Effectiveness of an mHealth App That Uses Financial Incentives and Gamification to Promote Health Behavior Change in Adolescents and Caregivers: Protocol for a Clinic-Based Randomized Controlled Trial.

BACKGROUND: Adolescent and adult obesity continues to be a public health epidemic in the United States. Despite the popularity of mHealth apps with gamification among adolescents, there are insufficient studies to evaluate the efficacy of gamified mHealth apps and financial incentives to motivate sustained health behavior change in adolescents or their adult caregivers. OBJECTIVE: This study aims to evaluate the effectiveness of gamification techniques and financial incentives used in the novel "CommitFit" mHealth app to motivate health behavior change and improve various mental and physical health metrics in adolescents and their caregivers. METHODS: This study is a 3-month randomized controlled trial (RCT) with 30 adolescents (aged 13-15 years) and their adult caregivers (N=60). It evaluates "CommitFit," which uses gamification including points and leaderboards to motivate logging and achievement of self-selected health behavior goals (eg, more water, sleep, physical activity, fruits, or vegetables or fewer sugary beverages). The RCT had three arms, each with 10 dyads: (1) CommitFit-only users; (2) CommitFit$, where adolescents were paid US $0.05 for each point they earned; and (3) waitlist control. Intervention dyads used the app for 3 months and had the option to use it for the fourth month without prompts or extra financial incentives. User analytic software was used to evaluate the frequency of user logs and goal achievement. Monthly surveys evaluated self-reported change in the 5 CommitFit health behaviors. Changes in BMI and blood pressure were evaluated for all participants at 3 clinical visits. Mental health, gamification, and behavior economics surveys were completed during the clinical visits. RESULTS: Recruitment began in August 2023 and was completed in 10 weeks. The research team successfully recruited and enrolled 30 dyads. Researchers emailed and called 89 caregivers on a physician-approved adolescent patient list, a 33% recruitment rate. Data collection and analysis will be conducted in the spring and summer of 2024. The results of this study are anticipated to be published between late 2024 and early 2025. CONCLUSIONS: This RCT will expand knowledge of the effectiveness of gamification techniques, financial incentives, and mHealth apps to motivate sustained health behavior change among adolescents and caregivers. These results may offer new opportunities to caregivers, health insurers, health care systems, and clinicians to motivate health behavior change in adolescents and caregivers, with the ultimate goal of preventing or reducing obesity and obesity-related diseases. Additional gamification, mental health surveys, and app user analytics included in the study may provide further insight into the characteristics of adolescents or caregivers who would benefit the most from using a gamified mHealth app like CommitFit. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/63505.

mHealth app features that facilitate adolescent use for lifestyle management, and are endorsed by caregivers and health care providers.

Background: Mobile health (mHealth) apps are becoming a promising tool to motivate sustainable lifestyle and behavior changes, including modifications to diet and exercise. However, most current mHealth apps do not have meaningful, and sustained user acceptance, particularly, among adolescents. They perceive mHealth apps designed for adults to be tedious and visually unexciting, which discourage adolescent usage. Researchers and adolescent mHealth app developers would benefit from a foundational understanding of which functions and features adolescents feel would most motivate app use. Capturing caregivers' and health care providers' inputs are also important as both groups play an integral role in adolescent health care decision-making. The purpose of the study is to explore and analyze mHealth app features identified by adolescents, caregivers, and health care providers that have the potential to inspire continued use, thereby resulting in sustained health behavior changes in adolescents. Methods: We used inductive thematic analysis of qualitative data obtained from semi-structured focus groups conducted via Zoom©. Important features of mHealth apps that encourage adoption and continued use were explored with 25 participants, including adolescents, their caregivers, and health care providers. Results: Common features facilitating continual usage of mHealth apps that were identified as significant by participating adolescents, their caregivers and health care providers were: look and feel of the app, customization, educational information/recommendations, and integration with electronic health record. Features such as gamification and social interaction that are usually lacking in current adolescent mHealth apps were well recognized as meaningful for motivational purposes. Conclusions: The findings suggest that adolescents and caregivers identify an app as valuable when it is user-friendly and intuitive and appreciate features that are motivating and can engage users in positive behaviors. Health care providers prefer mHealth apps that are user-friendly and can be effectively integrated into the cycle of care, thereby enabling delivery of efficient and value-based health care. Thus, mHealth app designs that are informed by health care providers' clinical experience and needs, in combination with app features that are desired and supported by both adolescents and their caregivers, have the potential to motivate widespread adoption and long-term use, which could result in improved health behaviors and outcomes among adolescents.

Clinician Needs for Electronic Health Record Pediatric and Adolescent Weight Management Tools: A Mixed-Methods Study.

BACKGROUND: Clinicians play an important role in addressing pediatric and adolescent obesity, but their effectiveness is restricted by time constraints, competing clinical demands, and the lack of effective electronic health record (EHR) tools. EHR tools are rarely developed with provider input. OBJECTIVES: We conducted a mixed method study of clinicians who provide weight management care to children and adolescents to determine current barriers for effective care and explore the role of EHR weight management tools to overcome these barriers. METHODS: In this mixed-methods study, we conducted three 1-hour long virtual focus groups at one medium-sized academic health center in Missouri and analyzed the focus group scripts using thematic analysis. We sequentially conducted a descriptive statistical analysis of a survey emailed to pediatric and family medicine primary care clinicians (n = 52) at two private and two academic health centers in Missouri. RESULTS: Surveyed clinicians reported that they effectively provided health behavior lifestyle counseling at well-child visits (mean of 60 on a scale of 1-100) and child obesity visits (63); however, most felt the current health care system (27) and EHR tools (41) do not adequately support pediatric weight management. Major themes from the clinician focus groups were that EHR weight management tools should display data in a way that (1) improves clinical efficiency, (2) supports patient-centered communication, (3) improves patient continuity between visits, and (4) reduces documentation burdens. An additional theme was (5) clinicians trust patient data entered in real time over patient recalled data. CONCLUSION: Study participants report that the health care system status quo and currently available EHR tools do not sufficiently support clinicians working to manage pediatric or adolescent obesity and provide health behavior counseling. Clinician input in the development and testing of EHR weight management tools provides opportunities to address barriers, inform content, and improve efficiencies of EHR use.

Weight stigma and bias: A guide for pediatric clinicians.

Introduction: Many children and adolescents with obesity experience weight stigma and bias, which can have detrimental mental health, medical, and social consequences. Weight stigma in the healthcare setting threatens the therapeutic relationship between health care providers and their pediatric patients and families. Methods: Data supporting this guidance were derived from cited references. Results: Based upon referenced citations, this review offers 7 best practices for pediatric providers to work to reduce weight stigma including: assess for personal weight bias, improve communication, provide a welcoming clinic environment, seek out additional training and informative experiences, evaluate the messaging and culture of the organization, screen for trauma and bullying, and enlist the help of board-certified obesity medicine specialists. Conclusions: Providers have an important role in mitigating the harmful effects of weight stigma. It is our hope these recommendations, as well as the other resources provided, will help providers to begin to address their own individual weight biases, as well as the institutional weight biases where we care for patients.

Mixed-methods study of development and design needs for CommitFit, an adolescent mHealth App.

Background: Adolescent obesity remains a significant public health issue within the United States. Mobile application technology growth and popularity offer new opportunities for research and health improvement. The development of a consolidated mobile health application (mHealth app) for adolescents on these platforms has the potential to improve health outcomes. Thus, this study describes the co-development process working with adolescent users. The aims are as follows: (I) to explore the visual design and functional requirements when developing the CommitFit mHealth app, (II) to uncover the gamification techniques that incentivize adolescents to set and achieve healthy lifestyle goals, and (III) to identify adolescent expectations when using the CommitFit mHealth application. Methods: In this mixed method study, we used semi-structured interviews/task analysis and surveys of adolescents (aged 13 to 15 years) to understand their user requirements and design preferences during the development of the CommitFit mHealth app. Interviews were conducted online, via Zoom. The survey included the user design industry-standard System Usability Scale (SUS) paired with a supplemental questionnaire on the specific features and functionalities of the CommitFit mHealth app. Participants were recruited from the electronic health record from the University of Missouri Healthcare system. Results: Ten adolescents, aged 13 to 15 years (average of 13.6 years), were interviewed and surveyed to explore adolescent preferences with visual app design and functionality. Our inductive thematic analysis found that adolescents preferred colorful, user-friendly interfaces paired with gamification in the CommitFit mHealth app. Our analysis of SUS survey data validated our user-centered and human-system design and adolescents confirmed their design, feature, and functionality preferences. Overall, adolescent users were able to confirm their preference to have educational resources, goal recommendations, leaderboard, points, reminders, and an avatar in the app. Conclusions: Adolescent feedback is crucial in the successful development of our adolescent-targeted mHealth app, CommitFit. Adolescents preferred vibrant colors, easy-to-use interface, gamification, customizable and personalized, and mature graphics. Adolescents were especially motivated by gamification techniques to maintain their interest in the application and their health behavior goals. Additional research is now needed to explore the clinical effectiveness of the CommitFit mHealth app, as a health and lifestyle intervention.

Healthcare Workers' Perceptions of On-Site Childcare.

GOAL: Measures taken by healthcare organizations to address COVID-19 highlighted the long-standing lack of childcare infrastructure required to support healthcare workers. This study, designed to provide evidence to support operations at an academic medical center, looked at the influence that in-house and emergency childcare could have on the retention, recruitment, and productivity of healthcare workers. This study also outlined the implications that childcare, or its lack, has for healthcare organizations during and after the COVID-19 pandemic. METHODS: We conducted a 35-question electronic employee survey (under institutional review board approval) during pandemic-induced public school closures, which included both quantitative and qualitative (write-in) questions. PRINCIPAL FINDINGS: The survey results showed that weekday on-site childcare was very or extremely important to more than half of survey respondents, the majority of whom were staff members (28%) or physicians (25%), followed by administrators (15%), researchers (12%), others (10%), nurses (5%), educators (2%), and residents (1%). Sixty percent of respondents reported that emergency on-site childcare was extremely important (34%) or very important (26%). Almost half (49%) reported that emergency childcare needs have disrupted their work in the past year, including canceling of clinics or surgical cases. Analysis of qualitative comments via a strategy based on coding and categorization showed that, when asked how childcare influences their work choices, employees responded that childcare availability has limited the hours or times they could work, that lack of childcare has prevented career growth, that they left a previous job or will leave their current job because of childcare needs, or that they stayed at a previous job or have remained in their current job longer because of the availability of childcare. PRACTICAL APPLICATIONS: Although data from this mixed-methods study support findings in the literature that there is a need for in-house and emergency childcare, the data suggest that current employees at this academic medical center do not currently expect it, likely because such childcare is not generally available at most academic institutions. With increased rates of burnout and healthcare workers leaving the field since COVID-19, offering in-house and emergency childcare provides hospital systems with new opportunities to retain and recruit physicians, nurses, and staff, as well as to improve their well-being and productivity.

A Longitudinal Effectiveness Study of a Child Obesity Electronic Health Record Tool.

BACKGROUND: Primary-care providers, clinic staff, and nurses play an important role in reducing child obesity; yet time restraints and clinical demands compete with effective pediatric weight management and prevention. METHODS: To investigate the potential impact of an electronic health record (EHR) enabled tool to assist primary care teams in addressing child obesity, we conducted a controlled effectiveness study of FitTastic compared with usual care on the BMI pattern of 291 children (2 to 17 years) up to 4 years later. RESULTS: Per χ2 analysis, a greater proportion of children with baseline overweight/obesity in the EHR tool group than the control group had a favorable BMI pattern (32% vs 13%, P = .03). In logistic regression, FitTastic children were more likely than control children to have a favorable BMI pattern at follow-up (OR 3.8, 95% CI 1.1 to 13.2), adjusted for age, gender, race, and parental education. CONCLUSION: Study findings suggest that EHR-enabled tools to assist primary care teams in managing child obesity may be useful for helping to address the weight in children with overweight/obesity, especially in younger children (2 to 5 years). Digital and EHR-enabled technologies may prove useful for partnering health care teams and families in the important tasks of setting positive, family-centered healthy lifestyle behavioral goals and managing child overweight and obesity.

Infections and antibiotic use in early life, and obesity in early childhood: a mediation analysis.

BACKGROUND/OBJECTIVE: Literature shows a positive association between antibiotics and obesity in childhood, but fails to account for confounding by indication. We evaluate the direct effect of infection on obesity and the indirect effect mediated by antibiotics by performing a mediation analysis of the infection-obesity association. METHODS: A Medicaid cohort of children age 2-14 years old between 2015-2019 (n = 61,330) is used to perform mediation analysis of infections and antibiotic use in the first year of life, and obesity in childhood in Missouri, U.S.A. RESULTS: An additional infection increases the risk of obesity in childhood (aIRR = 1.050, p < 0.001); however, mediation by antibiotic use is clinically and statistically insignificant. If the number of infections is not considered in the analysis, then antibiotic use as a risk factor for obesity is overstated (aIRR = 1.037 vs. 1.013 p < 0.001). CONCLUSIONS: The number of infections exhibits a significant relationship with obesity and is a stronger risk factor for obesity than antibiotic use. In particular, a greater number of bronchitis, otitis media, and upper respiratory infections in the first year of life are associated with a significant increased risk of obesity in childhood. We find only weak evidence that an additional antibiotics claim increases the risk of obesity in childhood and this risk may not be clinically meaningful. Further research is needed to explore the association between early childhood infections, especially in the first 6 months of life, and obesity including the biological mechanism and environmental factor of early life infections associated with obesity.

Predictors of Operative Intervention in Patients With Lactic Acidosis.

BACKGROUND: Lactate levels in clinical practice are often used as a quantitative indicator for the severity of hypoperfusion and the responsiveness to therapeutic interventions. In the hospital acute care setting, lactic acidosis combined with the appropriate clinical exam signs warrants surgical evaluation. The purpose of our study was to evaluate all surgical consults for lactic acidosis in a single community hospital to identify what cofactors were most often predictive of the need for surgical management and operative intervention. MATERIALS AND METHODS: A retrospective chart review within a 5-year period was conducted on all consultations to general surgery in which patients additionally had lactic acidosis defined as >2mEq. Within this population, various subjective and objective parameters were evaluated. Final analysis compared these parameters between patients with lactic acidosis who underwent surgical intervention and those who did not require operative intervention. RESULTS: Within the 5-year period, 432 patients met our criteria of a surgical consult placed for lactic acidosis. Final results from the highest quality statistical model showed significant variables as diffuse tenderness on physical exam (P-value = .0010, Odds Ratio (OR) = 2.77) and focal tenderness on physical exam (P-value = .0440, OR = 1.76). The presence of peritoneal signs (P-value = .0521, OR = 2.02) resulted in operative intervention twice as often in patients with lactic acidosis. DISCUSSION: To better appropriate health care costs, measures need to be taken to ensure resources are being utilized properly. In patients with lactic acidosis, one should go "back to the basics" with the physical examination to determine which patients truly need a surgical consultation.

Assessing Racial and Ethnic Discrimination in Children: A Scoping Review of Available Measures for Child Health Disparities Research.

Objectives: To characterize the availability, content, and psychometric properties of self-reported measures that assess race/ethnicity-related discrimination or psychosocial stress and have potential relevance to studies of health disparities in children and adolescents. Design: Using PRISMA extension guidelines for scoping reviews, we searched Ovid Medline, CINAHL, PsychInfo, and Scopus databases from 1946 to April 20, 2020, using the search terms "stress," "child," "adolescents," "discrimination," and "psychometrics." We limited the search to articles in English, with children and adolescents, in the United States. For each measure, we extracted information about the content, reliability, and construct validity. Results: The 12 measures that met inclusion criteria assessed discrimination or stress from racial discrimination in African American children and adolescents (n=8), acculturative stress in Hispanic/Latino children (n=1), or bicultural stress in Mexican American adolescents (n=2), and one measure assessed both discrimination-related and acculturative stress in Hispanic/Latino children. The majority (n=7) articles were published between 2001 and 2010. All discrimination measures evaluated individual experiences of discrimination and one also evaluated stressfulness of discrimination and coping. The acculturative stress measures assessed general stress and immigration-related discrimination, and the bicultural stress measures evaluated many different aspects of biculturalism. Conclusions: Despite the recent increased interest in the racial discrimination and stress as a contributor to racial or ethnic health disparities affecting U.S. children and adolescents, the small number of eligible measures identified and incomplete coverage of various types of racial and ethnic discrimination within and across population groups indicates a currently inadequate capacity to conduct child health disparity studies on this issue.

Success of Hospital Intervention and State Legislation on Decreasing and Standardizing Postoperative Opioid Prescribing Practices.

BACKGROUND: We sought to evaluate change in postoperative prescription practices in an independent community-based hospital after hospital interventions and a state legislation change. STUDY DESIGN: This is a retrospective review of opioid-naïve adult subjects who underwent 5 common general surgical procedures between 2015 and 2017, including cholecystectomy, appendectomy, minimally invasive inguinal hernia repair, open inguinal hernia repair, and breast lumpectomy. Educational interventions were introduced, new statewide legislation was passed, and 129 subsequent cases were reviewed. RESULTS: Mean ± SD oral morphine equivalent (OME) prescribed for all procedures on retrospective review was 218.8 ± 113.7 (n = 722), cholecystectomy 235.3 ± 133.8 (n = 248), appendectomy 220.2 ± 103.2 (n = 175), open inguinal hernia repair 214.4 ± 97.2 (n = 119), minimally invasive inguinal hernia repair 187.7 ± 87.8 (n = 117), and lumpectomy 212.5 ± 114.5 (n = 63). There was significant variation in OME prescribed by procedure and by surgeon (p = 0.006 and p = 0.008, respectively). Review of post-intervention cases showed a significant reduction in the OME prescribed each year (mean OME 197.6 in 2015 to 2017 vs 72.3 in 2018; p < 0.005), and a 60% to 70% reduction in mean OME per procedure. Post-intervention data also revealed resolution of previously seen variation in prescription practices, and a significant increase in the percentage of patients prescribed multimodal pain therapy (23.5% in 2015 to 2017 to 31.5% in 2018; p < 0.05). CONCLUSIONS: We achieved a 60% to 70% decrease in postoperative opioid prescription at our community hospital for 5 common surgical procedures, and resolution of variation in opioid prescription practices after a hospital-wide intervention and statewide legislation.

Lysyl oxidase expression in bronchogenic carcinoma.

BACKGROUND: Lysyl oxidase catalyzes a key step in the cross-linking of collagen and elastin in the extracellular matrix. Recent studies have documented differential lysyl oxidase expression in the stromal reaction to colon, breast, prostate, and lung cancer. The present study was undertaken to test the hypothesis that lysyl oxidase mRNA and protein expression decrease with advancing tumor stage in patients with bronchogenic carcinoma. METHODS: Tumor specimens were obtained from 17 patients undergoing resection for bronchogenic carcinoma. Real-time polymerase chain reaction was used to determine steady-state lysyl oxidase mRNA expression, and protein expression was qualitatively assessed by immunohistochemistry. RESULTS: Real-time polymerase chain reaction studies documented a 3.4-fold graded decrease in lysyl oxidase mRNA levels as tumors progressed from stage I to IV. Similar qualitative changes in lysyl oxidase protein expression were demonstrated by immunohistochemistry. CONCLUSIONS: These results support the hypothesis that variations in lysyl oxidase expression may correlate with the invasive and metastatic potential of bronchogenic carcinoma.