Evaluation of Patient-Facing Mobile Apps to Support Physiotherapy Care: Systematic Review

BACKGROUND

Mobile health interventions delivered through mobile apps are increasingly used in physiotherapy care. This may be because of the potential of apps to facilitate changes in behavior, which is central to the aims of care delivered by physiotherapists. A benefit of using apps is their ability to incorporate behavior change techniques (BCTs) that can optimize the effectiveness of physiotherapeutic interventions. Research continues to suggest that despite their importance, behavior change strategies are often missing in patient management. Evaluating mobile apps that physiotherapists can use to drive behavior change may inform clinical practice and potentially improve patient outcomes. Examining the quality of apps and exploring their key features that can support behavior change and physiotherapy care are important aspects of such an evaluation.

OBJECTIVE

The primary aim of this study was to describe the range of mobile apps in app stores that are intended for use by patients to support physiotherapy care. The secondary aims were to assess app quality, BCTs, and their behavior change potential.

METHODS

A systematic review of mobile apps in app stores was undertaken. The Apple App Store and Google Play were searched using a 2-step search strategy, using terms relevant to the physiotherapy discipline. Strict inclusion and exclusion criteria were applied: apps had to be intended for use by patients and be self-contained (or stand-alone) without the requirement to be used in conjunction with a partner wearable device or another plugin. Included apps were coded for BCTs using the Behavior Change Technique Taxonomy version 1. App quality was assessed using the Mobile App Rating Scale, and the App Behavior Change Scale was used to assess the app's potential to change behavior.

RESULTS

In total, 1240 apps were screened, and 35 were included. Of these 35 apps, 22 (63%) were available on both the Apple App Store and Google Play platforms. In total, 24 (69%) were general in their focus (eg, not condition-specific), with the remaining 11 (31%) being more specific (eg, knee rehabilitation and pelvic floor training). The mean app quality score (Mobile App Rating Scale) was 3.7 (SD 0.4) of 5 (range 2.8-4.5). The mean number of BCTs identified per app was 8.5 (SD 3.6). BCTs most frequently included in the apps were instruction on how to perform a behavior (n=32), action planning (n=30), and self-monitoring of behavior (n=28). The mean behavior change potential score (App Behavior Change Scale) was 8.5 (SD 3.1) of 21 (range 3-15).

CONCLUSIONS

Mobile apps available to support patient care received from a physiotherapist are of variable quality. Although they contain some BCTs, the potential for behavior change varied widely across apps.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/29047.

A multidimensional assessment of payback: Evaluating the impact of Breast Cancer Trials

AIM

This study evaluates the impact created by clinical trial investment and research undertaken by Breast Cancer Trials (BCT).

METHODS

The approach involved using the Payback Framework, and included a review of BCT archival information, public health data, a questionnaire sent to BCT members, individual interviews with key informants, a focus group with members of the organization's Consumer Advisory Panel, and case studies of select BCT trials. The evaluation assessed the evidence against the Payback Framework criteria: informing policy and product development, knowledge production, the research system, health and health sector benefits, and broader economic benefits.

RESULTS

Analysis using the Payback Framework revealed impact was created in each category and a range of positive outcomes were identified for various stakeholder groups. BCT is maximizing the impact of its research and contributing to a global pool of scientific knowledge by collaborating with over 100 institutions and 820 researchers, yet its benefits go beyond research contributions. Findings highlight strong financial returns from BCT's research program and that BCT has played an important role in enhancing the public perception of clinical trials by promoting participation in trials, educating and empowering participants, and communicating trial outcomes.

CONCLUSION

BCT's clinical trials have had a significant impact on the prevention, detection, treatment, and management of breast cancer. Measuring and reporting impact can be resource intensive but support BCT in remaining accountable to all those invested in the organization and in breast cancer clinical trials, evidencing the multiple dimensions of payback resulting from the organization's research.

Training Australian Dietitians in Behavior Change Techniques Through Educational Workshops: Protocol for a Randomized Controlled Trial

BACKGROUND

The use of education alone as a technique to change behavior in interventions is usually insufficient, particularly in health interventions. Behavior change techniques have been shown to be effective in fostering positive changes in health behaviors such as diet and physical activity. The upskilling of health professionals can increase perceived capability and motivation toward eliciting change in clients' behaviors. However, to date, dietitians have received limited training in behavior change and have expressed a need for continuous professional development.

OBJECTIVE

The study objectives are to (1) develop and evaluate the effectiveness and acceptability of two 2-hour behavior change workshops on changing dietitians behavior (ie, range of behavior change techniques used and frequency of use) across 3 time points; (2) determine if participation in these workshops will elicit changes in dietitians' perceived capability, opportunity, and motivation toward using behavior change techniques; and (3) determine the acceptability of the training and its application in practice by dietitians.

METHODS

We will recruit registered dietitians (N=140) in Australia to participate in this randomized controlled trial. Participants will be randomly assigned to either the intervention or 3-month waitlist control condition and complete outcome measures at 3 time points: baseline, after the workshop, and follow-up at 3 months. Both groups will complete 2 workshops on behavior change that are guided by the COM-B (Capability, Opportunity, Motivation, and Behavior) Model and embedded with behavior change techniques. The primary outcome is changes in behavior, (ie, the range of behavior change techniques used and their frequency of use). Secondary outcomes include changes in perceived capability, opportunity, motivation, and preparedness as a health professional toward delivering behavior change techniques. The acceptability of the workshops will also be assessed after the workshop through the postworkshop survey and semistructured interviews. A series of 2-way repeated measures ANOVAs and regressions will be used. Qualitative data will be analyzed using thematic analysis.

RESULTS

Participant recruitment commenced in June 2023. The results of the study are expected to be published in November 2024. The results will allow us to assess comparisons between the intervention and waitlist control groups, as well as changes in perceived capability, opportunity, motivation, and preparedness over a 3-month period. It will also provide an understanding of the acceptability of the training as a form of continuous professional development for dietitians.

CONCLUSIONS

If found to be effective, the results of this 2-arm randomized controlled trial will guide future training and continuous professional development for health professionals in changing behavior in practice. Our findings will contribute to our understanding of the application of behavior change techniques in practice with clients and identify components of COM-B where dietitians may need future support.

TRIAL REGISTRATION

ACTRN12623000525684; https://www.anzctr.org.au/ACTRN12623000525684.aspx.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/49723.

Supporting Adolescent Engagement with Artificial Intelligence-Driven Digital Health Behavior Change Interventions

Understanding and optimizing adolescent-specific engagement with behavior change interventions will open doors for providers to promote healthy changes in an age group that is simultaneously difficult to engage and especially important to affect. For digital interventions, there is untapped potential in combining the vastness of process-level data with the analytical power of artificial intelligence (AI) to understand not only how adolescents engage but also how to improve upon interventions with the goal of increasing engagement and, ultimately, efficacy. Rooted in the example of the INSPIRE narrative-centered digital health behavior change intervention (DHBCI) for adolescent risky behaviors around alcohol use, we propose a framework for harnessing AI to accomplish 4 goals that are pertinent to health care providers and software developers alike: measurement of adolescent engagement, modeling of adolescent engagement, optimization of current interventions, and generation of novel interventions. Operationalization of this framework with youths must be situated in the ethical use of this technology, and we have outlined the potential pitfalls of AI with particular attention to privacy concerns for adolescents. Given how recently AI advances have opened up these possibilities in this field, the opportunities for further investigation are plenty.

Increasing Machine-Related Safety on Farms: Development of an Intervention Using the Behaviour Change Wheel Approach

Farming is essential work, but it suffers from very high injury and fatality rates. Machinery, including tractors, are a leading cause of serious injuries and fatalities to farmers and farm workers in many countries. Herein, we document the systematic development of an evidence-based, theory-informed behaviour change intervention to increase machine-related safety on farms. Intervention development progressed through four phases. Phase 1 defined the problem in behavioural terms based a review of the literature, Phase 2 identified candidate intervention targets through a series of focus groups guided by the Capability-Opportunity-Motivation-Behaviour (COM-B) model and Phase 3 employed expert and stakeholder consultation guided by the Behaviour Change Wheel (BCW) to consider potential target behaviours and intervention components and finalise the intervention content. Phase 4 finalised the evaluation strategies with a team of agricultural advisors who supported the rollout and identified outcome measures for the first trial. The target intervention was the identification of blind spots of farm tractors, and three priority target behaviours (farm safety practices) were identified. Following Phase 3, the intervention comprised four components that are delivered in a group-based, face-to-face session with farmers. In Phase 4, the acceptability, feasibility, and fidelity of these components were identified as the outcome measures for the first trial of the intervention. The four-phase systematic method detailed here constitutes an initial template for developing theory-based, stakeholder-driven, behaviour-change-based interventions targeting farmers and reporting such developments.

Reducing patient delay in acute coronary syndrome: Randomized controlled trial testing effect of behaviour change intervention on intentions to seek help

OBJECTIVES

The aim of this study was to evaluate the efficacy of a behaviour change intervention to reduce patient delay with symptoms of acute coronary syndrome.

DESIGN

A 3-arm web-based, parallel randomized controlled trial.

METHODS

The intervention comprised 12 behaviour change techniques (BCTs) embedded in a text-only or text+visual narrative (the techniques were systematically identified through systematic review and a consensus exercise). Between February and November 2017, n = 145 people who had recently experienced acute coronary syndrome were randomly allocated to intervention ('text+visual' or 'text-only') or control. Intentions to phone an ambulance immediately for acute coronary syndrome symptoms were assessed before and after the intervention using symptom scenarios, and the change in intention was compared across the three groups.

RESULTS

Significant increases in intention to phone an ambulance immediately for ACS symptoms were seen following the 'text+visual' intervention but not following 'text-only' or control. However, the study was underpowered to detect any significant changes in intention between the 3 groups. There were no unintended effects on intentions for non-urgent symptoms.

CONCLUSIONS

A 'text+visual' BCT-based intervention may significantly increase intention to phone an ambulance with symptoms of ACS. Further testing of the effect of the intervention on actual behaviour is required.

Antiviral and anti-inflammatory activity of novel belladonna formulation against Japanese encephalitis virus via inhibition of p65 nuclear translocation and TNF-α mediated NF-kB signaling

Japanese encephalitis (JE) is a mosquito-borne flavivirus infection, a major cause of viral encephalitis in South-East Asia with a CFR of ~30% and no specific treatment. Therefore, a novel belladonna formulation (BCT) was prepared and its antiviral and anti-inflammatory activity was elucidated during Japanese encephalitis virus (JEV) infection. Anti-JEV role of BCT was investigated aiming to prevent the infection in the peripheral immune cells. Antiviral activity of BCT was evaluated by plaque reduction assay, cell survival and apoptosis assay. BCT-mediated reduction in JEV-envelope expression was measured by indirect immunofluorescence, RT-PCR and Western blot assays. NF-κB expression and p65 nuclear translocation assays were determined to explore the mechanism of the action of BCT. TNF-α level was measured to evaluate the anti-inflammatory role of BCT during JEV infection. Consequently, molecular docking was performed with the TRAF2-TRADD complex. Our data suggested that BCT treatment reduces the JEV-plaque formation, JEV-induced cytopathic effects and increases cell survival. The antiviral effect of BCT was confirmed by reduction in the JEV-envelope protein expression. Moreover, BCT treatment and prevents the NF-κB activation via preventing the nuclear translocation of p65 and reduces the TNF-α levels. Our molecular docking analysis suggested that belladonna alkaloids interfere with the TRAF2-TRADD complex that results in inhibition of TNF-induced NF-κB signaling. For the first time, our data suggested that BCT reduces JEV expression and interferes with TNF-induced NF-κB signaling, thereby increasing cell survival via preventing the p65 nuclear translocation and may be used for the treatment and prevention of JE.Abbreviation: CFR: Case fatality rate; CAM: Complementary and alternative medicines; COX-2: Cyclooxygenase-2; IκB: Inhibitor kappa B; JE: Japanese encephalitis; JEV: Japanese encephalitis virus; NF-κB: Nuclear factor kappa-light-chain-enhancer of activated B cells; ORF: Open reading frame; TNFR: Tumor necrosis factor receptor; TNF-α: Tumor necrosis factor-α; TRADD: TNFR1-associated death domain protein; TRAF2: TNF Receptor Associated Factor 2.

Behavior Change Techniques in Digital Health Interventions for Midlife Women: Systematic Review

BACKGROUND

Digital health interventions are efficacious in health-promoting behaviors (eg, healthy eating and regular physical activity) that mitigate health risks and menopausal symptoms in midlife. However, integrated evidence-based knowledge about the mechanisms of change in these interventions is unclear.

OBJECTIVE

This systematic review aimed to evaluate studies on behavior change techniques (BCTs) and mechanisms of change in digital health interventions aimed at promoting health-enhancing behaviors in midlife women (aged 40-65 years).

METHODS

A systematic literature search of the electronic databases PubMed, Web of Science, PsycINFO, and Cochrane Central Register of Controlled Trials in the Cochrane Library was conducted. In total, 2 independent reviewers selected the studies for inclusion, extracted data, and completed BCT mapping of eligible studies. The mechanism of action and intervention functions of eligible studies were evaluated using the behavior change wheel framework. Reporting of psychological theory use within these interventions was explored using the Theory Coding Scheme. Mode of delivery, psychological theory, and BCTs were presented as descriptive statistics.

RESULTS

In total, 13 interventions (including 1315 women) reviewed used 13 (SD 4.30, range 6-21) BCTs per intervention on average. The "Shaping knowledge" and "Repetition and substitution" behavior change categories were used most frequently, with 92% (12/13) of the interventions implementing at least one of the BCTs from these 2 categories. Only 13.98% (169/1209) of the 93 available BCTs were used, with "Instructions on behaviour" most frequently used (12/13, 92%). The behavior change wheel mapping suggests that half of the intervention content aimed to increase "Capability" (49/98, 50% of the intervention strategies), "Motivation" (41/98, 42%), and "Opportunity" (8/98, 8%). "Behavioural Regulation" was the most frequently used mechanism of action (15/98, 15%), followed by increasing "Knowledge" (13/98, 13%) and "Cognitive and Interpersonal skills" (10/98, 10%). A total of 78% (7/9) of the intervention functions were used in the studies to change behavior, primarily through "Enablement" (60/169, 35.5%), whereas no study used "Restriction" or "Modelling" functions. Although 69% (9/13) of the interventions mentioned a psychological theory or model, most (10/13, 77%) stated or suggested rather than demonstrated the use of a theoretical base, and none reported explicit links between all BCTs within the intervention and the targeted theoretical constructs. Technological components were primarily based on web-based (9/13, 69%) modes of delivery, followed by phone or SMS text message (8/13, 62%) and wearables (7/13, 54%).

CONCLUSIONS

The findings of this review indicate an overall weak use of theory, low levels of treatment fidelity, insignificant outcomes, and insufficient description of several interventions to support the assessment of how specific BCTs were activated. Thus, the identified limitations in the current literature provide an opportunity to improve the design of lifestyle health-enhancing interventions for women in midlife.

TRIAL REGISTRATION

PROSPERO CRD42021259246; https://tinyurl.com/4ph74a9u.

Behavioral Change Factors and Retention in Web-Based Interventions for Informal Caregivers of People Living With Dementia: Scoping Review

BACKGROUND

Web-based interventions aimed at supporting informal caregivers of people living with dementia have the potential to improve caregivers' well-being and psychological health. However, few interventions are widely implemented for this population, and none of the prior reviews have systematically examined the use of behavior change techniques (BCTs), theories, and agents in web-based interventions for informal caregivers of people living with dementia. To better understand this implementation gap, we reviewed the literature to map behavioral factors (BCTs, theories, and agents) deployed in the studies. Furthermore, because there is an emerging consensus that retention could be shaped by participant characteristics and behavioral factors, we explored relationships between these features and retention rates across studies.

OBJECTIVE

We pursued 3 objectives: to map behavioral factors involved in the web-based interventions for informal caregivers of people living with dementia; to examine the relationship between behavioral change elements and retention in the studies; and to examine the relationship between participant characteristics (gender, age, and spouse or adult children caregiver proportion) and study retention.

METHODS

We conducted a literature review using the following keywords and their corresponding Medical Subject Headings terms: dementia, caregivers, and web-based intervention. The time limits were January 1998 to March 2022. Using the BCTv1 taxonomy, which specifies active behavioral components in interventions, 2 coders collected, summarized, and analyzed the frequency distributions of BCTs. Similarly, they abstracted and analyzed participant characteristics, behavior change theories, behavior change agents, and retention rates in the studies.

RESULTS

The average age was 61.5 (SD 7.4) years, and the average proportion of spousal informal caregivers, adult children informal caregivers, and retention rates were 51.2% (SD 24.8%), 44.8% (SD 22%), and 70.4% (SD 17%), respectively. Only 53% (17/32) of the studies used behavior change theories, but 81% (26/32) included behavior change agents. The most common BCTv1 clusters were shaping knowledge and social support. The median number of BCTv1 clusters was 5 (IQR 3). We observed a negative correlation between the proportion of spousal informal caregivers and the retention rate (r=-0.45; P=.02) and between the number of BCTv1 clusters and retention rates (r=-0.47; P=.01). We also found that the proportion of adult children informal caregivers in the study was significantly and positively correlated with the retention rate (r=0.5; P=.03). No other participant characteristics or behavioral factors were associated with retention rates.

CONCLUSIONS

We found that almost half of the studies were not informed by behavior change theories. In addition, spousal involvement and a higher number of BCTs were each associated with lower retention rates, while the involvement of adult children caregivers in the study was associated with higher retention. In planning future studies, researchers should consider matching participant characteristics with their intended intervention as the alignment might improve their retention rates.

Comparisons of glandular breast dose between digital mammography, tomosynthesis and breast CT based on anthropomorphic patient-derived breast phantoms

PURPOSE

To evaluate the bias to the mean glandular dose (MGD) estimates introduced by the homogeneous breast models in digital breast tomosynthesis (DBT) and to have an insight into the glandular dose distributions in 2D (digital mammography, DM) and 3D (DBT and breast dedicated CT, BCT) x-ray breast imaging by employing breast models with realistic glandular tissue distribution and organ silhouette.

METHODS

A Monte Carlo software for DM, DBT and BCT simulations was adopted for the evaluation of glandular dose distribution in 60 computational anthropomorphic phantoms. These computational phantoms were derived from 3D breast images acquired via a clinical BCT scanner.

RESULTS

g·c·s·T conversion coefficients based on homogeneous breast model led to a MGD overestimate of 18% in DBT when compared to MGD estimated via anthropomorphic phantoms; this overestimate increased up to 21% for recently computed DgN_DBT conversion coefficients. The standard deviation of the glandular dose distribution in BCT resulted 60% lower than in DM and 55% lower than in DBT. The glandular dose peak - evaluated as the average value over the 5% of the gland receiving the highest dose - is 2.8 times the MGD in DM, this factor reducing to 2.6 and 1.6 in DBT and BCT, respectively.

CONCLUSIONS

Conventional conversion coefficients for MGD estimates based on homogeneous breast models overestimate MGD by 18%, when compared to MGD estimated via anthropomorphic phantoms. The ratio between the peak glandular dose and the MGD is 2.8 in DM. This ratio is 8% and 75% higher than in DBT and BCT, respectively.

Survival Outcomes After Breast-Conserving Therapy Compared With Mastectomy for Patients With Early-Stage Invasive Micropapillary Carcinoma of the Breast: A SEER Population-Based Study

Background

Invasive micropapillary breast carcinoma (IMPC) is a relatively rare pathological type of invasive breast cancer. Little is currently known on the efficacy and safety of breast-conserving treatment (BCT, lumpectomy plus postsurgical radiation) compared with mastectomy in women diagnosed with early-stage IMPC. Accordingly, we sought to investigate the long-term prognostic differences between BCT and mastectomy in patients with T1-3N0-3M0 invasive micropapillary breast carcinoma using data from the Surveillance, Epidemiology, and End Results (SEER) database.

Materials and Methods

We retrospectively analyzed 1,203 female patients diagnosed with early-stage IMPC between 2004 and 2015 from the SEER database. The impact of different surgical approaches on patient prognosis was assessed by the Kaplan-Meier method and Cox proportional risk models.

Results

A total of 609 and 594 patients underwent mastectomy and BCT, respectively. Compared with patients who underwent a mastectomy, patients in the BCT group were older and had lower tumor diameters, lower rates of lymph nodes metastasis, and higher rates of ER receptor positivity and PR receptor positivity (p < 0.05). Kaplan-Meier plots showed that the overall survival (OS) and breast cancer-specific survival (BCSS) were higher in the BCT group than in the mastectomy group. In subgroup analysis, patients with T2 stage in the BCT group had better OS than the mastectomy group. Multivariate analysis showed no statistical difference in OS and BCSS for patients in the mastectomy group compared with the BCT group (hazard ratio (HR) = 0.727; 95% confidence interval (95% CI) 0.369–1.432, p = 0.357; HR = 0.762; 95% CI 0.302–1.923, p = 0.565; respectively). During the multivariate analysis and stratifying for the T stage, a better OS was found for patients with T2 stage in the BCT group than the mastectomy group (HR = 0.333, 95% CI: 0.149–0.741, p = 0.007). There was no significant difference in OS for patients with T1 and T3 stages between the BCT and mastectomy groups (p > 0.05).

Conclusion

In women with early-stage IMPC, BCT was at least equivalent to mastectomy in terms of survival outcomes. When both procedures are feasible, BCT should be recommended as the standard surgical treatment, especially for patients with T2 disease.

Bayes factor testing of equality and order constraints on measures of association in social research

Measures of association play a central role in the social sciences to quantify the strength of a linear relationship between the variables of interest. In many applications researchers can translate scientific expectations to hypotheses with equality and/or order constraints on these measures of association. In this paper a Bayes factor test is proposed for testing multiple hypotheses with constraints on the measures of association between ordinal and/or continuous variables, possibly after correcting for certain covariates. This test can be used to obtain a direct answer to the research question how much evidence there is in the data for a social science theory relative to competing theories. The stand-alone software package 'BCT' allows users to apply the methodology in an easy manner. The methodology will also be available in the R package 'BFpack'. An empirical application from leisure studies about the associations between life, leisure and relationship satisfaction and an application about the differences about egalitarian justice beliefs across countries are used to illustrate the methodology.

Identifying behavior change techniques for inclusion in a complex intervention targeting antipsychotic prescribing to nursing home residents with dementia

Nursing home residents with dementia are commonly prescribed antipsychotics despite the associated increased risk of harms. Interventions to optimize prescribing practice have been found to be effective in the short term, but there is a lack of evidence to support sustainability of effects, along with a lack of theory, public involvement, and transparency in the intervention development process. Using theory has been advocated as a means of improving intervention sustainability. The aim of this study was, therefore, to identify behavior change techniques (BCTs) for inclusion in a complex intervention targeting antipsychotic prescribing to nursing home residents with dementia. A comprehensive approach to identifying a long list of all potential BCTs from three different sources was undertaken. The most appropriate BCTs were then selected through a two-round Delphi consensus survey with a broad range of experts (n = 18 panelists). Advisory groups of people with dementia, family carers, and professional stakeholders provided feedback on the final BCTs included. After two Delphi survey rounds, agreement was reached on 22 BCTs. Further refinement of the selected BCTs based on advisory group and panelists' feedback, along with use of the APEASE criteria (Affordability, Practicability, Effectiveness, Acceptability, Side effects/safety, and Equity) resulted in a final list of 16 BCTs. The next step in intervention development will be to identify the most appropriate mode of delivery of the 16 BCTs identified for inclusion. The study provides a case example of a systematic approach to incorporating evidence with stakeholder views in the identification of appropriate BCTs.

Smartphone-Based Interventions for Physical Activity Promotion: Scoping Review of the Evidence Over the Last 10 Years

Background

Several reviews of mobile health (mHealth) physical activity (PA) interventions suggest their beneficial effects on behavior change in adolescents and adults. Owing to the ubiquitous presence of smartphones, their use in mHealth PA interventions seems obvious; nevertheless, there are gaps in the literature on the evaluation reporting processes and best practices of such interventions.

Objective

The primary objective of this review is to analyze the development and evaluation trajectory of smartphone-based mHealth PA interventions and to review systematic theory- and evidence-based practices and methods that are implemented along this trajectory. The secondary objective is to identify the range of evidence (both quantitative and qualitative) available on smartphone-based mHealth PA interventions to provide a comprehensive tabular and narrative review of the available literature in terms of its nature, features, and volume.

Methods

We conducted a scoping review of qualitative and quantitative studies examining smartphone-based PA interventions published between 2008 and 2018. In line with scoping review guidelines, studies were not rejected based on their research design or quality. This review, therefore, includes experimental and descriptive studies, as well as reviews addressing smartphone-based mHealth interventions aimed at promoting PA in all age groups (with a subanalysis conducted for adolescents). Two groups of studies were additionally included: reviews or content analyses of PA trackers and meta-analyses exploring behavior change techniques and their efficacy.

Results

Included articles (N=148) were categorized into 10 groups: commercial smartphone app content analyses, smartphone-based intervention review studies, activity tracker content analyses, activity tracker review studies, meta-analyses of PA intervention studies, smartphone-based intervention studies, qualitative formative studies, app development descriptive studies, qualitative follow-up studies, and other related articles. Only 24 articles targeted children or adolescents (age range: 5-19 years). There is no agreed evaluation framework or taxonomy to code or report smartphone-based PA interventions. Researchers did not state the coding method, used various evaluation frameworks, or used different versions of behavior change technique taxonomies. In addition, there is no consensus on the best behavior change theory or model that should be used in smartphone-based interventions for PA promotion. Commonly reported systematic practices and methods have been successfully identified. They include PA recommendations, trial designs (randomized controlled trials, experimental trials, and rapid design trials), mixed methods data collection (surveys, questionnaires, interviews, and focus group discussions), scales to assess app quality, and industry-recognized reporting guidelines.

Conclusions

Smartphone-based mHealth interventions aimed at promoting PA showed promising results for behavior change. Although there is a plethora of published studies on the adult target group, the number of studies and consequently the evidence base for adolescents is limited. Overall, the efficacy of smartphone-based mHealth PA interventions can be considerably improved through a more systematic approach of developing, reporting, and coding of the interventions.

Behavioral Intervention Components Associated With Cost-effectiveness: A Comparison of Six Domains

Background

To help implement behavior change interventions (BCIs) it is important to be able to characterize their key components and determine their effectiveness.

Purpose

This study assessed and compared the components of BCIs in terms of intervention functions identified using the Behaviour Change Wheel Framework (BCW) and in terms of their specific behavior change techniques (BCTs) identified using the BCT TaxonomyV1, across six behavioral domains and the association of these with cost-effectiveness.

Methods

BCIs in 251 studies targeting smoking, diet, exercise, sexual health, alcohol and multiple health behaviors, were specified in terms of their intervention functions and their BCTs, grouped into 16 categories. Associations with cost-effectiveness measured in terms of incremental cost-effectiveness ratio (ICER) upper and lower estimates were determined using regression analysis.

Results

The most prevalent functions were increasing knowledge through education (72.1%) and imparting skills through training (74.9%). The most prevalent BCT groupings were shaping knowledge (86.5%), changing behavioral antecedents (53.0%), supporting self-regulation (47.7%), and providing social support (44.6%). Intervention functions associated with better cost-effectiveness were those based on training (β_low = −15044.3; p = .002), persuasion (β_low = −19384.9; p = .001; β_upp = −25947.6; p < .001) and restriction (β_upp = −32286.1; p = .019), and with lower cost-effectiveness were those based on environmental restructuring (β = 15023.9_low; p = .033). BCT groupings associated with better cost-effectiveness were goals and planning (β_low = −8537.3; p = .019 and β_upp = −12416.9; p = .037) and comparison of behavior (β_low = −13561.9, p = .047 and β_upp = −30650.2; p = .006). Those associated with lower cost-effectiveness were natural consequences (β_low = 7729.4; p = .033) and reward and threat (β_low = 20106.7; p = .004).

Conclusions

BCIs that focused on training, persuasion and restriction may be more cost-effective, as may those that encourage goal setting and comparison of behaviors with others.

Assessment of Skeletal Strength: Bone Density Testing and Beyond

A bone fractures when a force applied to it exceeds its strength. Assessment of bone strength is an important component in determining the risk of fracture and guiding treatment decisions. Dual-energy X-ray absorptiometry is used to diagnosis osteoporosis, estimate fracture risk, and monitor changes in bone density. Fracture risk algorithms provide enhanced fracture risk predictability. Advanced technologies with computed tomography (CT) and MRI can measure parameters of bone microarchitecture. Mathematical modeling using CT data can evaluate the behavior of bone structures in response to external loading. Microindentation techniques directly measure the strength of outer bone cortex.

The effectiveness of app-based mobile interventions on nutrition behaviours and nutrition-related health outcomes: A systematic review and meta-analysis

A systematic review and meta-analysis were conducted to assess the effectiveness of app-based mobile interventions for improving nutrition behaviours and nutrition-related health outcomes, including obesity indices (eg, body mass index [BMI]) and clinical parameters (eg, blood lipids). Seven databases were searched for studies published between 2006 and 2017. Forty-one of 10 132 identified records were included, comprising 6348 participants and 373 outcomes with sample sizes ranging from 10 to 833, including 27 randomized controlled trials (RCTs). A beneficial effect of app-based mobile interventions was identified for improving nutrition behaviours (g = 0.19; CI, 0.06-0.32, P = .004) and nutrition-related health outcomes (g = 0.23; CI, 0.11-0.36, P < .001), including positive effects on obesity indices (g = 0.30; CI, 0.15-0.45, P < .001), blood pressure (g = 0.21; CI, 0.01-0.42, P = .043), and blood lipids (g = 0.15; CI, 0.03-0.28, P = .018). Most interventions were composed of four behaviour change technique (BCT) clusters, namely, "goals/planning," "feedback/monitoring," "shaping knowledge," and "social support." Moderating effects including study design, type of app (commercial/research app), sample characteristics (clinical/non-clinical sample), and intervention characteristics were not statistically significant. The inclusion of additional treatment components besides the app or the number or type of BCTs implemented did not moderate the observed effectiveness, which underscores the potential of app-based mobile interventions for implementing effective and feasible interventions operating at scale for fighting the obesity epidemic in a broad spectrum of the population.

T1-2N0M0 Triple-Negative Breast Cancer Treated With Breast-Conserving Therapy Has Better Survival Compared to Mastectomy: A SEER Population-Based Retrospective Analysis

BACKGROUND

For early-stage breast cancer, the two current mainstay treatments are breast-conserving therapy (BCT; lumpectomy followed by radiotherapy [RT] and BCT) and mastectomy. Generally, triple-negative breast cancer (TNBC) is more aggressive compared to hormone receptor-positive breast cancer. We sought to investigate the effect of BCT compared to mastectomy on overall survival (OS) and breast cancer-specific survival (BCSS) in T1-2N0M0 TNBC.

PATIENTS AND METHODS

A population-based retrospective analysis was performed using the Surveillance, Epidemiology, and End Results (SEER) database. Patients included in the analysis were divided into 3 groups according to surgical modality and RT: BCT, mastectomy alone, and mastectomy with RT. The survival end points were OS and BCSS, and survival analysis was performed by the Kaplan-Meier method and the log-rank test among treatment types.

RESULTS

A total of 14,910 female subjects with T1-2N0M0 TNBC diagnosed between 2010 and 2014 were included. A total of 7381 patients had BCT; 6967 had mastectomy alone, and 562 had mastectomy with RT. Patients treated with BCT had better OS (log-rank P < .05) and BCSS (log-rank P < .05) than those receiving mastectomy with or without RT. The 5-year OS was 88.6% for BCT, 83.0% for mastectomy alone, and 79.6% for mastectomy with RT. The 5-year BCSS was 94.3% for BCT, 93.3% for mastectomy alone, and 83.7% for mastectomy with RT.

CONCLUSION

In patients with T1-2N0M0 TNBC, BCT was associated with superior OS and BCSS compared to mastectomy with or without RT. After mastectomy, there was no evidence of survival benefit of RT.

What is the evidence for the clinical value of SBRT in cancer of the cervix?

AIM

The aim of this review is to describe and analyze indications and results of the use of SBRT in uterine cervix cancer, reviewing articles published from January 2010 up to August 2017, for any one of the four indications listed:1Patient refusal or anatomic impediments to interstitial or intracavitary brachytherapy (BCT), i.e. SBRT as an "alternative" for BCT;2Patients with voluminous tumors, or asymmetric tumors where BCT alone would not achieve curative doses, i.e. SBRT as a primary adjunct to BCT;3Pelvic and para aortic adenopathy where SBRT could be used as a boost, i.e. SBRT as a primary adjunct to external beam pelvic radiotherapy;4Small volume recurrences (postoperative or post radiotherapy), i.e. SBRT for salvage.

BACKGROUND

Cervix cancer standard treatment involves pelvic irradiation and chemotherapy, recent advances in irradiation techniques might offer new possible approaches.

MATERIAL AND METHODS

Systematic review of the English language literature about Cervix cancer, SBRT, published from January 2010 to January 2018 identified through a database search of PubMed, and Ovid MEDLINE, using pre-defined search phrases.

RESULTS

The results in the literature, in general, demonstrate rather weak efficacy of SBRT. In this review, we did not find strong evidence to recommend routine SBRT as a primary treatment for cervico-uterine cancers, i.e. as a replacement for BCT; in highly selected cases it might be considered useful as salvage therapy for relapsed cervix cancer.

CONCLUSION

The existing data to not warrant recommending SBRT for the definitive treatment of cervix cancer, but may have some value in the recurrent/relapsed setting.

Non-invasive fetal RHD genotyping for RhD negative women stratified into RHD gene deletion or variant groups: comparative accuracy using two blood collection tube types

Non-invasive fetal RHD genotyping in Australia to reduce anti-D usage will need to accommodate both prolonged sample transport times and a diverse population demographic harbouring a range of RHD blood group gene variants. We compared RHD genotyping accuracy using two blood sample collection tube types for RhD negative women stratified into deleted RHD gene haplotype and RHD gene variant cohorts. Maternal blood samples were collected into EDTA and cell-free (cf)DNA stabilising (BCT) tubes from two sites, one interstate. Automated DNA extraction and polymerase chain reaction (PCR) were used to amplify RHD exons 5 and 10 and CCR5. Automated analysis flagged maternal RHD variants, which were classified by genotyping. Time between sample collection and processing ranged from 2.9 to 187.5 hours. cfDNA levels increased with time for EDTA (range 0.03-138 ng/μL) but not BCT samples (0.01-3.24 ng/μL). For the 'deleted' cohort (n=647) all fetal RHD genotyping outcomes were concordant, excepting for one unexplained false negative EDTA sample. Matched against cord RhD serology, negative predictive values using BCT and EDTA tubes were 100% and 99.6%, respectively. Positive predictive values were 99.7% for both types. Overall 37.2% of subjects carried an RhD negative baby. The 'variant' cohort (n=15) included one novel RHD and eight hybrid or African pseudogene variants. Review for fetal RHD specific signals, based on one exon, showed three EDTA samples discordant to BCT, attributed to high maternal cfDNA levels arising from prolonged transport times. For the deleted haplotype cohort, fetal RHD genotyping accuracy was comparable for samples collected in EDTA and BCT tubes despite higher cfDNA levels in the EDTA tubes. Capacity to predict fetal RHD genotype for maternal carriers of hybrid or pseudogene RHD variants requires stringent control of cfDNA levels. We conclude that fetal RHD genotyping is feasible in the Australian environment to avoid unnecessary anti-D immunoglobulin prophylaxis.

Reducing patient delay in Acute Coronary Syndrome (RAPiD): research protocol for a web-based randomized controlled trial examining the effect of a behaviour change intervention

AIMS

To evaluate the efficacy of a behaviour change technique-based intervention and compare two possible modes of delivery (text + visual and text-only) with usual care.

BACKGROUND

Patient delay prevents many people from achieving optimal benefit of time-dependent treatments for acute coronary syndrome. Reducing delay would reduce mortality and morbidity, but interventions to change behaviour have had mixed results. Systematic inclusion of behaviour change techniques or a visual mode of delivery might improve the efficacy of interventions.

DESIGN

A three-arm web-based, parallel randomized controlled trial of a theory-based intervention.

METHODS

The intervention comprises 12 behaviour change techniques systematically identified following systematic review and a consensus exercise undertaken with behaviour change experts. We aim to recruit n = 177 participants who have experienced acute coronary syndrome in the previous 6 months from a National Health Service Hospital. Consenting participants will be randomly allocated in equal numbers to one of three study groups: i) usual care, ii) usual care plus text-only behaviour change technique-based intervention or iii) usual care plus text + visual behaviour change technique-based intervention. The primary outcome will be the change in intention to phone an ambulance immediately with symptoms of acute coronary syndrome ≥15-minute duration, assessed using two randomized series of eight scenarios representing varied symptoms before and after delivery of the interventions or control condition (usual care). Funding granted January 2014.

DISCUSSION

Positive results changing intentions would lead to a randomized controlled trial of the behaviour change intervention in clinical practice, assessing patient delay in the event of actual symptoms.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov: NCT02820103.

Outcomes of patients with inflammatory breast cancer treated by breast-conserving surgery

PURPOSE

Inflammatory breast cancer (IBC) is rare and associated with a poor prognosis. Following neoadjuvant chemotherapy or endocrine therapy, the multidisciplinary team selected a small number of patients for breast-conservation therapy (BCT). The aim of this study was to determine the outcome of IBC patients treated with BCT in Edinburgh.

METHODS

Between January 1999 and December 2013, thirty-five women with IBC were treated by BCT. The median follow-up was 80 months.

RESULTS

The 5-year actuarial survival for the 35 patients was 70.3 %. Median survival for 20 neoadjuvant chemotherapy patients was 12.9 years (95 % CI 7.6, 18.1), and for 14 patient neoadjuvant endocrine therapy patients, it was 11.8 years (95 % CI 1.1, 22.6) (p = 0.34). Five patients developed locoregional recurrence (LRR) between 11 and 72 months after BCT (median 37 months). Three had breast only recurrence, one patient had both breast and axillary recurrence, and one developed axillary recurrence. The 5-year LR-free survival was 87.5 % (95 % CI 76.0, 99.0). In 4 of the 5 patients with LRR, systemic metastases were diagnosed within 6 months and survival post-LRR in these 4 patients was short.

CONCLUSION

IBC is not an absolute contraindication to BCT. LRR in patients after BCT appears part of widespread recurrent disease rather than inadequate local treatment. Multicentre data should be collected to confirm that women with IBC who have a good response to systemic therapy may be offered BCT in the knowledge that in a larger series our observations are confirmed.

Evaluating the effectiveness of a smartphone app to reduce excessive alcohol consumption: protocol for a factorial randomised control trial

Background

Excessive alcohol consumption is a leading cause of death and morbidity worldwide and interventions to help people reduce their consumption are needed. Interventions delivered by smartphone apps have the potential to help harmful and hazardous drinkers reduce their consumption of alcohol. However, there has been little evaluation of the effectiveness of existing smartphone interventions.

A systematic review, amongst other methodologies, identified promising modular content that could be delivered by an app: self-monitoring and feedback; action planning; normative feedback; cognitive bias re-training; and identity change. This protocol reports a factorial randomised controlled trial to assess the comparative potential of these five intervention modules to reduce excessive alcohol consumption.

Methods

A between-subject factorial randomised controlled trial. Hazardous and harmful drinkers aged 18 or over who are making a serious attempt to reduce their drinking will be randomised to one of 32 (2⁵) experimental conditions after downloading the ‘Drink Less’ app. Participants complete baseline measures on downloading the app and are contacted after 1-month with a follow-up questionnaire. The primary outcome measure is change in past week consumption of alcohol. Secondary outcome measures are change in AUDIT score, app usage data and usability ratings for the app. A factorial between-subjects ANOVA will be conducted to assess main and interactive effects of the five intervention modules for the primary and secondary outcome measures.

Discussion

This study will establish the extent to which the five intervention modules offered in this app can help reduce hazardous and harmful drinking. This is the first step in optimising and understanding what component parts of an app could help to reduce excessive alcohol consumption. The findings from this study will be used to inform the content of a future integrated treatment app and evaluated against a minimal control in a definitive randomised control trial with long-term outcomes.

Trial registration

ISRCTN40104069 Date of registration: 10/2/2016

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3140-8) contains supplementary material, which is available to authorized users.

Increased rates of long-term complications after MammoSite brachytherapy compared with whole breast radiation therapy

BACKGROUND

Due to its short duration of therapy and low rates of local recurrence, women undergoing breast conservation are increasingly opting for partial breast irradiation with the MammoSite (Cytyc/Hologic) catheter. In early follow-up studies, few complications were reported. Few data, however, exist regarding longer-term complications. We compared the long-term local toxicities of MammoSite partial breast irradiation with those resulting from whole breast radiation.

STUDY DESIGN

This was a retrospective study performed in a single academic medical center. All patients who underwent breast-conserving surgery between 2003 and 2008, who met institutional criteria for brachytherapy, were included. We compared women treated with MammoSite with patients treated with whole breast radiation therapy (WBRT). Endpoints included incidence of palpable masses at the lumpectomy site, telangiectasias, and local recurrence.

RESULTS

Seventy-one MammoSite patients and 245 WBRT patients were well matched with regard to clinical characteristics. Median follow-up was 4 years. A palpable mass developed at the site of lumpectomy in 27% of the MammoSite patients compared with 7% of the WBRT patients (p < 0.0001). Telangiectasias developed more frequently in the MammoSite group than in the WBRT group (24% vs 4%, p < 0.001). Forty-two percent of patients treated with MammoSite developed a palpable mass, telangectasia, or both.

CONCLUSIONS

Palpable masses and telangiectasias are frequent long-term complications after MammoSite brachytherapy and occur at a significantly higher rate after MammoSite brachytherapy than after WBRT. This increased rate of long-term local toxicity should be considered when counseling women on options for adjuvant radiation therapy after breast-conserving surgery.

A validated web-based nomogram for predicting positive surgical margins following breast-conserving surgery as a preoperative tool for clinical decision-making

BACKGROUND

Breast-conserving therapy, consisting of lumpectomy and adjuvant radiotherapy, is considered standard treatment for early-stage breast cancer. One of the most important risk factors of local recurrence is the presence of positive surgical margins following lumpectomy. We aimed to develop and validate a predictive model (nomogram) to predict for positive margins following the first attempt at lumpectomy as a preoperative tool for clinical decision-making.

METHODS

Patients with clinical T1-2N0-1Mx-0 histology-proven invasive breast carcinoma who underwent BCT throughout the North-East region of The Netherlands between June 2008 and July 2009 were selected from the Netherlands Cancer Registry (n = 1185). Results from multivariate logistic regression analyses served as the basis for development of the nomogram. Nomogram calibration and discrimination were assessed graphically and by calculation of a concordance index, respectively. Nomogram performance was validated on an external independent dataset (n = 331) from the University Medical Center Groningen.

RESULTS

The final multivariate regression model included clinical, radiological, and pathological variables. Concordance indices were calculated of 0.70 (95% CI: 0.66-0.74) and 0.69 (95% CI: 0.63-0.76) for the modeling and the validation group, respectively. Calibration of the model was considered adequate in both groups. A nomogram was developed as a graphical representation of the model. Moreover, a web-based application (http://www.breastconservation.com) was build to facilitate the use of our nomogram in a clinical setting.

CONCLUSION

We developed and validated a nomogram that enables estimation of the preoperative risk of positive margins in breast-conserving surgery. Our nomogram provides a valuable tool for identifying high-risk patients who might benefit from preoperative MRI and/or oncoplastic surgery.