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Seid A, Fufa DD, Bitew ZW. The use of internet-based smartphone apps consistently improved consumers' healthy eating behaviors: a systematic review of randomized controlled trials. Front Digit Health 2024; 6:1282570. [PMID: 38283582 PMCID: PMC10811159 DOI: 10.3389/fdgth.2024.1282570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 01/02/2024] [Indexed: 01/30/2024] Open
Abstract
Introduction Digital tools, such as mobile apps and the Internet, are being increasingly used to promote healthy eating habits. However, there has been inconsistent reporting on the effectiveness of smartphones and web-based apps in influencing dietary behaviors. Moreover, previous reviews have been limited in scope, either by focusing on a specific population group or by being outdated. Therefore, the purpose of this review is to investigate the impacts of smartphone- and web-based dietary interventions on promoting healthy eating behaviors worldwide. Methods A systematic literature search of randomized controlled trials was conducted using databases such as Google Scholar, PubMed, Global Health, Informit, Web of Science, and CINAHL (EBSCO). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to prepare the entire document. EndNote (version 20) was used for reference management. The risk of bias in the articles was assessed using the "Revised Cochrane Risk of Bias tool for randomized trials (RoB 2.0)" by the Cochrane Collaboration. Narrative synthesis, using text and tables, was used to present the results. The study was registered in PROSPERO under protocol number CRD42023464315. Results This review analyzed a total of 39 articles, which consisted of 25 smartphone-based apps and 14 web-based apps. The studies involved a total of 14,966 participants. Out of the 25 studies, 13 (52%) showed that offline-capable smartphone apps are successful in promoting healthier eating habits. The impact of smartphone apps on healthy adults has been inconsistently reported. However, studies have shown their effectiveness in chronically ill patients. Likewise, internet-based mobile apps, such as social media or nutrition-specific apps, have been found to effectively promote healthy eating behaviors. These findings were consistent across 14 studies, which included healthy adults, overweight or obese adults, chronically ill patients, and pregnant mothers. Conclusion Overall, the findings suggest that smartphone apps contribute to improving healthy eating behaviors. Both nutrition-specific and social media-based mobile apps consistently prove effective in promoting long-term healthy eating habits. Therefore, policymakers in the food system should consider harnessing the potential of internet-based mobile apps and social media platforms to foster sustainable healthy eating behaviors.
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Affiliation(s)
- Awole Seid
- Department of Adult Health Nursing, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
- Center for Food Science and Nutrition, Addis Ababa University, Addis Ababa, Ethiopia
| | - Desta Dugassa Fufa
- Center for Food Science and Nutrition, Addis Ababa University, Addis Ababa, Ethiopia
- Haramaya Institute of Technology, Haramaya University, Dire Dawa, Ethiopia
| | - Zebenay Workneh Bitew
- Center for Food Science and Nutrition, Addis Ababa University, Addis Ababa, Ethiopia
- Saint Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
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2
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Brown A, Nathan N, Janssen L, Chooi A, Lecathelinais C, Hudson N, Wolfenden L, Sutherland R. New models to support parents to pack healthy lunchboxes: Parents acceptability, feasibility, appropriateness, and adoption of the SWAP IT m-Health program. Aust N Z J Public Health 2023; 47:100043. [PMID: 37087847 DOI: 10.1016/j.anzjph.2023.100043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/23/2023] [Indexed: 04/25/2023] Open
Abstract
OBJECTIVES This report aims to evaluate the acceptability, appropriateness, feasibility, and adoption of a healthy lunchbox program (SWAP IT), from the parent perspective. METHODS SWAP IT is an mobile health (m-Health) program aimed to support parents in swapping out discretionary foods for healthier alternatives. Following receipt of the program, parents completed validated scales assessing the Acceptability (AIM), Intervention Appropriateness (IAM), and Feasibility (FIM) via a computer-assisted telephone interview (CATI). Parents were asked about their awareness of strategies in SWAP IT and whether the program supported them to make lunchbox swaps from discretionary to everyday foods. RESULTS Of the 679 parents who consented, 413 completed the CATI (61% response rate). Parent's mean AIM score (out of a total score of 5) was 4.22 (SD 0.48); FIM score was 4.27 (SD 0.54); and IAM score was 4.24 (SD 0.54). Most parents reported receiving the lunchbox messages (54%), with 45% reporting opening all 10 messages and 64% of parents reporting the program helped swap out discretionary foods. CONCLUSION The m-Health lunchbox program, SWAP IT, is highly acceptable, easy to adopt, appropriate, and feasible to parents. IMPLICATIONS TO PUBLIC HEALTH Not only is SWAP IT effective, but favourable implementation factors highlight the potential scalability of the program in improving child nutrition.
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Affiliation(s)
- Alison Brown
- Hunter New England Population Health, Wallsend, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.
| | - Nicole Nathan
- Hunter New England Population Health, Wallsend, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.
| | - Lisa Janssen
- Hunter New England Population Health, Wallsend, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.
| | - Amelia Chooi
- Hunter New England Population Health, Wallsend, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.
| | - Christophe Lecathelinais
- Hunter New England Population Health, Wallsend, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.
| | - Nayerra Hudson
- Hunter New England Population Health, Wallsend, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.
| | - Luke Wolfenden
- Hunter New England Population Health, Wallsend, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.
| | - Rachel Sutherland
- Hunter New England Population Health, Wallsend, Australia; School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.
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3
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Mielke J, Brunkert T, Zúñiga F, Simon M, Zullig LL, De Geest S. Methodological approaches to study context in intervention implementation studies: an evidence gap map. BMC Med Res Methodol 2022; 22:320. [PMID: 36517765 PMCID: PMC9749183 DOI: 10.1186/s12874-022-01772-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/25/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Within implementation science studies, contextual analysis is increasingly recognized as foundational to interventions' successful and sustainable implementation. However, inconsistencies between methodological approaches currently limit progress in studying context and guidance to standardize the use of those approaches is scant. Therefore, this study's objective was to systematically review and map current methodological approaches to contextual analysis in intervention implementation studies. The results would help us both to systematize the process of contextual analysis and identify gaps in the current evidence. METHODS We conducted an evidence gap map (EGM) based on literature data via a stepwise approach. First, using an empirically developed search string, we randomly sampled 20% of all intervention implementation studies available from PubMed per year (2015-2020). Second, we assessed included studies that conducted a contextual analysis. Data extraction and evaluation followed the Basel Approach for CoNtextual ANAlysis (BANANA), using a color-coded rating scheme. Also based on BANANA and on the Context and Implementation of Complex Interventions (CICI) framework-an implementation framework that pays ample attention to context- we created visual maps of various approaches to contextual analysis. RESULTS Of 15, 286 identified intervention implementation studies and study protocols, 3017 were screened for inclusion. Of those, 110 warranted close examination, revealing 22% that reported on contextual analysis. Only one study explicitly applied a framework for contextual analysis. Data were most commonly collected via surveys (n = 15) and individual interviews (n = 13). Ten studies reported mixed-methods analyses. Twenty-two assessed meso-level contextual and setting factors, with socio-cultural aspects most commonly studied. Eighteen described the use of contextual information for subsequent project phases (e.g., intervention development/adaption, selecting implementation strategies). Nine reported contextual factors' influences on implementation and/or effectiveness outcomes. CONCLUSIONS This study describes current approaches to contextual analysis in implementation science and provides a novel framework for evaluating and mapping it. By synthesizing our findings graphically in figures, we provide an initial evidence base framework that can incorporate new findings as necessary. We strongly recommend further development of methodological approaches both to conduct contextual analysis and to systematize the reporting of it. These actions will increase the quality and consistency of implementation science research.
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Affiliation(s)
- Juliane Mielke
- Institute of Nursing Science, Department Public Health, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
| | - Thekla Brunkert
- Institute of Nursing Science, Department Public Health, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
- University Department of Geriatric Medicine FELIX PLATTER, Basel, Switzerland
| | - Franziska Zúñiga
- Institute of Nursing Science, Department Public Health, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
| | - Michael Simon
- Institute of Nursing Science, Department Public Health, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
| | - Leah L. Zullig
- Center for Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System and Department of Population Health Sciences, Duke University Medical Center, Durham, NC USA
| | - Sabina De Geest
- Institute of Nursing Science, Department Public Health, University of Basel, Bernoullistrasse 28, CH-4056 Basel, Switzerland
- Department of Public Health and Primary Care, KU Leuven, Academic Center for Nursing and Midwifery, Louvain, Belgium
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Mahdi S, Michalik-Denny EK, Buckland NJ. An Assessment of Behavior Change Techniques in Two Versions of a Dietary Mobile Application: The Change4Life Food Scanner. Front Public Health 2022; 10:803152. [PMID: 35284376 PMCID: PMC8904754 DOI: 10.3389/fpubh.2022.803152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
The Change4Life Food Scanner app is a UK Government dietary app designed to provide feedback on the nutritional content of packaged foods to parents and their children. To understand its intended mechanism of behavior change and how Behavior Change Technique (BCT) content evolves with app updates, this research aimed to map out the BCTs of two versions of the Change4Life Food Scanner app. Two coders undertook a descriptive comparative analysis of the use of BCTs in the Food Scanner app using the Behavior Change Technique Taxonomy [both the outdated (v1.6) and updated (v2.0) versions of the app were coded]. Results showed that both versions encompass the BCTs "goal setting (behavior)", "feedback on behavior", "social support (unspecified)", "instruction on how to perform behavior", "salience of consequences", "prompts/cues" and "credible source". The outdated version contained the BCT "behavior substitution" which had been dropped in the updated version. The updated version featured the additional BCTs "information about social and environmental consequences", "information about emotional consequences", "social reward" and "social incentive" and was comparatively more BCT intensive in terms of content and occurrence. The BCT content of the Food Scanner app resembles that of existing dietary apps and incorporates several BCTs which have previously been found to be effective. Future work to evaluate the effectiveness of the app is recommended. This will provide insight into whether the combination of BCTs used in the Change4Life Food Scanner app are effective in improving dietary choices.
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Affiliation(s)
- Sundus Mahdi
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Emily K Michalik-Denny
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Nicola J Buckland
- Department of Psychology, University of Sheffield, Sheffield, United Kingdom
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Leeman J, Boisson A, Go V. Scaling Up Public Health Interventions: Engaging Partners Across Multiple Levels. Annu Rev Public Health 2021; 43:155-171. [PMID: 34724390 DOI: 10.1146/annurev-publhealth-052020-113438] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Advancing the science of intervention scale-up is essential to increasing the impact of effective interventions at the regional and national levels. In contrast with work in high-income countries (HICs), where scale-up research has been limited, researchers in low- and middle-income countries (LMICs) have conducted numerous studies on the regional and national scale-up of interventions. In this article, we review the state of the science on intervention scale-up in both HICs and LMICs. We provide an introduction to the elements of scale-up followed by a description of the scale-up process, with an illustrative case study from our own research. We then present findings from a scoping review comparing scale-up studies in LMIC and HIC settings. We conclude with lessons learned and recommendations for improving scale-up research. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Jennifer Leeman
- School of Nursing, University of North Carolina, Chapel Hill, North Carolina, USA;
| | - Alix Boisson
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA;
| | - Vivian Go
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA;
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Sutherland R, Brown A, Nathan N, Yoong S, Janssen L, Chooi A, Hudson N, Wiggers J, Kerr N, Evans N, Gillham K, Oldmeadow C, Searles A, Reeves P, Davies M, Reilly K, Cohen B, Wolfenden L. A Multicomponent mHealth-Based Intervention (SWAP IT) to Decrease the Consumption of Discretionary Foods Packed in School Lunchboxes: Type I Effectiveness-Implementation Hybrid Cluster Randomized Controlled Trial. J Med Internet Res 2021; 23:e25256. [PMID: 34185013 PMCID: PMC8277365 DOI: 10.2196/25256] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/20/2020] [Accepted: 01/20/2021] [Indexed: 12/31/2022] Open
Abstract
Background There is significant opportunity to improve the nutritional quality of foods packed in children’s school lunchboxes. Interventions that are effective and scalable targeting the school and home environment are therefore warranted. Objective This study aimed to assess the effectiveness of a multicomponent, mobile health–based intervention, SWAP IT, in reducing the energy contribution of discretionary (ie, less healthy) foods and drinks packed for children to consume at school. Methods A type I effectiveness–implementation hybrid cluster randomized controlled trial was conducted in 32 primary schools located across 3 local health districts in New South Wales, Australia, to compare the effects of a 6-month intervention targeting foods packed in children’s lunchboxes with those of a usual care control. Primary schools were eligible if they were not participating in other nutrition studies and used the required school communication app. The Behaviour Change Wheel was used to co-design the multicomponent SWAP IT intervention, which consisted of the following: school lunchbox nutrition guidelines, curriculum lessons, information pushed to parents digitally via an existing school communication app, and additional parent resources to address common barriers to packing healthy lunchboxes. The primary outcome, mean energy (kilojoules) content of discretionary lunchbox foods and drinks packed in lunchboxes, was measured via observation using a validated school food checklist at baseline (May 2019) and at 6-month follow-up (October 2019). Additional secondary outcomes included mean lunchbox energy from discretionary foods consumed, mean total lunchbox energy packed and consumed, mean energy content of core lunchbox foods packed and consumed, and percentage of lunchbox energy from discretionary and core foods, all of which were also measured via observation using a validated school food checklist. Measures of school engagement, consumption of discretionary foods outside of school hours, and lunchbox cost were also collected at baseline and at 6-month follow-up. Data were analyzed via hierarchical linear regression models, with controlling for clustering, socioeconomic status, and remoteness. Results A total of 3022 (3022/7212, 41.90%) students consented to participate in the evaluation (mean age 7.8 years; 1487/3022, 49.22% girls). There were significant reductions between the intervention and control groups in the primary trial outcome, mean energy (kilojoules) content of discretionary foods packed in lunchboxes (–117.26 kJ; 95% CI –195.59 to –39.83; P=.003). Relative to the control, the intervention also significantly reduced secondary outcomes regarding the mean total lunchbox energy (kilojoules) packed (–88.38 kJ; 95% CI –172.84 to –3.92; P=.04) and consumed (–117.17 kJ; 95% CI –233.72 to –0.62; P=.05). There was no significant difference between groups in measures of student engagement, consumption of discretionary foods outside of school hours, or cost of foods packed in children’s lunchboxes. Conclusions The SWAP IT intervention was effective in reducing the energy content of foods packed for and consumed by primary school–aged children at school. Dissemination of the SWAP IT program at a population level has the potential to influence a significant proportion of primary school–aged children, impacting weight status and associated health care costs. Trial Registration Australian Clinical Trials Registry ACTRN12618001731280; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376191&isReview=true International Registered Report Identifier (IRRID) RR2-10.1186/s12889-019-7725-x
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Affiliation(s)
- Rachel Sutherland
- Hunter New England Population Health, Wallsend, Australia.,School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, Australia
| | - Alison Brown
- Hunter New England Population Health, Wallsend, Australia
| | - Nicole Nathan
- Hunter New England Population Health, Wallsend, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, Australia
| | - Serene Yoong
- Hunter New England Population Health, Wallsend, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, Australia.,Department of Nursing and Allied Health, School of Health Sciences, Swinburne University of Technology, Hawthorn, Australia
| | - Lisa Janssen
- Hunter New England Population Health, Wallsend, Australia
| | - Amelia Chooi
- Hunter New England Population Health, Wallsend, Australia
| | - Nayerra Hudson
- Hunter New England Population Health, Wallsend, Australia
| | - John Wiggers
- Hunter New England Population Health, Wallsend, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, Australia
| | - Nicola Kerr
- Mid North Coast Local Health District, Port Macquarie, Australia
| | - Nicole Evans
- Central Coast Local Health District, Gosford, Australia
| | - Karen Gillham
- Hunter New England Population Health, Wallsend, Australia
| | | | - Andrew Searles
- Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Penny Reeves
- Hunter New England Population Health, Wallsend, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Marc Davies
- New South Wales Ministry of Health, Liverpool, Australia
| | - Kathryn Reilly
- Hunter New England Population Health, Wallsend, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia.,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, Australia
| | | | - Luke Wolfenden
- Hunter New England Population Health, Wallsend, Australia
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Martín-Payo R, Fernández-Álvarez MDM, Zabaleta-del-Olmo E, García-García R, González-Méndez X, Carrasco-Santos S. Feasibility Study of an Educational Intervention to Improve Water Intake in Adolescent Soccer Players: A Two-Arm, Non-Randomized Controlled Cluster Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18031339. [PMID: 33540715 PMCID: PMC7908608 DOI: 10.3390/ijerph18031339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/29/2021] [Accepted: 01/30/2021] [Indexed: 11/16/2022]
Abstract
This study aimed to assess the feasibility of an educational intervention on hydration behavior in adolescent soccer players. A pilot study of a two-arm, non-randomized controlled cluster trial was conducted. A total of 316 players aged 13-16 agreed to participate. The response variables were the players' participation in the intervention, their perception of the knowledge acquired, the usefulness and the overall assessment of the intervention. Hydration patterns and acquisition of knowledge on hydration behavior were also assessed. The intervention involved two elements: posters and a web app. A total of 259 adolescents completed the study (intervention group (IG) = 131; control group (CG) = 128). 80.6% of the players responded to the survey assessing the feasibility of the intervention. The mean number of correct answers regarding behavior was significantly higher in the IG (3.54; SD = 1.162) than in the CG (2.64; SD = 1.174) (p < 0.001). The water consumption pattern at all the clubs was ad libitum. Of the players, 10% did not drink any water at all during the game. In conclusion, this intervention has been shown to be feasible for implementation with adolescent soccer players. It suggests that hydration guidelines should be informed by personal factors and that ad libitum water consumption should be avoided.
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Affiliation(s)
- Rubén Martín-Payo
- Faculty of Medicine and Health Sciences, University of Oviedo, Campus del Cristo s/n, 33006 Oviedo, Spain;
- PRECAM Research Team, Health Research Institute of the Principality of Asturias, Avenida Roma s/n, 33011 Oviedo, Spain; (R.G.-G.); (X.G.-M.); (S.C.-S.)
| | - María del Mar Fernández-Álvarez
- Faculty of Medicine and Health Sciences, University of Oviedo, Campus del Cristo s/n, 33006 Oviedo, Spain;
- PRECAM Research Team, Health Research Institute of the Principality of Asturias, Avenida Roma s/n, 33011 Oviedo, Spain; (R.G.-G.); (X.G.-M.); (S.C.-S.)
- Correspondence:
| | - Edurne Zabaleta-del-Olmo
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08007 Barcelona, Spain;
- Gerència Territorial de Barcelona, Institut Català de la Salut, 08007 Barcelona, Spain
- Nursing Department, Nursing Faculty, Universitat de Girona, 17004 Girona, Spain
- Campus Bellaterra, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
| | - Rebeca García-García
- PRECAM Research Team, Health Research Institute of the Principality of Asturias, Avenida Roma s/n, 33011 Oviedo, Spain; (R.G.-G.); (X.G.-M.); (S.C.-S.)
- Hospital Universitario Central de Asturias, Avenida Roma s/n, 33011 Oviedo, Spain
| | - Xana González-Méndez
- PRECAM Research Team, Health Research Institute of the Principality of Asturias, Avenida Roma s/n, 33011 Oviedo, Spain; (R.G.-G.); (X.G.-M.); (S.C.-S.)
- Hospital Universitario San Agustín de Avilés, Camino de Heros 6, 33401 Avilés, Spain
| | - Sergio Carrasco-Santos
- PRECAM Research Team, Health Research Institute of the Principality of Asturias, Avenida Roma s/n, 33011 Oviedo, Spain; (R.G.-G.); (X.G.-M.); (S.C.-S.)
- Hospital Universitario San Agustín de Avilés, Camino de Heros 6, 33401 Avilés, Spain
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