Content analysis of patient material resources on the internet for oral cancer-An exploratory study.

BACKGROUND: Oral cancer is one of the leading causes of mortality in the world over and is a major public health problem. There are numerous resources on the internet which provide information related to oral cancer. However, they may not be optimal and standardized. The present study was conducted to assess the quality, readability, and content of the online resources for oral cancer. METHODS: The content analysis approach was employed for the present study. Google search engine was employed to search for various online resources on oral cancer. The first 50 websites were evaluated for their quality and readability. Flesch-Kincaid readability tests were used to assess the readability of the internet material and consisted of Flesch reading ease and Flesch-Kincaid grade level. The quality of websites was assessed by Journal of American Medical Association (JAMA) benchmarks and HONcode (Health Over Net code). RESULTS: A total of 12 (32.43%) of the websites were fairly difficult to comprehend, while none of the websites were easy/very easy to comprehend. A total of 8 (21.62%) websites were readable by only college-level graduates. Overall, 21 (56.76%) of the websites did not have HONcode certification. CONCLUSION: The present study revealed that a majority of the websites were fairly difficult to comprehend and readable by college-level graduates. There is a definite need to monitor the quality of the websites on oral cancer. The present study highlights the need for stringent norms and regulations regarding oral cancer made available to the common man on the internet.

An online review of informational sources for advanced or high-risk cutaneous squamous cell carcinoma.

OBJECTIVE: Cutaneous squamous cell carcinoma (cSCC) is one of the most prevalent non-melanoma skin cancers worldwide. While usually treatable, patients with high-risk or advanced disease have few treatment options and limited resources available. This review assesses what online information resources are available to patients and their families about either high-risk or advanced cSCC. METHODS: Searches were run, via Google, using 8 terms such as 'advanced cutaneous squamous cell carcinoma patient information'. Advertisements were removed and the first 3 pages/30 results from each search were screened for duplicates and then against eligibility criteria. Websites needed to have been updated within the past 5 years, be freely accessible, designed specifically for patients and refer to the advanced disease or high-risk setting. Remaining results were assessed using the DISCERN tool. RESULTS: Of the final 240 results, 121 were duplicates and 104 were ineligible. The remaining 15 sources were predominantly aimed at American audiences, used variable terminology and revealed differing treatment pathways. Only 3 sites were deemed as 'high'-quality information sources. CONCLUSION: There is a lack of accessible online information on high-risk or advanced cSCC for patients. What is available is often too scientific or clinical and lacks clarity about the disease and treatment options. PRACTICE IMPLICATIONS: Further work is needed to improve the integrity and accessibility of online sources and to signpost patients to the most reliable information. This should include elements of patient led research, clinical education and information development.

How Internet Contracts Impact Research: Content Analysis of Terms of Service on Consumer Product Websites.

BACKGROUND: Companies use brand websites as a promotional tool to engage consumers on the web, which can increase product use. Given that some products are harmful to the health of consumers, it is important for marketing associated with these products to be subject to public health surveillance. However, terms of service (TOS) governing the use of brand website content may impede such important research. OBJECTIVE: The aim of this study is to explore the TOS for brand websites with public health significance to assess possible legal and ethical challenges for conducting research on consumer product websites. METHODS: Using Statista, we purposefully constructed a sample of 15 leading American tobacco, alcohol, psychiatric pharmaceutical, fast-food, and gun brands that have associated websites. We developed and implemented a structured coding system for the TOS on these websites and coded for the presence versus absence of different types of restriction that might impact the ability to conduct research. RESULTS: All TOS stated that by accessing the website, users agreed to abide by the TOS (15/15, 100%). A total of 11 out of 15 (73%) websites had age restrictions in their TOS. All alcohol brand websites (5/15, 33%) required users to enter their age or date of birth before viewing website content. Both websites for tobacco brands (2/15, 13%) further required that users register and verify their age and identity to access any website content and agree that they use tobacco products. Only one website (1/15, 7%) allowed users to display, download, copy, distribute, and translate the website content as long as it was for personal and not commercial use. A total of 33% (5/15) of TOS unconditionally prohibited or put substantial restrictions on all of these activities and/or failed to specify if they were allowed or prohibited. Moreover, 87% (13/15) of TOS indicated that website access could be restricted at any time. A total of 73% (11/15) of websites specified that violating TOS could result in deleting user content from the website, revoking access by having the user's Internet Protocol address blocked, terminating log-in credentials, or enforcing legal action resulting in civil or criminal penalties. CONCLUSIONS: TOS create complications for public health surveillance related to e-marketing on brand websites. Recent court opinions have reduced the risk of federal criminal charges for violating TOS on public websites, but this risk remains unclear for private websites. The public health community needs to establish standards to guide and protect researchers from the possibility of legal repercussions related to such efforts.

A Pilot Randomized Controlled Trial of a Web-Based Growth Mindset Intervention to Enhance the Effectiveness of a Smartphone App for Smoking Cessation.

BACKGROUND: Although smartphone apps have shown promise for smoking cessation, there is a need to enhance their low engagement rates. This study evaluated the application of the growth mindset theory, which has demonstrated the potential to improve persistence in behavior change in other domains, as a means to improve engagement and cessation. OBJECTIVE: This study aimed to explore the feasibility, utility, and efficacy of a Web-based growth mindset intervention for addiction when used alongside a smoking cessation app. METHODS: Daily smokers (N=398) were all recruited on the Web and randomly assigned to receive either a cessation app alone or the app plus a Web-delivered growth mindset intervention. The primary outcome was engagement, that is, the number of log-ins to the smoking cessation app. The secondary outcome was 30-day point prevalence abstinence at 2-month follow-up collected through a Web-based survey. RESULTS: The 2-month outcome data retention rate was 91.5% (364/398). In addition, 77.9% (310/398) of the participants in the experimental arm viewed at least 1 page of their growth mindset intervention, and 21.1% (84/398) of the group viewed all the growth mindset intervention. The intention-to-treat analysis did not show statistically significant differences between the experimental and comparison arms on log-ins to the app (19.46 vs 21.61; P=.38). The experimental arm had cessation rates, which trended higher than the comparison arm (17% vs 13%; P=.10). The modified intent-to-treat analysis, including only participants who used their assigned intervention at least once (n=115 in experimental group and n=151 in the control group), showed that the experimental arm had a similar number of log-ins (32.31 vs 28.48; P=.55) but significantly higher cessation rates (21% vs 13%; P=.03) than the comparison arm. CONCLUSIONS: A growth mindset intervention for addiction did not increase engagement rates, although it may increase cessation rates when used alongside a smartphone app for smoking cessation. Future research is required to refine the intervention and assess efficacy with long-term follow-up to evaluate the efficacy of the mindset intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT03174730; https://clinicaltrials.gov/ct2/show/NCT03174730.

Workload: a comparison between the online and observational methods / Carga horaria de trabajo: comparación de los métodos observacionales y online / Carga horária de trabalho: comparação dos métodos observacional e on-line

ABSTRACT Objective: To measure nursing Workload (WL) of nurses who work in the Inpatient Unit, as recommended by the Nursing Interventions Classification (NIC), comparing observational and online methods to propose supervision strategies for academic professionals. Method: Quantitative, descriptive, observational study performed in a Clinical/Surgical Hospital Unit. 30 direct and indirect activities. Data collected in observational and online records. Statistical analysis: SPSS 18.0 software, percentage frequencies and associated times between groups by Fisher's Exact test, 95% confidence interval, significance level 5%. Results: Comparing the activities performed with the NIC time: from the direct 16, five observational and five online, were out of range, with no significant difference between frequencies (P=0.427). Of the 14 indirect, only in the observational, two were out of the range, without significant difference (P=0.486). Conclusion: Both methods measure WL; the online method developed accompanies activities performed in real time.

RESUMEN Objetivo: Medir la carga de trabajo (CT) de los enfermeros que actúan en Unidad de Internación, según preconiza la Nursing Interventions Classification (NIC), comparando los métodos observacional y online, para proponer estrategias de supervisión de los profesionales y académicos. Método: Estudio observacional descriptivo cuantitativo realizado en una Unidad de Internación Clínica/Quirúrgica. 30 actividades directas e indirectas. Datos recogidos en registros observacionales y en línea. Análisis estadístico: Software SPSS 18.0, frecuencias porcentuales y tiempos asociados entre grupos por la prueba Exacto de Fisher, intervalo de confianza 95%, nivel de significancia 5%. Resultados: Comparando las actividades realizadas con el tiempo preconizado por la NIC: de las 16 directas, cinco en el observacional y cinco en el on-line, estaban fuera del intervalo, sin diferencia significativa entre frecuencias (P=0,427). De las 14 indirectas, sólo en el observacional, dos estaban fuera del intervalo, sin diferencia significativa (P=0,486). Conclusión: Ambos métodos sirven para medir CT; el método online desarrollado acompaña actividades ejecutadas en tiempo real.

RESUMO Objetivo: Mensurar a Carga de Trabalho (CT) dos enfermeiros que atuam em Unidade de Internação, conforme preconiza a Nursing Interventions Classification (NIC), comparando os métodos observacional e on-line, para propor estratégias de supervisão dos profissionais eacadêmicos. Método: Estudo observacional descritivo quantitativo realizado em uma Unidade de Internação Clínica/Cirúrgica. 30 atividades diretas e indiretas. Dados levantados em registros observacional e on-line. Análise estatística: Software SPSS 18.0, frequências percentuais e tempos associadas entre grupos pelo teste Exato de Fisher, intervalo de confiança 95%, nível de significância 5%. Resultados: Comparando as atividades executadas com o tempo preconizado pela NIC: das 16 diretas, cinco no observacional e cinco no on-line, estavam fora do intervalo, sem diferença significativa entre frequências (P=0,427). Das 14 indiretas, apenas no observacional, duas estavam fora do intervalo, sem diferença significativa (P=0,486). Conclusão: Ambos os métodos servem para medir CT; o método on-line desenvolvido acompanha atividades executadas em tempo real.

Uptake of Tailored Text Message Smoking Cessation Support in Pregnancy When Advertised on the Internet (MiQuit): Observational Study.

BACKGROUND: Smoking in pregnancy is a major public health concern. Pregnant smokers are particularly difficult to reach, with low uptake of support options and few effective interventions. Text message-based self-help is a promising, low-cost intervention for this population, but its real-world uptake is largely unknown. OBJECTIVE: The objective of this study was to explore the uptake and cost-effectiveness of a tailored, theory-guided, text message intervention for pregnant smokers ("MiQuit") when advertised on the internet. METHODS: Links to a website providing MiQuit initiation information (texting a short code) were advertised on a cost-per-click basis on 2 websites (Google Search and Facebook; £1000 budget each) and free of charge within smoking-in-pregnancy webpages on 2 noncommercial websites (National Childbirth Trust and NHS Choices). Daily budgets were capped to allow the Google and Facebook adverts to run for 1 and 3 months, respectively. We recorded the number of times adverts were shown and clicked on, the number of MiQuit initiations, the characteristics of those initiating MiQuit, and whether support was discontinued prematurely. For the commercial adverts, we calculated the cost per initiation and, using quit rates obtained from an earlier clinical trial, estimated the cost per additional quitter. RESULTS: With equal capped budgets, there were 812 and 1889 advert clicks to the MiQuit website from Google (search-based) and Facebook (banner) adverts, respectively. MiQuit was initiated by 5.2% (42/812) of those clicking via Google (95% CI 3.9%-6.9%) and 2.22% (42/1889) of those clicking via Facebook (95% CI 1.65%-2.99%). Adverts on noncommercial webpages generated 53 clicks over 6 months, with 9 initiations (9/53, 17%; 95% CI 9%-30%). For the commercial websites combined, mean cost per initiation was £24.73; estimated cost per additional quitter, including text delivery costs, was £735.86 (95% CI £227.66-£5223.93). Those initiating MiQuit via Google were typically very early in pregnancy (median gestation 5 weeks, interquartile range 10 weeks); those initiating via Facebook were distributed more evenly across pregnancy (median gestation 16 weeks, interquartile range 14 weeks). CONCLUSIONS: Commercial online adverts are a feasible, likely cost-effective method for engaging pregnant smokers in digital cessation support and may generate uptake at a faster rate than noncommercial websites. As a strategy for implementing MiQuit, online advertising has large reach potential and can offer support to a hard-to-reach population of smokers.

Physical Activity, Sedentary Behavior, and Diet-Related eHealth and mHealth Research: Bibliometric Analysis.

BACKGROUND: Electronic health (eHealth) and mobile health (mHealth) approaches to address low physical activity levels, sedentary behavior, and unhealthy diets have received significant research attention. However, attempts to systematically map the entirety of the research field are lacking. This gap can be filled with a bibliometric study, where publication-specific data such as citations, journals, authors, and keywords are used to provide a systematic overview of a specific field. Such analyses will help researchers better position their work. OBJECTIVE: The objective of this review was to use bibliometric data to provide an overview of the eHealth and mHealth research field related to physical activity, sedentary behavior, and diet. METHODS: The Web of Science (WoS) Core Collection was searched to retrieve all existing and highly cited (as defined by WoS) physical activity, sedentary behavior, and diet related eHealth and mHealth research papers published in English between January 1, 2000 and December 31, 2016. Retrieved titles were screened for eligibility, using the abstract and full-text where needed. We described publication trends over time, which included journals, authors, and countries of eligible papers, as well as their keywords and subject categories. Citations of eligible papers were compared with those expected based on published data. Additionally, we described highly-cited papers of the field (ie, top ranked 1%). RESULTS: The search identified 4805 hits, of which 1712 (including 42 highly-cited papers) were included in the analyses. Publication output increased on an average of 26% per year since 2000, with 49.00% (839/1712) of papers being published between 2014 and 2016. Overall and throughout the years, eHealth and mHealth papers related to physical activity, sedentary behavior, and diet received more citations than expected compared with papers in the same WoS subject categories. The Journal of Medical Internet Research published most papers in the field (9.58%, 164/1712). Most papers originated from high-income countries (96.90%, 1659/1717), in particular the United States (48.83%, 836/1712). Most papers were trials and studied physical activity. Beginning in 2013, research on Generation 2 technologies (eg, smartphones, wearables) sharply increased, while research on Generation 1 (eg, text messages) technologies increased at a reduced pace. Reviews accounted for 20 of the 42 highly-cited papers (n=19 systematic reviews). Social media, smartphone apps, and wearable activity trackers used to encourage physical activity, less sedentary behavior, and/or healthy eating were the focus of 14 highly-cited papers. CONCLUSIONS: This study highlighted the rapid growth of the eHealth and mHealth physical activity, sedentary behavior, and diet research field, emphasized the sizeable contribution of research from high-income countries, and pointed to the increased research interest in Generation 2 technologies. It is expected that the field will grow and diversify further and that reviews and research on most recent technologies will continue to strongly impact the field.

Development of an Internet-Administered Cognitive Behavior Therapy Program (ENGAGE) for Parents of Children Previously Treated for Cancer: Participatory Action Research Approach.

BACKGROUND: Parenting a child through cancer is a distressing experience, and a subgroup of parents report negative long-term psychological consequences years after treatment completion. However, there is a lack of evidence-based psychological interventions for parents who experience distress in relation to a child's cancer disease after end of treatment. OBJECTIVE: One aim of this study was to develop an internet-administered, cognitive behavior therapy-based, psychological, guided, self-help intervention (ENGAGE) for parents of children previously treated for cancer. Another aim was to identify acceptable procedures for future feasibility and efficacy studies testing and evaluating the intervention. METHODS: Participatory action research methodology was used. The study included face-to-face workshops and related Web-based exercises. A total of 6 parents (4 mothers, 2 fathers) of children previously treated for cancer were involved as parent research partners. Moreover, 2 clinical psychologists were involved as expert research partners. Research partners and research group members worked collaboratively throughout the study. Data were analyzed iteratively using written summaries of the workshops and Web-based exercises parallel to data collection. RESULTS: A 10-week, internet-administered, cognitive behavior therapy-based, psychological, guided, self-help intervention (ENGAGE) was developed in collaboration with parent research partners and expert research partners. The content of the intervention, mode and frequency of e-therapist support, and the individualized approach for feedback were modified based on the research partner input. Shared solutions were reached regarding the type and timing of support from an e-therapist (eg, initial video or telephone call, multiple methods of e-therapist contact), duration and timing of intervention (eg, 10 weeks, 30-min assessments), and the removal of unnecessary support functions (eg, removal of chat and forum functions). Preferences for study procedures in future studies testing and evaluating the intervention were discussed; consensus was not reached for all aspects. CONCLUSIONS: To the best of our knowledge, this study is the first use of a participatory action research approach to develop a psychological intervention for parents of children previously treated for cancer and to identify acceptable study procedures. Involvement of parents with lived experience was vital in the development of a potentially relevant and acceptable intervention for this population.

Trajectories of 12-Month Usage Patterns for Two Smoking Cessation Websites: Exploring How Users Engage Over Time.

BACKGROUND: Little is known about how individuals engage with electronic health (eHealth) interventions over time and whether this engagement predicts health outcomes. OBJECTIVE: The objectives of this study, by using the example of a specific type of eHealth intervention (ie, websites for smoking cessation), were to determine (1) distinct groups of log-in trajectories over a 12-month period, (2) their association with smoking cessation, and (3) baseline user characteristics that predict trajectory group membership. METHODS: We conducted a functional clustering analysis of 365 consecutive days of log-in data from both arms of a large (N=2637) randomized trial of 2 website interventions for smoking cessation (WebQuit and Smokefree), with a primary outcome of 30-day point prevalence smoking abstinence at 12 months. We conducted analyses for each website separately. RESULTS: A total of 3 distinct trajectory groups emerged for each website. For WebQuit, participants were clustered into 3 groups: 1-week users (682/1240, 55.00% of the sample), 5-week users (399/1240, 32.18%), and 52-week users (159/1240, 12.82%). Compared with the 1-week users, the 5- and 52-week users had 57% higher odds (odds ratio [OR] 1.57, 95% CI 1.13-2.17; P=.007) and 124% higher odds (OR 2.24, 95% CI 1.45-3.43; P<.001), respectively, of being abstinent at 12 months. Smokefree users were clustered into 3 groups: 1-week users (645/1309, 49.27% of the sample), 4-week users (395/1309, 30.18%), and 5-week users (269/1309, 20.55%). Compared with the 1-week users, 5-week users (but not 4-week users; P=.99) had 48% higher odds (OR 1.48, 95% CI 1.05-2.07; P=.02) of being abstinent at 12 months. In general, the WebQuit intervention had a greater number of weekly log-ins within each of the 3 trajectory groups as compared with those of the Smokefree intervention. Baseline characteristics associated with trajectory group membership varied between websites. CONCLUSIONS: Patterns of 1-, 4-, and 5-week usage of websites may be common for how people engage in eHealth interventions. The 5-week usage of either website, and 52-week usage only of WebQuit, predicted a higher odds of quitting smoking. Strategies to increase eHealth intervention engagement for 4 more weeks (ie, from 1 week to 5 weeks) could be highly cost effective. TRIAL REGISTRATION: ClinicalTrials.gov NCT01812278; https://www.clinicaltrials.gov/ct2/show/NCT01812278 (Archived by WebCite at http://www.webcitation.org/6yPO2OIKR).

Rapid and Accurate Behavioral Health Diagnostic Screening: Initial Validation Study of a Web-Based, Self-Report Tool (the SAGE-SR).

BACKGROUND: The Structured Clinical Interview for DSM (SCID) is considered the gold standard assessment for accurate, reliable psychiatric diagnoses; however, because of its length, complexity, and training required, the SCID is rarely used outside of research. OBJECTIVE: This paper aims to describe the development and initial validation of a Web-based, self-report screening instrument (the Screening Assessment for Guiding Evaluation-Self-Report, SAGE-SR) based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the SCID-5-Clinician Version (CV) intended to make accurate, broad-based behavioral health diagnostic screening more accessible within clinical care. METHODS: First, study staff drafted approximately 1200 self-report items representing individual granular symptoms in the diagnostic criteria for the 8 primary SCID-CV modules. An expert panel iteratively reviewed, critiqued, and revised items. The resulting items were iteratively administered and revised through 3 rounds of cognitive interviewing with community mental health center participants. In the first 2 rounds, the SCID was also administered to participants to directly compare their Likert self-report and SCID responses. A second expert panel evaluated the final pool of items from cognitive interviewing and criteria in the DSM-5 to construct the SAGE-SR, a computerized adaptive instrument that uses branching logic from a screener section to administer appropriate follow-up questions to refine the differential diagnoses. The SAGE-SR was administered to healthy controls and outpatient mental health clinic clients to assess test duration and test-retest reliability. Cutoff scores for screening into follow-up diagnostic sections and criteria for inclusion of diagnoses in the differential diagnosis were evaluated. RESULTS: The expert panel reduced the initial 1200 test items to 664 items that panel members agreed collectively represented the SCID items from the 8 targeted modules and DSM criteria for the covered diagnoses. These 664 items were iteratively submitted to 3 rounds of cognitive interviewing with 50 community mental health center participants; the expert panel reviewed session summaries and agreed on a final set of 661 clear and concise self-report items representing the desired criteria in the DSM-5. The SAGE-SR constructed from this item pool took an average of 14 min to complete in a nonclinical sample versus 24 min in a clinical sample. Responses to individual items can be combined to generate DSM criteria endorsements and differential diagnoses, as well as provide indices of individual symptom severity. Preliminary measures of test-retest reliability in a small, nonclinical sample were promising, with good to excellent reliability for screener items in 11 of 13 diagnostic screening modules (intraclass correlation coefficient [ICC] or kappa coefficients ranging from .60 to .90), with mania achieving fair test-retest reliability (ICC=.50) and other substance use endorsed too infrequently for analysis. CONCLUSIONS: The SAGE-SR is a computerized adaptive self-report instrument designed to provide rigorous differential diagnostic information to clinicians.

Scope, Breadth, and Differences in Online Physician Ratings Related to Geography, Specialty, and Year: Observational Retrospective Study.

BACKGROUND: Physician ratings websites have emerged as a novel forum for consumers to comment on their health care experiences. Little is known about such ratings in Canada. OBJECTIVE: We investigated the scope and trends for specialty, geographic region, and time for online physician ratings in Canada using a national data source from the country's leading physician-rating website. METHODS: This observational retrospective study used online ratings data from Canadian physicians (January 2005-September 2013; N=640,603). For specialty, province, and year of rating, we assessed whether physicians were likely to be rated favorably by using the proportion of ratings greater than the overall median rating. RESULTS: In total, 57,412 unique physicians had 640,603 individual ratings. Overall, ratings were positive (mean 3.9, SD 1.3). On average, each physician had 11.2 (SD 10.1) ratings. By comparing specialties with Canadian Institute of Health Information physician population numbers over our study period, we inferred that certain specialties (obstetrics and gynecology, family practice, surgery, and dermatology) were more commonly rated, whereas others (pathology, radiology, genetics, and anesthesia) were less represented. Ratings varied by specialty; cardiac surgery, nephrology, genetics, and radiology were more likely to be rated in the top 50th percentile, whereas addiction medicine, dermatology, neurology, and psychiatry were more often rated in the lower 50th percentile of ratings. Regarding geographic practice location, ratings were more likely to be favorable for physicians practicing in eastern provinces compared with western and central Canada. Regarding year, the absolute number of ratings peaked in 2007 before stabilizing and decreasing by 2013. Moreover, ratings were most likely to be positive in 2007 and again in 2013. CONCLUSIONS: Physician-rating websites are a relatively novel source of provider-level patient satisfaction and are a valuable source of the patient experience. It is important to understand the breadth and scope of such ratings, particularly regarding specialty, geographic practice location, and changes over time.

Information Architecture of Web-Based Interventions to Improve Health Outcomes: Systematic Review.

BACKGROUND: The rise in usage of and access to new technologies in recent years has led to a growth in digital health behavior change interventions. As the shift to digital platforms continues to grow, it is increasingly important to consider how the field of information architecture (IA) can inform the development of digital health interventions. IA is the way in which digital content is organized and displayed, which strongly impacts users' ability to find and use content. While many information architecture best practices exist, there is a lack of empirical evidence on the role it plays in influencing behavior change and health outcomes. OBJECTIVE: Our aim was to conduct a systematic review synthesizing the existing literature on website information architecture and its effect on health outcomes, behavioral outcomes, and website engagement. METHODS: To identify all existing information architecture and health behavior literature, we searched articles published in English in the following databases (no date restrictions imposed): ACM Digital Library, CINAHL, Cochrane Library, Google Scholar, Ebsco, and PubMed. The search terms used included information terms (eg, information architecture, interaction design, persuasive design), behavior terms (eg, health behavior, behavioral intervention, ehealth), and health terms (eg, smoking, physical activity, diabetes). The search results were reviewed to determine if they met the inclusion and exclusion criteria created to identify empirical research that studied the effect of IA on health outcomes, behavioral outcomes, or website engagement. Articles that met inclusion criteria were assessed for study quality. Then, data from the articles were extracted using a priori categories established by 3 reviewers. However, the limited health outcome data gathered from the studies precluded a meta-analysis. RESULTS: The initial literature search yielded 685 results, which was narrowed down to three publications that examined the effect of information architecture on health outcomes, behavioral outcomes, or website engagement. One publication studied the isolated impact of information architecture on outcomes of interest (ie, website use and engagement; health-related knowledge, attitudes, and beliefs; and health behaviors), while the other two publications studied the impact of information architecture, website features (eg, interactivity, email prompts, and forums), and tailored content on these outcomes. The paper that investigated IA exclusively found that a tunnel IA improved site engagement and behavior knowledge, but it decreased users' perceived efficiency. The first study that did not isolate IA found that the enhanced site condition improved site usage but not the amount of content viewed. The second study that did not isolate IA found that a tailored site condition improved site usage, behavior knowledge, and some behavior outcomes. CONCLUSIONS: No clear conclusion can be made about the relationship between IA and health outcomes, given limited evidence in the peer-reviewed literature connecting IA to behavioral outcomes and website engagement. Only one study reviewed solely manipulated IA, and we therefore recommend improving the scientific evidence base such that additional empirical studies investigate the impact of IA in isolation. Moreover, information from the gray literature and expert opinion might be identified and added to the evidence base, in order to lay the groundwork for hypothesis generation to improve empirical evidence on information architecture and health and behavior outcomes.

Evolution of Electronic Cigarette Brands From 2013-2014 to 2016-2017: Analysis of Brand Websites.

BACKGROUND: The electronic cigarette (e-cigarette) industry has grown in size and organizational complexity in recent years, most notably with the entry of major tobacco companies in 2012 and the proliferation of vape shops. Many brands maintain retail websites that present e-cigarette marketing claims and sell directly to consumers. Understanding of the evolving composition of different types of e-cigarette brand websites is currently underdeveloped. OBJECTIVE: This paper presents how e-cigarette brand websites surveyed in 2013-2014 evolved by 2016-2017, and how the websites run by different types of e-cigarette producers currently differ. METHODS: In 2016-2017, we revisited 466 e-cigarette brand websites surveyed in 2013-2014, 288 of which were extant, and identified 145 new English-language websites. We compared product designs, marketing claims, and age-based warnings presented by types of e-cigarette producers: major tobacco companies, independent vape shops, and independent internet-only companies. RESULTS: Among the 433 websites examined in 2016-2017, 12 were owned by major tobacco companies, 162 operated a physical vape shop, and 259 were internet-only operations. Closed-system product designs were sold by 83% (10/12) of tobacco-owned brands. In comparison, 29.0% (47/162, P<.001) of vape shop and 55.2% (143/259, P=.06) of internet-only brands sold closed-system designs. Compared with vape shop and internet-only brands, tobacco-owned brands offered a smaller set of product models (P values <.001) and a narrower range of flavors (P values <.01), with greater emphasis on the traditional combustible cigarette flavors of tobacco and menthol (P values <.001). Tobacco-owned brands also offered a narrower range of nicotine options than the vape shops (P=.002) and were less likely to offer nicotine-free e-liquid compared with internet-only and vape shop brands (P values <.001). Finally, 83% (10/12) of tobacco-owned brand websites featured age verification pop-up windows. In comparison, only 50.2% (130/259) of internet-only brands (P=.01) and 60.5% (98/162) of vape shop brands (P=.06) featured age verification windows. Websites surveyed in both 2013-2014 and 2016-2017 became more likely to sell open-system mods (P<.001) and sold an increased number of product models (P<.001), flavors (P<.001), and nicotine options (P<.001). Prevalence of several types of claims decreased significantly, including indirect claims regarding smoking cessation (P<.001), claims regarding e-cigarettes as healthier (P<.001), less expensive (P<.001), and usable in more places (P<.001) compared with combustible cigarettes. CONCLUSIONS: The number of e-cigarette brands has not appeared to increase since 2014, even as website messaging evolved, with brands owned by tobacco companies and vape shops pulling in opposite directions. Brands owned by tobacco companies offered a limited range of e-cigarette products, whereas brands owned by vape shops emphasized a panoply of flavor and nicotine options. Furthermore, the Food and Drug Administration's regulatory action may influence the types of e-cigarette products offered and the market shares of various companies.

Implementation of Digital Awareness Strategies to Engage Patients and Providers in a Lung Cancer Screening Program: Retrospective Study.

BACKGROUND: Lung cancer is the leading cause of cancer-related deaths in the United States. Despite mandated insurance coverage for eligible patients, lung cancer screening rates remain low. Digital platforms, including social media, provide a potentially valuable tool to enhance health promotion and patient engagement related to lung cancer screening (LCS). OBJECTIVE: The aim was to assess the effectiveness of LCS digital awareness campaigns on utilization of low-dose computed tomography (LDCT) and visits to institutional online educational content. METHODS: A pay-per-click campaign utilizing Google and Facebook targeted adults aged 55 years and older and caregivers aged 18 years and older (eg, spouses, adult children) with LCS content during a 20-week intervention period from May to September 2016. A concurrent pay-per-click campaign using LinkedIn and Twitter targeted health care providers with LCS content. Geographic target radius was within 60 miles of an academic medical center. Social media data included aggregate demographics and click-through rates (CTRs). Primary outcome measures were visits to institutional Web pages and scheduled LDCT exams. Study period was 20 weeks before, during, and after the digital awareness campaigns. RESULTS: Weekly visits to the institutional LCS Web pages were significantly higher during the digital awareness campaigns compared to the 20-week period prior to implementation (mean 823.9, SD 905.8 vs mean 51, SD 22.3, P=.001). The patient digital awareness campaign surpassed industry standard CTRs on Google (5.85%, 1108/18,955 vs 1.8%) and Facebook (2.59%, 47,750/1,846,070 vs 0.8%). The provider digital awareness campaign surpassed industry standard CTR on LinkedIn (1.1%, 630/57,079 vs 0.3%) but not Twitter (0.19%, 1139/587,133 vs 0.25%). Mean scheduled LDCT exam volumes per week before, during, and after the digital awareness campaigns were 17.4 (SD 7.5), 20.4 (SD 5.4), and 26.2 (SD 6.4), respectively, with the difference between the mean number of scheduled exams after the digital awareness campaigns and the number of exams scheduled before and after the digital awareness campaigns being statistically significant (P<.001). CONCLUSIONS: Implementation of the LCS digital awareness campaigns was associated with increased visits to institutional educational Web pages and scheduled LDCT exams. Digital platforms are an important tool to enhance health promotion activities and engagement with patients and providers.

Patient-Reported Measures for Person-Centered Coordinated Care: A Comparative Domain Map and Web-Based Compendium for Supporting Policy Development and Implementation.

BACKGROUND: Patient-reported measure (PRM) questionnaires were originally used in research to measure outcomes of intervention studies. They have now evolved into a diverse family of tools measuring a range of constructs including quality of life and experiences of care. Current health and social care policy increasingly advocates their use for embedding the patient voice into service redesign through new models of care such as person-centered coordinated care (P3C). If chosen carefully and used efficiently, these tools can help improve care delivery through a variety of novel ways, including system-level feedback for health care management and commissioning. Support and guidance on how to use these tools would be critical to achieve these goals. OBJECTIVE: The objective of this study was to develop evidence-based guidance and support for the use of P3C-PRMs in health and social care policy through identification of PRMs that can be used to enhance the development of P3C, mapping P3C-PRMs against an existing model of domains of P3C, and integration and organization of the information in a user-friendly Web-based database. METHODS: A pragmatic approach was used for the systematic identification of candidate P3C-PRMs, which aimed at balancing comprehensiveness and feasibility. This utilized a number of resources, including existing compendiums, peer-reviewed and gray literature (using a flexible search strategy), and stakeholder engagement (which included guidance for relevant clinical areas). A subset of those candidate measures (meeting prespecified eligibility criteria) was then mapped against a theoretical model of P3C, facilitating classification of the construct being measured and the subsequent generation of shortlists for generic P3C measures, specific aspects of P3C (eg, communication or decision making), and condition-specific measures (eg, diabetes, cancer) in priority areas, as highlighted by stakeholders. RESULTS: In total, 328 P3C-PRMs were identified, which were used to populate a freely available Web-based database. Of these, 63 P3C-PRMs met the eligibility criteria for shortlisting and were classified according to their measurement constructs and mapped against the theoretical P3C model. We identified tools with the best coverage of P3C, thereby providing evidence of their content validity as outcome measures for new models of care. Transitions and medications were 2 areas currently poorly covered by existing measures. All the information is currently available at a user-friendly web-based portal (p3c.org.uk), which includes all relevant information on each measure, such as the constructs targeted and links to relevant literature, in addition to shortlists according to relevant constructs. CONCLUSIONS: A detailed compendium of P3C-PRMs has been developed using a pragmatic systematic approach supported by stakeholder engagement. Our user-friendly suite of tools is designed to act as a portal to the world of PRMs for P3C, and have utility for a broad audience, including (but not limited to) health care commissioners, managers, and researchers.

Perceived Threat and Internet Use Predict Intentions to Get Bowel Cancer Screening (Colonoscopy): Longitudinal Questionnaire Study.

BACKGROUND: Many people use the Internet for health-related information search, which is known to help regulate their emotional state. However, not much is known yet about how Web-based information search together with negative emotional states (ie, threat of cancer diagnosis) relate to preventive medical treatment decisions (ie, colonoscopy intentions). OBJECTIVE: The aim of this study was to investigate how frequency of health-related Internet use together with perceived threat of a possible (bowel) cancer diagnosis influences intentions to get a colonoscopy. Previous research has shown that people who experience threat preferentially process positive information in an attempt to downregulate the aversive emotional state. The Internet can facilitate this regulatory strategy through allowing self-directed, unrestricted, and thus biased information search. In the context of threat regarding a possible bowel cancer diagnosis, feelings of threat can still be effectively reduced through cancer screening (ie, colonoscopy). We, therefore, predict that in that particular context, feelings of threat should be related to stronger colonoscopy intentions, and that this relationship should be enhanced for people who use the Internet often. METHODS: A longitudinal questionnaire study was conducted among healthy participants who were approaching or just entering the bowel cancer risk group (aged 45-55 years). Perceived threat of a possible (bowel) cancer diagnosis, frequency of health-related Internet use, and intentions to have a colonoscopy were assessed at 2 time points (6-month time lag between the 2 measurement points T1 and T2). Multiple regression analyses were conducted to test whether threat and Internet use at T1 together predicted colonoscopy intentions at T2. RESULTS: In line with our predictions, we found that the threat of a possible (bowel) cancer diagnosis interacted with the frequency of Internet use (both T1) to predict colonoscopy intentions (T2; B=.23, standard error [SE]=0.09, P=.01). For people who used the Internet relatively often (+1 SD), the positive relationship between threat and colonoscopy intentions was significantly stronger (B=.56, SE=0.15, P<.001) compared with participants who used the Internet less often (-1 SD; B=.17, SE=0.09, P=.07). This relationship was unique to Web-based (vs other types of) information search and independent of risk factors (eg, body mass index [BMI] and smoking). CONCLUSIONS: The results of this study suggest that health-related Internet use can facilitate emotion-regulatory processes. People who feel threatened by a possible (bowel) cancer diagnosis reported stronger colonoscopy intentions, especially when they used the Internet often. We propose that this is because people who experience threat are more likely to search for and process information that allows them to downregulate their aversive emotional state. In the present case of (bowel) cancer prevention, the most effective way to reduce threat is to get screened.

Ecuadorian Cancer Patients' Preference for Information and Communication Technologies: Cross-Sectional Study.

BACKGROUND: The instantaneous spread of information, low costs, and broad availability of information and communication technologies (ICTs) make them an attractive platform for managing care, patient communication, and medical interventions in cancer treatment. There is little information available in Latin America about the level of usage of ICTs for and by cancer patients. Our study attempts to fill this gap. OBJECTIVE: The aim of this study was to assess the level of ICT use and patterns of preferences among cancer patients. METHODS: We conducted an anonymous cross-sectional survey study in 500 Ecuadorian cancer patients. This questionnaire consisted of 22 items about demographic and clinical data, together with the preferences of people who use ICTs. Chi-square, crude, and adjusted logistic regressions were performed. RESULTS: Of the total, 43.2% (216/500) of participants reported that they had access to the Internet, and 25.4% (127/500) reported that they neither owned a cell phone nor did they have access to the Internet. The Internet constituted the highest usage rate as a source of information about malignant diseases (74.3%, 162/218) regardless of age (P<.001). With regard to the preferences on how patients would like to use ICTs to receive information about diseases, WhatsApp (66.5%, 145/218) and short message service (SMS) text messaging (61.0%, 133/218) were widely reported as interesting communication channels. Similarly, WhatsApp (72.0%, 157/218) followed by SMS (63.8%, 139/218) were reported as the preferred ICTs through which patients would like to ask physicians about diseases. Adjusted regression analysis showed that patients aged between 40 and 64 years were more likely to be interested in receiving information through SMS (odds ratio, OR 5.09, 95% CI 1.92-13.32), as well as for asking questions to physicians through this same media (OR 9.78, CI 3.45-27.67) than the oldest group. CONCLUSIONS: WhatsApp, SMS, and email are effective and widely used ICTs that can promote communication between cancer patients and physicians. According to age range, new ICTs such as Facebook are still emerging. Future studies should investigate how to develop and promote ICT-based resources more effectively to engage the outcomes of cancer patients. The widespread use of ICTs narrows the gap between cancer patients with restricted socioeconomic conditions and those with wealth and easily available technological means, thereby opening up new possibilities in low-income countries.

Leveraging Social Networking Sites for an Autoimmune Hepatitis Genetic Repository: Pilot Study to Evaluate Feasibility.

BACKGROUND: Conventional approaches to participant recruitment are often inadequate in rare disease investigation. Social networking sites such as Facebook may provide a vehicle to circumvent common research limitations and pitfalls. We report our preliminary experience with Facebook-based methodology for participant recruitment and participation into an ongoing study of autoimmune hepatitis (AIH). OBJECTIVE: The goal of our research was to conduct a pilot study to assess whether a Facebook-based methodology is capable of recruiting geographically widespread participants into AIH patient-oriented research and obtaining quality phenotypic data. METHODS: We established a Facebook community, the Autoimmune Hepatitis Research Network (AHRN), in 2014 to provide a secure and reputable distillation of current literature and AIH research opportunities. Quarterly advertisements for our ongoing observational AIH study were posted on the AHRN over 2 years. Interested and self-reported AIH participants were subsequently enrolled after review of study materials and completion of an informed consent by our study coordinator. Participants returned completed study materials, including epidemiologic questionnaires and genetic material, to our facility via mail. Outside medical records were obtained and reviewed by a study physician. RESULTS: We successfully obtained all study materials from 29 participants with self-reported AIH within 2 years from 20 different states. Liver biopsy results were available for 90% (26/29) of participants, of which 81% (21/29) had findings consistent with AIH, 15% (4/29) were suggestive of AIH with features of primary biliary cholangitis (PBC), and 4% (1/29) had PBC alone. A total of 83% (24/29) had at least 2 of 3 proposed criteria: positive autoimmune markers, consistent histologic findings of AIH on liver biopsy, and reported treatment with immunosuppressant medications. Self-reported and physician records were discrepant for immunosuppressant medications or for AIH/PBC diagnoses in 4 patients. CONCLUSIONS: Facebook can be an effective ancillary tool for facilitating patient-oriented research in rare diseases. A social media-based approach transcends established limitations in rare disease research and can further develop research communities.