Mobile phone-based interventions for improving contraception use.

BACKGROUND: Contraception provides significant benefits for women's and children's health, yet many women have an unmet need for contraception. Rapid expansion in the use of mobile phones in recent years has had a dramatic impact on interpersonal communication. Within the health domain text messages and smartphone applications offer means of communication between clients and healthcare providers. This review focuses on interventions delivered by mobile phone and their effect on use of contraception. OBJECTIVES: To evaluate the benefits and harms of mobile phone-based interventions for improving contraception use. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was August 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of mobile phone-based interventions to improve forms of contraception use amongst users or potential users of contraception. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. uptake of contraception, 2. uptake of a specific method of contraception, 3. adherence to contraception method, 4. safe method switching, 5. discontinuation of contraception and 6. pregnancy or abortion. Our secondary outcomes were 7. road traffic accidents, 8. any physical or psychological effect reported and 9. violence or domestic abuse. MAIN RESULTS: Twenty-three RCTs (12,793 participants) from 11 countries met our inclusion criteria. Eleven studies were conducted in high-income resource settings and 12 were in low-income settings. Thirteen studies used unidirectional text messaging-based interventions, six studies used interactive text messaging, four used voice message-based interventions and two used mobile-phone apps to improve contraception use. All studies received funding from non-commercial bodies. Mobile phone-based interventions probably increase contraception use compared to the control (odds ratio (OR) 1.30, 95% confidence interval (CI) 1.06 to 1.60; 16 studies, 8972 participants; moderate-certainty evidence). There may be little or no difference in rates of unintended pregnancy with the use of mobile phone-based interventions compared to control (OR 0.82, 95% CI 0.48 to 1.38; 8 trials, 2947 participants; moderate-certainty evidence). Subgroup analysis assessing unidirectional mobile phone interventions versus interactive mobile phone interventions found evidence of a difference between the subgroups favouring interactive interventions (P = 0.003, I2 = 88.5%). Interactive interventions had an OR of 1.71 (95% CI 1.28 to 2.29; P = 0.0003, I2 = 63%; 8 trials, 3089 participants) whilst unidirectional interventions had an OR of 1.03 (95% CI 0.87 to 1.22; P = 0.72, I2 = 17%; 9 trials, 5883 participants). Subgroup analysis assessing high-income versus low-income trial settings found no difference between groups (subgroup difference test: P = 0.70, I2 = 0%). Only six trials reported on safety and unintended outcomes; one trial reported increased partner violence whilst another four trials reported no difference in physical violence rates between control and intervention groups. One trial reported no road traffic accidents with mobile phone intervention use. AUTHORS' CONCLUSIONS: This review demonstrates there is evidence to support the use of mobile phone-based interventions in improving the use of contraception, with moderate-certainty evidence. Interactive mobile phone interventions appear more effective than unidirectional methods. The cost-effectiveness, cost benefits, safety and long-term effects of these interventions remain unknown, as does the evidence of this approach to support contraception use among specific populations. Future research should investigate the effectiveness and safety of mobile phone-based interventions with better quality trials to help establish the effects of interventions delivered by mobile phone on contraception use. This review is limited by the quality of the studies due to flaws in methodology, bias or imprecision of results.

ChroniSense National Early Warning Score Study: Comparison Study of a Wearable Wrist Device to Measure Vital Signs in Patients Who Are Hospitalized.

BACKGROUND: Wearable devices could be used to continuously monitor vital signs in patients who are hospitalized, but they require validation. OBJECTIVE: This study aimed to evaluate the clinical validity of the prototype of a semiautomated wearable wrist device (ChroniSense Polso) to measure vital signs and provide National Early Warning Scores (NEWSs). METHODS: Vital signs and NEWSs measured using the wearable device were compared with standard, nurse-lead manual measurements. We enrolled adult patients (aged ≥18 years) who required vital sign measurements at least every 6 hours in a UK teaching district general hospital. Wearable device measurements were not used for clinical decision-making. The primary outcome was the agreement on the individual National Early Warning parameter scores and vital sign measurements: respiratory rate, oxygen saturation, body temperature, systolic blood pressure, and heart rate. Secondary outcomes were the agreement on the total NEWS, incidence of adverse events, and user acceptance. To compare the wearable device measurements with the standard measurements, we analyzed vital sign measurements by limits of agreement (Bland-Altman analysis) and conducted κ agreement analyses for NEWSs. A user experience survey was conducted with questions about comfort of the wrist device, safety, preference, and use. RESULTS: We included 132 participants in the study, with a mean age of 62 (SD 15.81) years; most of them were men (102/132, 77.3%). The highest weighted κ values were found for heart rate (0.69, 95% CI 0.57-0.81 for all 385 measurements) and systolic blood pressure (0.39, 95% CI 0.30-0.47 for all 339 measurements). Weighted κ values were low for respiration rate (0.03, 95% CI -0.001 to 0.05 for all 445 measurements), temperature (0, 95% CI 0-0 for all 231 measurements), and oxygen saturation (-0.11, 95% CI -0.20 to -0.02 for all 187 measurements). Weighted κ using Cicchetti-Allison weights showed κ of 0.20 (95% CI 0.03-0.38) when using all 56 total NEWSs. The user acceptance survey found that approximately half (45/91, 49%) of the participants found it comfortable to wear the device and liked its appearance. Most (85/92, 92%) of them said that they would wear the device during their next hospital visit, and many (74/92, 80%) said that they would recommend it to others. CONCLUSIONS: This study shows the promising use of a prototype wearable device to measure vital signs in a hospital setting. Agreement between the standard measurements and wearable device measurements was acceptable for systolic blood pressure and heart rate, but needed to be improved for respiration rate, temperature, and oxygen saturation. Future studies need to improve the clinical validity of this wearable device. Large studies are required to assess clinical outcomes and cost-effectiveness of wearable devices for vital sign measurement. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2018-028219.

Effectiveness of WeChat for Improving Exclusive Breastfeeding in Huzhu County China: Randomized Controlled Trial.

BACKGROUND: The benefits of breastfeeding for both infants and mothers have been well recognized. However, the exclusive breastfeeding rate in China is low and decreasing. Mobile technologies have rapidly developed; communication apps such as WeChat (one of the largest social networking platforms in China) are widely used and have the potential to conveniently improve health behaviors. OBJECTIVE: This study aimed to assess the effectiveness of using WeChat to improve breastfeeding practices. METHODS: This 2-arm randomized controlled trial was conducted among pregnant women from May 2019 to April 2020 in Huzhu County, Qinghai Province, China. Pregnant women were eligible to participate if they were aged 18 years or older, were 11 to 37 weeks pregnant with a singleton fetus, had no known illness that could limit breastfeeding after childbirth, used WeChat through their smartphone, and had access to the internet. A total of 344 pregnant women were recruited at baseline, with 170 in the intervention group and 174 in the control group. Women in the intervention group received breastfeeding knowledge and promotion information weekly through a WeChat official account from their third month of pregnancy to 6 months postpartum. The primary outcome of exclusive and predominant breastfeeding rate was measured 0-1 month, 2-3 months, and 4-5 months postpartum. RESULTS: At 0-1 month postpartum, the exclusive breastfeeding rate was significantly higher in the intervention group than that in the control group (81.1% vs 63.3%; odds ratio [OR] 2.75, 95% CI 1.58-4.78; P<.001). Similarly, mothers in the intervention group were more likely to provide predominantly breast milk (OR 2.77, 95% CI 1.55-4.96; P<.001) and less likely to give dairy products to their children (OR 0.40, 95% CI 0.21-0.75; P=.005). There was no statistically significant difference for exclusive breastfeeding rate 2-3 months (P=.09) and 4-5 months postpartum (P=.27), though more children in the intervention group were exclusively breastfed than those in the control group 2-3 months postpartum (intervention: 111/152, 73.0%; control: 96/152, 63.2%) and 4-5 months postpartum(intervention: 50/108, 46.3%; control: 46/109, 42.2%). CONCLUSIONS: This study is the first effort to promote exclusive breastfeeding through WeChat in China, which proved to be an effective method of promoting exclusive breastfeeding in early life. WeChat health education can be used in addition to local breastfeeding promotion programs. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR1800017364; http://www.chictr.org.cn/showproj.aspx?proj=29325. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12889-019-7676-2.

Massive Open Online Course Evaluation Methods: Systematic Review.

BACKGROUND: Massive open online courses (MOOCs) have the potential to make a broader educational impact because many learners undertake these courses. Despite their reach, there is a lack of knowledge about which methods are used for evaluating these courses. OBJECTIVE: The aim of this review was to identify current MOOC evaluation methods to inform future study designs. METHODS: We systematically searched the following databases for studies published from January 2008 to October 2018: (1) Scopus, (2) Education Resources Information Center, (3) IEEE (Institute of Electrical and Electronic Engineers) Xplore, (4) PubMed, (5) Web of Science, (6) British Education Index, and (7) Google Scholar search engine. Two reviewers independently screened the abstracts and titles of the studies. Published studies in the English language that evaluated MOOCs were included. The study design of the evaluations, the underlying motivation for the evaluation studies, data collection, and data analysis methods were quantitatively and qualitatively analyzed. The quality of the included studies was appraised using the Cochrane Collaboration Risk of Bias Tool for randomized controlled trials (RCTs) and the National Institutes of Health-National Heart, Lung, and Blood Institute quality assessment tool for cohort observational studies and for before-after (pre-post) studies with no control group. RESULTS: The initial search resulted in 3275 studies, and 33 eligible studies were included in this review. In total, 16 studies used a quantitative study design, 11 used a qualitative design, and 6 used a mixed methods study design. In all, 16 studies evaluated learner characteristics and behavior, and 20 studies evaluated learning outcomes and experiences. A total of 12 studies used 1 data source, 11 used 2 data sources, 7 used 3 data sources, 4 used 2 data sources, and 1 used 5 data sources. Overall, 3 studies used more than 3 data sources in their evaluation. In terms of the data analysis methods, quantitative methods were most prominent with descriptive and inferential statistics, which were the top 2 preferred methods. In all, 26 studies with a cross-sectional design had a low-quality assessment, whereas RCTs and quasi-experimental studies received a high-quality assessment. CONCLUSIONS: The MOOC evaluation data collection and data analysis methods should be determined carefully on the basis of the aim of the evaluation. The MOOC evaluations are subject to bias, which could be reduced using pre-MOOC measures for comparison or by controlling for confounding variables. Future MOOC evaluations should consider using more diverse data sources and data analysis methods. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/12087.

The effectiveness of using a WeChat account to improve exclusive breastfeeding in Huzhu County Qinghai Province, China: protocol for a randomized control trial.

BACKGROUND: An exclusive breastfeeding rate in the first 6 months of life of at least 50% is one of the six World Health Organization global nutrition targets for 2025. However, the exclusive breastfeeding rate in China is quite low and decreasing which makes it urgent to explore effective ways to reverse the current downward trend. As mobile technologies have rapidly developed, mobile communication apps such as WeChat (one of the largest social networking platforms in China) are well accepted and have the potential to improve health behaviors in a convenient way. The current paper describes the study protocol of a WeChat intervention that aims to promote breastfeeding in rural areas in China. METHODS: The study is designed as a randomized controlled trial in rural Qinghai Province, China. Women who are 14-36 weeks pregnant will be randomized to routine antenatal and postnatal care, or routine care plus the WeChat breastfeeding education. pregnant women with a severe disease and complications of pregnancy or HIV-1 will be excluded. Breastfeeding knowledge and promotion information will be delivered to the intervention group through a WeChat official account from 3 months pregnancy to 6 months postpartum. The outcome assessments are conducted at baseline through face-to-face interviews, and at one week, 1 month, 3 months and 6 months postpartum by telephone interviews. The primary outcome is difference in the exclusive breastfeeding rate at 1 month, 3 months, and 6 months postpartum between the intervention group and the control group. Secondary outcomes include the overall duration of any and exclusive breastfeeding across the first 6 months postpartum; mothers' knowledge of breastfeeding; the proportion of early initiation of breastfeeding; and the timing of the introduction of solid food to infants. Intention-to-treat-analysis will be used. Survival analysis will be used to compare the overall duration of any and exclusive breastfeeding between groups. DISCUSSION: This study is the first effort to promote exclusive breastfeeding through WeChat in China. Our results will provide scientific evidence for the effect of health education through WeChat on breastfeeding. Thereby this may offer a comprehensive intervention to promote exclusive breastfeeding in China and other settings. TRIAL REGISTRATION: Chinese Clinical Trial Registry -ChiCTR1800017364. Registered 26 July 2018. http://www.chictr.org.cn/showproj.aspx?proj=29325.

Sustainable Adoption of Digital Health Innovations: Perspectives From a Stakeholder Workshop.

BACKGROUND: There are various complex reasons that influence sustainable adoption of innovations in health care systems. Low adoption can be caused by a lack of support from one or more stakeholders because their needs and expectations are not always considered or aligned. OBJECTIVE: This study aimed to identify stakeholders' perceptions of barriers and facilitators toward the sustainable adoption of digital health innovations. METHODS: A stakeholder workshop was attended by 12 participants with a range of backgrounds on August 25, 2017, including people representing the views from patients, carers, local hospitals, pharmacy retailers, health insurers, health services researchers, engineers, and technology and pharmaceutical companies in Switzerland. On the basis of adoption of innovation frameworks, we asked participants to interview each other about 3 factors influencing the adoption of digitally delivered health interventions: (1) Facilitators and barriers in the external system, (2) Needs and expectations of stakeholders, and (3) Safety, quality, and usability of innovations. The worksheets and videos generated from the workshop were qualitatively analyzed and summarized. RESULTS: Facilitators for adoption mentioned were high levels of income and education, and digital health is a high priority to stakeholders. Main common interests of different stakeholders were patient satisfaction and job protection. Health care spending was a misaligned interest: although some stakeholders were keen on spending more to obtain or provide the highest quality of care, others were focused on reducing health care spending to provide cost-effective services. Switzerland's diversity and complexity, in terms of its organization with 26 cantons (administrative divisions), were barriers as these made it harder to ensure interoperability of interventions. A culture of innovation was considered a push factor, but adoption was inhibited by persistent paper-based systems, a fear of change, and unwillingness to share data. The sustainability of interventions can be promoted by making them patient-centered, meaning that patients should be involved throughout their development. CONCLUSIONS: Promoting sustainable adoption of digital health remains challenging despite various push factors being in place. Barriers related to fragmentation, patient-centeredness, data security, privacy, trust, and job security need to be addressed. A strength is that people from a wide range of backgrounds attended the workshop. A limitation is that the findings are focused on the macro level. In-depth case studies of specific issues need to be conducted in different settings.

Effectiveness of a smartphone app on improving immunization of children in rural Sichuan Province, China: a cluster randomized controlled trial.

BACKGROUND: The aim of this study was to assess the effectiveness of an EPI smartphone application (EPI app) on improving vaccination coverage in rural Sichuan Province, China. METHODS: This matched-pair cluster randomized controlled study included 32 village doctors, matched in 16 pairs, and took place from 2013 to 2015. Village doctors in the intervention group used the EPI app and reminder text messages while village doctors in the control group used their usual procedures and text messages. The primary outcome was full vaccination coverage with all five vaccines (1 dose of BCG, 3 doses of hepatitis B, 3 doses of OPV, 3 doses of DPT and 1 dose of measles vaccine), and the secondary outcome was coverage with each dose of the five individual vaccines. We also conducted qualitative interviews with village doctors to understand perceptions on using the EPI app and how this changed their vaccination work. RESULTS: The full vaccination coverage increased statistically significant from baseline to end-line in both the intervention (67 % [95 % CI:58-75 %] to 84 % [95 % CI:76-90 %], P = 0.028) and control group (71 % [95 % CI:62-79 %] to 82 % [95 % CI:74-88 %], P = 0.014). The intervention group had higher increase in full vaccination coverage from baseline to end-line compared to the control group (17 % vs 10 %), but this was not statistically significant (P = 0.164). Village doctors found it more convenient to use the EPI app to manage child vaccination and also reported saving time by looking up information of caregivers and contacting caregivers for overdue vaccinations quicker. However, village doctors found it hard to manage children who migrated out of the counties. CONCLUSIONS: This study showed that an app and text messages can be used by village doctors to improve full vaccination coverage, though no significant increase in vaccination coverage was found when assessing the effect of the app on its own. Village doctors using EPI app reported having improved their working efficiency of managing childhood vaccination. Future studies should be conducted to evaluate the impact of more integrated approach of mHealth intervention on child immunization. TRIAL REGISTRATION: Chinese Clinical Trials Registry (ChiCTR): ChiCTR-TRC- 13003960 , registered on December 6, 2013.

Feasibility of extracting data from electronic medical records for research: an international comparative study.

BACKGROUND: Electronic medical records (EMR) offer a major potential for secondary use of data for research which can improve the safety, quality and efficiency of healthcare. They also enable the measurement of disease burden at the population level. However, the extent to which this is feasible in different countries is not well known. This study aimed to: 1) assess information governance procedures for extracting data from EMR in 16 countries; and 2) explore the extent of EMR adoption and the quality and consistency of EMR data in 7 countries, using management of diabetes type 2 patients as an exemplar. METHODS: We included 16 countries from Australia, Asia, the Middle East, and Europe to the Americas. We undertook a multi-method approach including both an online literature review and structured interviews with 59 stakeholders, including 25 physicians, 23 academics, 7 EMR providers, and 4 information commissioners. Data were analysed and synthesised thematically considering the most relevant issues. RESULTS: We found that procedures for information governance, levels of adoption and data quality varied across the countries studied. The required time and ease of obtaining approval also varies widely. While some countries seem ready for secondary uses of data from EMR, in other countries several barriers were found, including limited experience with using EMR data for research, lack of standard policies and procedures, bureaucracy, confidentiality, data security concerns, technical issues and costs. CONCLUSIONS: This is the first international comparative study to shed light on the feasibility of extracting EMR data across a number of countries. The study will inform future discussions and development of policies that aim to accelerate the adoption of EMR systems in high and middle income countries and seize the rich potential for secondary use of data arising from the use of EMR solutions.

mHealth adoption in low-resource environments: a review of the use of mobile healthcare in developing countries.

The acknowledged potential of using mobile phones for improving healthcare in low-resource environments of developing countries has yet to translate into significant mHealth policy investment. The low uptake of mHealth in policy agendas may stem from a lack of evidence of the scalable, sustainable impact on health indicators. The mHealth literature in low- and middle-income countries reveals a burgeoning body of knowledge; yet, existing reviews suggest that the projects yield mixed results. This article adopts a stage-based approach to understand the varied contributions to mHealth research. The heuristic of inputs-mechanism-outputs is proposed as a tool to categorize mHealth studies. This review (63 articles comprising 53 studies) reveals that mHealth studies in developing countries tend to concentrate on specific stages, principally on pilot projects that adopt a deterministic approach to technological inputs (n = 32), namely introduction and implementation. Somewhat less studied were research designs that demonstrate evidence of outputs (n = 15), such as improvements in healthcare processes and public health indicators. The review finds a lack of emphasis on studies that provide theoretical understanding (n = 6) of adoption and appropriation of technological introduction that produces measurable health outcomes. As a result, there is a lack of dominant theory, or measures of outputs relevant to making policy decisions. Future work needs to aim for establishing theoretical and measurement standards, particularly from social scientific perspectives, in collaboration with researchers from the domains of information technology and public health. Priorities should be set for investments and guidance in evaluation disseminated by the scientific community to practitioners and policymakers.

Coverage, quality of and barriers to postnatal care in rural Hebei, China: a mixed method study.

BACKGROUND: Postnatal care is an important link in the continuum of care for maternal and child health. However, coverage and quality of postnatal care are poor in low- and middle-income countries. In 2009, the Chinese government set a policy providing free postnatal care services to all mothers and their newborns in China. Our study aimed at exploring coverage, quality of care, reasons for not receiving and barriers to providing postnatal care after introduction of this new policy. METHODS: We carried out a mixed method study in Zhao County, Hebei Province, China from July to August 2011. To quantify the coverage, quality of care and reasons for not using postnatal care, we conducted a household survey with 1601 caregivers of children younger than two years of age. We also conducted semi-structured interviews with 24 township maternal and child healthcare workers to evaluate their views on workload, in-service training and barriers to postnatal home visits. RESULTS: Of 1442 (90% of surveyed caregivers) women who completed the postnatal care survey module, 8% received a timely postnatal home visit (within one week after delivery) and 24% of women received postnatal care within 42 days after delivery. Among women who received postnatal care, 37% received counseling or guidance on infant feeding and 32% on cord care. 24% of women reported that the service provider checked jaundice of their newborns and 18% were consulted on danger signs and thermal care of their newborns. Of 991 mothers who did not seek postnatal care within 42 days after birth, 65% of them said that they did not knew about postnatal care and 24% of them thought it was unnecessary. Qualitative findings revealed that staff shortages and inconvenient transportation limited maternal and child healthcare workers in reaching out to women at home. In addition, maternal and child healthcare workers said that in-service training was inadequate and more training on postnatal care, hands-on practice, and supervision were needed. CONCLUSIONS: Coverage and quality of postnatal care were low in rural Hebei Province and far below the targets set by Chinese government. We identified barriers both from the supply and demand side.

Effectiveness of a smart phone app on improving immunization of children in rural Sichuan Province, China: study protocol for a paired cluster randomized controlled trial.

BACKGROUND: Although good progress has been achieved in expanding immunization of children in China, disparities exist across different provinces. Information gaps both from the service supply and demand sides hinder timely vaccination of children in rural areas. The rapid development of mobile health technology (mHealth) provides unprecedented opportunities for improving health services and reaching underserved populations. However, there is a lack of literature that rigorously evaluates the impact of mHealth interventions on immunization coverage as well as the usability and feasibility of smart phone applications (apps). This study aims to assess the effectiveness of a smart phone-based app (Expanded Program on Immunization app, or EPI app) on improving the coverage of children's immunization. METHODS/DESIGN: This cluster randomized trial will take place in Xuanhan County, Sichuan Province, China. Functionalities of the app include the following: to make appointments automatically, record and update children's immunization information, generate a list of children who missed their vaccination appointments, and send health education information to village doctors. After pairing, 36 villages will be randomly allocated to the intervention arm (n=18) and control arm (n=18). The village doctors in the intervention arm will use the app while the village doctors in the control arm will record and manage immunization in the usual way in their catchment areas. A household survey will be used at baseline and at endline (8 months of implementation). The primary outcome is full-dose coverage and the secondary outcome is immunization coverage of the five vaccines that are included in the national Expanded Program on Immunization program as well as Hib vaccine, Rotavirus vaccine and Pneumococcal conjugate vaccine. Multidimensional evaluation of the app will also be conducted to assess usability and feasibility. DISCUSSION: This study is the first to evaluate the effectiveness of a smart phone app for child immunization in rural China. This study will contribute to the knowledge about the usability and feasibility of a smart phone app for managing immunization in rural China and to similar populations in different settings. TRIAL REGISTRATION: Chinese Clinical Trials Registry (ChiCTR): ChiCTR-TRC-13003960.

Text messaging data collection for monitoring an infant feeding intervention program in rural China: feasibility study.

BACKGROUND: An effective data collection method is crucial for high quality monitoring of health interventions. The traditional face-to-face data collection method is labor intensive, expensive, and time consuming. With the rapid increase of mobile phone subscribers, text messaging has the potential to be used for evaluation of population health interventions in rural China. OBJECTIVE: The objective of this study was to explore the feasibility of using text messaging as a data collection tool to monitor an infant feeding intervention program. METHODS: Participants were caregivers of children aged 0 to 23 months in rural China who participated in an infant feeding health education program. We used the test-retest method. First, we collected data with a text messaging survey and then with a face-to-face survey for 2 periods of 3 days. We compared the response rate, data agreement, costs, and participants' acceptability of the two methods. Also, we interviewed participants to explore their reasons for not responding to the text messages and the reasons for disagreement in the two methods. In addition, we evaluated the most appropriate time during the day for sending text messages. RESULTS: We included 258 participants; 99 (38.4%) participated in the text messaging survey and 177 (68.6%) in the face-to-face survey. Compared with the face-to-face survey, the text messaging survey had much lower response rates to at least one question (38.4% vs 68.6%) and to all 7 questions (27.9% vs 67.4%) with moderate data agreement (most kappa values between .5 and .75, the intraclass correlation coefficients between .53 to .72). Participants who took part in both surveys gave the same acceptability rating for both methods (median 4.0 for both on a 5-point scale, 1=disliked very much and 5=liked very much). The costs per questionnaire for the text messaging method were much lower than the costs for the face-to-face method: ¥19.7 (US $3.13) versus ¥33.9 (US $5.39) for all questionnaires, and ¥27.1 (US $4.31) versus ¥34.4 (US $5.47) for completed questionnaires. The main reasons for not replying were that participants did not receive text messages, they were too busy to reply, or they did not see text messages in time. The main reasons for disagreement in responses were that participants forgot their answers in the text messaging survey and that they changed their minds. We found that participants were more likely to reply to text messages immediately during 2 time periods: 8 AM to 3 PM and 8 PM to 9 PM. CONCLUSIONS: The text messaging method had reasonable data agreement and low cost, but a low response rate. Further research is needed to evaluate effectiveness of measures that can increase the response rate, especially in collecting longitudinal data by text messaging.

Care-seeking and quality of care for outpatient sick children in rural Hebei, China: a cross-sectional study.

AIM: To assess the quality of outpatient pediatric care provided by township and village doctors, prevalence of common childhood diseases, care-seeking behavior, and coverage of key interventions in Zhao County in China. METHODS: We conducted two cross-sectional surveys: 1) maternal, newborn, and child health household survey including1601 caregivers of children younger than two years; 2) health facility survey on case management of 348 sick children younger than five years by local health workers and assessment of the availability of drugs and supplies in health facility. RESULTS: Our household survey showed that the prevalence of fever, cough, and diarrhea was 16.8%, 9.2%, and 15.6% respectively. Caregivers of children with fever, cough, and diarrhea sought care primarily in village clinics and township hospitals. Only 41.2% of children with suspected pneumonia received antibiotics, and very few children with diarrhea received oral rehydration solutions (1.2%) and zinc (4.4%). Our facility survey indicated that very few sick children were fully assessed, and only 43.8% were correctly classified by health workers when compared with the gold standard. Use of antibiotics for sick children was high and not according to guidelines. CONCLUSION. We showed poor quality of services for outpatient sick children in Zhao County. Since Integrated Management of Childhood Illness strategy has shown positive effects on child health in some areas of China, it is advisable to implement it in other areas as well.

The effectiveness of a WeChat-based self-assessment with a tailored feedback report on improving complementary feeding and movement behaviour of children aged 6-20 months in rural China: a cluster randomized controlled trial.

Background: Appropriate infant feeding and movement behaviour (i.e. physical activity, sedentary behaviour, sleep) play an important role in children's healthy development during the first two years of life. The popular Chinese social media app 'WeChat' has become a potential data collection and health promotion tool. We aimed to evaluate the effectiveness of a WeChat-based self-assessment with a tailored feedback report on improving complementary feeding practices and movement behaviour of children aged 6-20 months in rural China. Methods: We conducted a two-armed cluster randomized control trial in Datong County, Qinghai Province, China. There were 106 clusters from 257 villages allocated (1:1) to two groups: the feeding group, which received a complementary feeding recommendations feedback report; the movement behaviour group, which received movement behaviour recommendations feedback report. The feeding group acted as a control for the movement behaviour group and vice versa. Children aged 6-20 months and their primary caregivers were invited to be participants. WeChat was used to collect the data on outcomes and to deliver the interventions. Participants received the interventions by filling out the WeChat self-assessment questionnaire and reading tailored feedback reports at baseline, at the first 1-month follow-up and at the second 2-month follow-up. Outcome measures included changes in the prevalence of minimum dietary diversity (MDD), minimum meal frequency (MMF), minimum acceptable diet (MAD); and the proportion of children who met physical activity time (PAT), outdoor time (OT) and screen time (ST) recommendation between the two groups at the two follow-ups. This study is registered at Chinese Clinical Trial Registry-ChiCTR2200062529. Findings: Between September 28th and October 12th 2022, we recruited 1610 children in 106 clusters, of which 53 clusters (800 children) were randomized to the feeding group and 53 clusters (810 children) to the movement behaviour group. All caregivers of children completed questionnaires at three time points without loss to follow-up. From baseline to the second follow-up, the prevalence of MDD (OR: 1.62 [95% CI, 1.16-2.28; p = 0.0058]), MMF (OR: 1.45 [95% CI, 1.03-2.04; p = 0.032]) and MAD (OR: 1.51 [95% CI, 1.12-2.05; p = 0.0081]) in the feeding group were significantly higher than that in the movement behaviour group. The proportion of children who met PAT during the last 24 h at the second follow-up (OR: 2.22 [95% CI, 1.26-2.17; p < 0.0001]) and OT at the second follow-up (OR: 1.94 [95% CI, 1.49-2.54; p < 0.0001]) significantly improved in the movement behaviour group compared to the feeding group. Furthermore, ST in the movement behaviour group showed a significant increase only at the first follow-up (OR: 1.36 [95% CI, 1.02-1.82; p = 0.036]). Interpretation: WeChat-based self-assessment with tailored feedback was an effective channel to deliver feeding and movement behaviour recommendations in rural China in our study. This approach can be applied to change feeding practices of caregivers of young children alongside routine child health care in rural China. Funding: Capital Institute of Pediatrics.

Life Course Digital Twins-Intelligent Monitoring for Early and Continuous Intervention and Prevention (LifeTIME): Proposal for a Retrospective Cohort Study.

BACKGROUND: Multimorbidity, which is associated with significant negative outcomes for individuals and health care systems, is increasing in the United Kingdom. However, there is a lack of knowledge about the risk factors (including health, behavior, and environment) for multimorbidity over time. An interdisciplinary approach is essential, as data science, artificial intelligence, and engineering concepts (digital twins) can identify key risk factors throughout the life course, potentially enabling personalized simulation of life-course risk for the development of multimorbidity. Predicting the risk of developing clusters of health conditions before they occur would add clinical value by enabling targeted early preventive interventions, advancing personalized care to improve outcomes, and reducing the burden on health care systems. OBJECTIVE: This study aims to identify key risk factors that predict multimorbidity throughout the life course by developing an intelligent agent using digital twins so that early interventions can be delivered to improve health outcomes. The objectives of this study are to identify key predictors of lifetime risk of multimorbidity, create a series of simulated computational digital twins that predict risk levels for specific clusters of factors, and test the feasibility of the system. METHODS: This study will use machine learning to develop digital twins by identifying key risk factors throughout the life course that predict the risk of later multimorbidity. The first stage of the development will be the training of a base predictive model. Data from the National Child Development Study, the North West London Integrated Care Record, the Clinical Practice Research Datalink, and Cerner's Real World Data will be split into subsets for training and validation, which will be done following the k-fold cross-validation procedure and assessed with the Prediction Model Risk of Bias Assessment Tool (PROBAST). In addition, 2 data sets-the Early-Life Data Cross-linkage in Research study and the Children and Young People's Health Partnership randomized controlled trial-will be used to develop a series of digital twin personas that simulate clusters of factors to predict different risk levels of developing multimorbidity. RESULTS: The expected results are a validated model, a series of digital twin personas, and a proof-of-concept assessment. CONCLUSIONS: Digital twins could provide an individualized early warning system that predicts the risk of future health conditions and recommends the most effective intervention to minimize that risk. These insights could significantly improve an individual's quality of life and healthy life expectancy and reduce population-level health burdens. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/35738.

Qualitative study on perceptions of use of Fractional Exhaled Nitric Oxide (FeNO) in asthma reviews.

Current methods to assess asthma and guide inhaled corticosteroid (ICS) dose titration mainly centre on patient-reported symptoms and lung function assessments. However, these methods correlate only weakly with airway inflammation making them unreliable predictors of future exacerbations and ICS requirement. Fractional Exhaled Nitric Oxide (FeNO) is a simple non-invasive objective measure of airways inflammation used predominantly in specialist clinics. Previous qualitative studies have mainly focused on the acceptability of FeNO in secondary care and there is limited insight to support clinicians and patients using FeNO in primary care asthma reviews. This study aimed to explore adult patient with asthma and primary care health care professional (HCP) views on introducing FeNO as part of routine asthma reviews. Twenty-three health care professionals and 22 patients were interviewed over the phone or online. Both groups reported that current asthma reviews are often seen as tick-box exercises and that introducing the FeNO test would make reviews more tailored to the individual patient, rather than relying on subjective patient reports of asthma control. Adults with asthma also highlighted support more open communication and their understanding of asthma, as they desired to feel more engaged in decisions and conversations about their asthma. HCPs reported valuing patient education and empowerment over a paternalistic approach, when time and resources allow. They also recognised FeNO to provide an objective measure of inflammation that could support them in the education and empowerment of patients. FeNO was seen by both groups as a potentially valuable addition to current asthma reviews mainly led by nurses, both for increasing their understanding of current risk of exacerbation and also to provide more tailored and personalised asthma management to patients. Our findings highlighted the need for open and clear communication about how to interpret FeNO results.

Trends in complementary feeding practices and caregivers' feeding knowledge among children aged 6-23 months: Repeated cross-sectional surveys in rural Qinghai China 2012-18.

BACKGROUND: Appropriate infant and young child feeding is the basis for child survival, growth and development. The aim of this study was to investigate trends in complementary feeding practices and caregivers' feeding knowledge among children from 2012 to 2018 in Huzhu County, Qinghai Province, China. METHODS: This study took place during and after a controlled interventional evaluation trial in Qinghai Province, China, which aimed to evaluate the effectiveness of community-based nutrient-dense complementary food supplements (YingYangBao) combined with dietary counseling on improving 6-23 month-old children's health status. We conducted four representative cross-sectional surveys on caregivers of children aged 6-23 months in Huzhu County, Qinghai Province, China (baseline survey for the trial (N = 1804) in August 2012, end-line survey for the trial (N = 2186) in August 2014, follow-up survey 1 (N = 496) in January 2016, and follow-up survey 2 (N = 754) in July 2018). In all surveys we used the same questionnaire to collect household information, infant feeding practices and caregivers' feeding knowledge. RESULTS: During the trial period (2012-2014), the proportion of children aged 6-8 months that introduced (semi-) solid food increased from 86.1% to 96.3% (P < 0.0001), however, there was a downward trend from 2014 to 2018 (P = 0.0014 for trend). The prevalence of minimum dietary diversity also increased from 51.4% at 2012 baseline survey to 57.5% at 2014 endline survey (P = 0.0004), but the upward trend did not maintain from 2014 to 2018 (P = 0.7863 for trend). The minimum dietary frequency, the minimum acceptable diet, and continued breastfeeding at one year were nearly unchanged from 2012 to 2018 (P = 0.9529, P = 0.7602 and P = 0.6013 for trend, respectively), remaining around 30%, 10% and 20% respectively in the four surveys. Caregivers' feeding knowledge on the duration of exclusive breastfeeding and introduction of semi or solid foods at 6-8 months increased from 2012 to 2018 (18.6% to 39.5%, 43.2% to 64.3%, respectively). CONCLUSION: This study showed that the sustainability of community-based YYB and dietary counseling program was suboptimal. We suggest that multiple information delivery channels such as smartphones and the Internet should be explored as a supplement to existing channels for delivering counseling information. TRIAL REGISTRATION: ChiCTRPRC12002444.

Developing a Blockchain-Based Supply Chain System for Advanced Therapies: Protocol for a Feasibility Study.

BACKGROUND: Advanced therapies, including cell and gene therapies, have shown therapeutic promise in curing life-threatening diseases, such as leukemia and lymphoma. However, these therapies can be complicated and expensive to deliver due to their sensitivity to environment; troublesome tissue, cell, or genetic material sourcing; and complicated regulatory requirements. OBJECTIVE: This study aims to create a novel connected supply chain logistics and manufacturing management platform based on blockchain, with cell and gene therapy as a use case. Objectives are to define the requirements and perform feasibility evaluations on the use of blockchain for standardized manufacturing and establishment of a chain of custody for the needle-to-needle delivery of autologous cell and gene therapies. A way of lowering overall regulatory compliance costs for running a network of facilities operating similar or parallel processes will be evaluated by lowering the monitoring costs through publishing zero-knowledge proofs and product release by exception. METHODS: The study will use blockchain technologies to digitally connect and integrate supply chain with manufacturing to address the security, scheduling, and communication issues between advanced therapy treatment centers and manufacturing facilities in order to realize a transparent, secure, automated, and cost-effective solution to the delivery of these life-saving therapies. An agile software development methodology will be used to develop, implement, and evaluate the system. The system will adhere to the EU and US good manufacturing practices and regulatory requirements. RESULTS: This is a proposed study protocol, and upon acceptance, grant funding will be pursued for its execution in 2021. CONCLUSIONS: The successful implementation of the integrated blockchain solution to supply chain and manufacturing of advanced therapies can push the industry standards toward a safer and more secure therapy delivery process. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/17005.

Long-Term Weight Management Using Wearable Technology in Overweight and Obese Adults: Systematic Review.

BACKGROUND: Although there are many wearable devices available to help people lose weight and decrease the rising prevalence of obesity, the effectiveness of these devices in long-term weight management has not been established. OBJECTIVE: This study aimed to systematically review the literature on using wearable technology for long-term weight loss in overweight and obese adults. METHODS: We searched the following databases: Medical Literature Analysis and Retrieval System Online, EMBASE, Compendex, ScienceDirect, Cochrane Central, and Scopus. The inclusion criteria were studies that took measurements for a period of ≥1 year (long-term) and had adult participants with a BMI >24. A total of 2 reviewers screened titles and abstracts and assessed the selected full-text papers for eligibility. The risk of bias assessment was performed using the following tools appropriate for different study types: the Cochrane risk of bias tool, Risk Of Bias In Nonrandomized Studies-of Interventions, A MeaSurement Tool to Assess systematic Reviews, and 6 questions to trigger critical thinking. The results of the studies have been provided in a narrative summary. RESULTS: We included five intervention studies: four randomized controlled trials and one nonrandomized study. In addition, we used insights from six systematic reviews, four commentary papers, and a dissertation. The interventions delivered by wearable devices did not show a benefit over comparator interventions, but overweight and obese participants still lost weight over time. The included intervention studies were likely to suffer from bias. Significant variances in objectives, methods, and results of included studies prevented meta-analysis. CONCLUSIONS: This review showed some evidence that wearable devices can improve long-term physical activity and weight loss outcomes, but there was not enough evidence to show a benefit over the comparator methods. A major issue is the challenge of separating the effect of decreasing use of wearable devices over time from the effect of the wearable devices on the outcomes. Consistency in study methods is needed in future long-term studies on the use of wearable devices for weight loss. TRIAL REGISTRATION: PROSPERO CRD42018096932; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=96932.

Application of Internet of Things in Cell-Based Therapy Delivery: Protocol for a Systematic Review.

BACKGROUND: Internet of Things (IoT), or Industry 4.0, represents a smart shift to more interconnected manufacturing processes where individual entities within the supply chain communicate with each other to achieve greater flexibility and responsiveness in general manufacturing and leaner manufacturing to reduce the cost of production. IoT has become instrumental in driving leaner manufacturing and more efficient systems in other industries such as transportation and logistics. Cell-based therapeutic products could potentially transform various diseases; however, the delivery of these products is complex and challenging. OBJECTIVE: This study aims to understand the applicability of IoT in cell-based product supply chains and delivery. METHODS: We will search Medline, EMBASE (OvidSP), Web of Science, Cochrane Library & HEED, Scopus, ACM digital library, INSPEC, ScienceDirect, and the IEEE Xplore Digital Library for studies published after 2008 using a combination of keywords and subject headings related to IoT used in cell therapies. Additionally, a Google search to identify gray literature will be conducted. Two authors will independently screen the titles and abstracts identified from the search and accept or reject the studies according to the study inclusion criteria. Any discrepancies will then be discussed and resolved. The quality of the selected literature will be assessed using the Critical Appraisal Skills Programme systematic review checklist. RESULTS: Data from eligible publications will be abstracted into a predesigned form to map the current and future directions of the technologies, applications, benefits, and challenges in the implementation of IoT in regenerative medicine. This study will be published in a peer-reviewed journal in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This systematic review will be executed by June 2020, and the completed review will be published in a peer-reviewed journal to inform future developments in IoT application for the delivery of cell-based therapies. CONCLUSIONS: This review paper will provide an overview of all technologies available in the area and inspect the current IoT applications in cell-based therapies to identify the benefits, challenges, and future directions of using IoT to allow safe and cost-effective delivery of cell-based therapies. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/16935.