greatest precision. 31.9% of the sample reported one or more of these behaviours.

Conclusions

This lifestyle risk factor index represents a useful summary metric in the context of adolescent health promotion and non-communicable disease prevention. Lifestyle risk factors were found to cluster in adolescence, supporting the implementation of multiple health behaviour change interventions.

A Mobile Phone-Based Healthy Lifestyle Monitoring Tool for People With Mental Health Problems (MyHealthPA): Development and Pilot Testing

Background

People with mental health disorders live, on average, 20 years less than those without, often because of poor physical health including cardiovascular disease (CVD). Evidence-based interventions are required to reduce this lifespan gap.

Objective

This study aimed to develop, test, and evaluate a mobile phone–based lifestyle program (MyHealthPA) to help people with mental health problems improve key health risk behaviors and reduce their risk of CVD.

Methods

The development of MyHealthPA occurred in 3 stages: (1) scoping of the literature, (2) a survey (n=251) among people with and without the experience of mental health problems, and (3) program development informed by stages 1 and 2. A small pilot trial among young people with and without mental health disorders was also conducted. Participants completed a baseline assessment and were given access to the MyHealthPA program for a period of 8 weeks. They were then asked to complete an end-of-treatment assessment and a follow-up assessment 1 month later.

Results

In the study, 28 young people aged 19 to 25 years were recruited to the pilot trial. Of these, 12 (12/28, 43%) had been previously diagnosed with a mental illness. Overall, 12 participants (12/28, 43%) completed the end-of-treatment assessment and 6 (6/28, 21%) completed the follow-up assessment. Small improvements in fruit and vegetable consumption, level of physical activity, alcohol use, and mood were found between baseline and end of treatment and follow-up, particularly among people with experience of mental health issues. Most participants (history of mental illness: 4/7, 57%; no history of mental illness: 3/5, 60%) reported the program had above average usability; however, only 29% (2/7, no history of mental illness) to 40% (2/5, history of mental illness) of participants reported that they would like to use the program frequently and would recommend it to other young people. Participants also identified a number of ways in which the program could be improved.

Conclusions

This study describes the formative research and process of planning that formed the development of MyHealthPA and the evidence base underpinning the approach. The MyHealthPA program represents an innovative approach to CVD risk reduction among people with mental health problems. MyHealthPA appears to be an acceptable, easy-to-use, and potentially effective mHealth intervention to assist young people with mental illness to monitor risk factors for CVD. However, ways in which the program could be improved for future testing and dissemination were identified and discussed.

Internet-Based Universal Prevention for Students and Parents to Prevent Alcohol and Cannabis Use Among Adolescents: Protocol for the Randomized Controlled Trial of Climate Schools Plus

Background

Early initiation of alcohol and cannabis use markedly increases the risk of harms associated with use, including the development of substance use and mental health disorders. To interrupt this trajectory, effective prevention during the adolescent period is critical. Despite evidence showing that parents can play a critical role in delaying substance use initiation, the majority of prevention programs focus on adolescents only. Accordingly, the Climate Schools Plus (CSP) program was developed to address this gap.

Objective

This paper outlines the protocol for a cluster randomized controlled trial (RCT) of the CSP program, a novel internet-based program for parents and students to prevent adolescent substance use and related harms. The CSP program builds on the success of the Climate Schools student programs, with the addition of a newly developed parenting component, which allows parents to access the internet-based content to equip them with knowledge and skills to help prevent substance use in their adolescents.

Methods

A cluster RCT is being conducted with year 8 students (aged 12-14 years) and their parents from 12 Australian secondary schools between 2018 and 2020. Using blocked randomization, schools are assigned to one of the two groups to receive either the CSP program (intervention) or health education as usual (control). The primary outcomes of the trial will be any student alcohol use (≥1 standard alcoholic drink/s) and any student drinking to excess (≥5 standard alcoholic drinks). Secondary outcomes will include alcohol- and cannabis-related knowledge, alcohol use-related harms, frequency of alcohol consumption, frequency of drinking to excess, student cannabis use, parents’ self-efficacy to stop their children using alcohol, parental supply of alcohol, and parent-adolescent communication. All students and their parents will complete assessments on three occasions—baseline and 12 and 24 months postbaseline. In addition, students and parents in the intervention group will be asked to complete program evaluations on two occasions—immediately following the year 8 program and immediately following the year 9 program.

Results

Analyses will be conducted using multilevel, mixed-effects models within an intention-to-treat framework. It is expected that students in the intervention group will have less uptake and excessive use of alcohol compared with the students in the control group.

Conclusions

This study will provide the first evaluation of a combined internet-based program for students and their parents to prevent alcohol and cannabis use.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12618000153213; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374178 (Archived by WebCite at http://www.webcitation.org/71E0prqfQ)

Registered Report Identifier

RR1-10.2196/10849

Post-operative C-reactive protein profile following abdominal wall reconstruction with transversus abdominis posterior components separation

INTRODUCTION

Abdominal wall reconstruction using posterior component separation with transversus abdominis release (AWTAR) produces a unique post-operative CRP profile, when compared to routine elective colorectal operations. Therefore, we aim to establish the normal post-operative C-reactive protein (poCRP) profile following AWRTAR and reduce the unnecessary invasive interventions in patients already at greater risk of septic complications.

METHODS

A retrospective analysis of daily poCRP levels was performed both for patients who underwent uncomplicated AWRTAR (n=12), and a comparator group of uncomplicated open right hemicolectomies (RH) matched for age and sex (n=24). All operations in both groups were performed by a single surgeon from 2013 to 2015.

RESULTS

The median (IQR) age was 62 (16) and 67 (16) years respectively, with a higher proportion of males to females in both groups (10:2 vs. 17:7). The poCRP profile follows an initial steep rise, peaking at day 2 followed by a gradual washout phase. The poCRP peak is significantly greater in the AWRTAR group compared to the RH group (274 [95%CI ±25] vs. 160 [95%CI±27]; p=0.0001), with a positive correlation between day 2 CRP levels and operative length (r=0.56).

CONCLUSIONS

We have demonstrated that uncomplicated AWRTAR provokes a significantly greater poCRP rise (>200) compared to that well described in the literature for uncomplicated open colectomy. As poCRP is an important marker of post-operative recovery with abnormally high levels associated with septic complications, these data should help clinicians interpret the post-operative clinical course after AWRTAR.

Progression of hepatitis C in the haemophiliac population in Ireland, after 30 years of infection in the pre-DAA treatment era

INTRODUCTION

Prior to the introduction of viral inactivation of factor concentrates and screening of blood, 225 people with haemophilia became infected with hepatitis C (HCV) in Ireland.

AIM

Our aim was to assess liver disease progression and mortality in this population after 30 years of infection.

METHODS

Demographic and clinical data were collected from medical records in five hepatology units and one infectious disease unit retrospectively in 2005, and on four subsequent occasions.

RESULTS

The participation rate was 73% (165/225). Eighty three percent of patients, who had been tested for RNA (n = 106/128), developed chronic HCV infection. Thirty four percent were co-infected with HIV. All-cause mortality, after approximately 30 years of infection with chronic HCV, was 44% in HIV positive patients and 29% in HIV negative patients. Liver-related mortality was 12.5% and did not vary significantly by HIV status. Thirty seven percent of patients had developed advanced liver disease, including 20% with cirrhosis and 9% with hepatocellular carcinoma. In the pre-interferon-free direct acting antivirals era, 57% (n = 60/106) of patients were treated for HCV, 65% of whom achieved a sustained virological response. Successfully treated patients had few adverse liver outcomes.

CONCLUSION

After 30 years of infection, 40% of the patients who had evidence of chronic HCV had developed advanced liver disease, such as cirrhosis and HCC, or had died from liver-related causes. This proportion is high relative to similar international cohorts despite good anti-HCV treatment uptake and responses.

Free smoking cessation mobile apps available in Australia: a quality review and content analysis

OBJECTIVES

This review aimed to identify free, high-quality, smoking cessation mobile applications (apps) that adhere to Australian smoking cessation treatment guidelines.

METHODS

A systematic search of smoking cessation apps was conducted using Google. The technical quality of relevant apps was rated using the Mobile Application Rating Scale. The content of apps identified as high quality was assessed for adherence to smoking cessation treatment guidelines.

RESULTS

112 relevant apps were identified. The majority were of poor technical quality and only six 'high-quality' apps were identified. These apps adhered to Australian treatment guidelines in part. The efficacy of two apps had been previously evaluated.

CONCLUSIONS

In lieu of more substantial research in this area, it is suggested that the high-quality apps identified in this review may be more likely than other available apps to encourage smoking cessation. Implications for public health: Smoking cessation apps have the potential to address many barriers that prevent smoking cessation support being provided; however few high-quality smoking cessation apps are currently available in Australia, very few have been evaluated and the app market is extremely volatile. More research to evaluate smoking cessation apps, and sustained funding for evidence-based apps, is needed.

Long-term follow-up of patients with spontaneous clearance of hepatitis C: does viral clearance mean cure?

Up to 40% of patients with hepatitis C virus (HCV) antibodies are negative for HCV RNA at initial evaluation. If there is a risk of viral re-activation, long term follow-up is required with attendant financial, psychological and medical implications. We investigated the risk of re-activation in the Irish anti-D cohort. Information was obtained from the national hepatitis C database which includes data on patients infected by anti-D immunoglobulin in two large outbreaks, 1977-9 and 1991-94. As part of a screening programme, starting in 1994, 64,907 females exposed to anti-D immunoglobulin were evaluated. Three hundred and forty-seven were found to be antibody positive but HCV RNA negative at initial assessment. 93% had subsequent RNA tests. There was no evidence of HCV recurrence in patients whose infection resolved spontaneously. It appears that two initial sequential negative results for HCV RNA are sufficient to confirm spontaneous viral clearance and probable cure of hepatitis C virus infection.

Is A Person Thinking About Suicide Likely to Find Help on the Internet? An Evaluation of Google Search Results

It is unclear whether individuals searching the Internet for assistance with thoughts of suicide are likely to encounter predominantly helpful or harmful resources. This study investigated websites retrieved by searching Google for information and support for suicidal thoughts. Google searches retrieved a high percentage of irrelevant websites (26%, n = 136). Of the 329 relevant websites retrieved, the majority were suicide preventive (68%); however, a considerable proportion of sites expressed mixed (22%) or neutral (8%) suicide attitudes, and 1% were explicitly pro-suicide. The results highlight a need for suicide prevention organization websites to be made more easily accessible. In the meantime, clinicians should be aware of appropriate websites to recommend to clients.

Knowledge of HIV PEP Among Healthcare Workers in Ireland, 2016: Room for Improvement

Post-exposure prophylaxis (PEP) is an important aspect of HIV prevention following potential exposure. We conducted a survey to assess knowledge of HIV PEP, and awareness of HIV PEP resources, among key healthcare professionals, using an anonymous online questionnaire. Twelve (18%) of 68 respondents answered five or more of six knowledge questions correctly; 49 (72%) cited the Emergency Management of Injuries (EMI) toolkit as a resource. Although most respondents were aware of the EMI Toolkit for HIV PEP, the low number of respondents correctly answering knowledge questions suggests a need for training to avoid potential suboptimal HIV PEP use.