The Triple E project: a factorial randomised controlled trial to enhance engagement with eHealth approaches to improve health risk behaviours among adolescents.

BACKGROUND: Digital, or eHealth, interventions are highly promising approaches to help adolescents improve their health behaviours and reduce their risk of chronic disease. However, they often have low uptake and retention. There is also a paucity of high-quality research into the predictors of eHealth engagement, and a lack of studies that have systematically evaluated existing engagement strategies in adolescent populations. This paper describes the protocol for a randomised controlled trial which primarily aims to assess the effectiveness of different strategies in increasing engagement with a healthy lifestyles app, Health4Life. Associations between the engagement strategies and improvements in adolescent health behaviours (healthy eating, physical activity, sleep, recreational screen time, smoking, alcohol use) will also be examined, along with potential predictors of adolescents' intentions to use health apps and their use of the Health4Life app. METHODS: The current study will aim to recruit 336 adolescent and parent/guardian dyads (total sample N = 672) primarily through Australia wide online advertising. All adolescent participants will have access to the Health4Life app (a multiple health behaviour change, self-monitoring mobile app). The trial will employ a 24 factorial design, where participants will be randomly allocated to receive 1 of 16 different combinations of the four engagement strategies to be evaluated: text messages, access to a health coach, access to additional gamified app content, and provision of parent/guardian information resources. Adolescents and parents/guardians will both complete consent processes, baseline assessments, and a follow-up assessment after 3 months. All participants will also be invited to complete a qualitative interview shortly after follow-up. The primary outcome, app engagement, will be assessed via an App Engagement Index (Ei) using data collected in the Health4Life app and the Mobile App Rating Scale - User version. DISCUSSION: This research will contribute significantly to building our understanding of the types of strategies that are most effective in increasing adolescents' engagement with health apps and which factors may predict adolescents' use of health apps. TRIAL REGISTRATION: The trial is registered at the Australian New Zealand Clinical Trials Registry (ACTRN12623000399695). Date registered: 19/04/2023.

Retrospective analysis of regional and metropolitan school food environments using Google Street View: A case study in New South Wales, Australia with youth consultation.

ISSUE ADDRESSED: Food environments surrounding schools have a strong influence on the adolescent's food choices. Moreover, the prevalence of diet-related chronic diseases is higher in regional than metropolitan areas in Australia. Understanding school food environments in these different settings is crucial for informing future strategies to improve adolescent health. METHODS: Google Street View was used to identify food outlets within 1.6 km around all secondary schools in Wagga Wagga and Blacktown in New South Wales which were selected as regional and metropolitan case study areas. Based on food outlet type, healthfulness categories were assigned, and Chi-squared tests were performed. The Health Advisory Panel for Youth at the University of Sydney (HAPYUS) were engaged to obtain their perspectives on findings. RESULTS: Unhealthful food outlets were consistently most prevalent around schools in Wagga Wagga and Blacktown over 17 years. In 2023, these were predominantly restaurants (19.4% vs. 21.1%), cafés (16.8% vs. 11.1%), fast-food franchise outlets (15.1% vs. 17.4%) and independent takeaway stores (14.1% vs. 9.6%). No significant difference in healthfulness between regional and metropolitan areas was found. Youth advisors recognised price and social reasons as major contributors to food choices. CONCLUSIONS: Google Street View was used as a novel resource to examine school food environments in regional and metropolitan areas which have remained consistently unhealthful for nearly two decades. SO WHAT?: Unhealthful school food environments may encourage poor diets and exacerbate rates of adolescent overweight and obesity. Critical government action is needed to improve school food environments.

Addressing disparities: A systematic review of digital health equity for adolescent obesity prevention and management interventions.

Adolescence is a high-risk life stage for obesity. Digital strategies are needed to prevent and manage obesity among adolescents. We assessed if digital health interventions are contributing to disparities in obesity outcomes and assessed the adequacy of reporting of digital health equity criteria across four levels of influence within the digital environment. The systematic search was conducted on 10 major electronic databases and limited to randomized controlled trials (RCTs) or cluster-RCTs for prevention or management of obesity among 10-19 year olds. Primary outcome was mean body mass index (BMI), or BMI z-score change. The Adapted Digital Health Equity Assessment Framework was applied to all studies. Thirty-three articles (27 unique studies with 8483 participants) were identified, with only eight studies targeting adolescents from disadvantaged populations. Post-intervention, only three studies reported significantly lower BMI outcomes in the intervention compared to control. Of the 432 digital health equity criteria assessed across 27 studies, 82% of criteria were "not addressed." Studies are not addressing digital health equity criteria or inadequately reporting information to assess if digital health interventions are contributing to disparities in obesity outcomes. Enhanced reporting is needed to inform decision-makers and support the development of equitable interventions to prevent and manage obesity among adolescents.

Facilitators and barriers to healthful eating among adolescents in high-income countries: A mixed-methods systematic review.

Adolescent obesity continues to be a public health challenge with poor quality diets contributing to its etiology. As part of the process to plan health promotion and policy interventions, understanding adolescents perceived facilitators and barriers to healthful eating is important. An integrative convergent mixed-methods systematic review was used to synthesize qualitative and quantitative evidence from studies among adolescents aged 10-19 years in high-income countries. Medline, Embase, PsycInfo, and Scopus were searched for peer-reviewed articles published between 2010 and 2023 and exploring adolescents' perspectives on healthful eating and contemporary contextual factors. Transformed quantitative data were integrated with qualitative data. Text was coded into subthemes and themes using an inductive approach. Key facilitators included health and physical appearance; motivation; taste; nutrition knowledge, awareness, and skills; nutrition education access; availability and accessibility of healthful foods; family; and social influences and digital media. Key barriers included taste and cravings for unhealthful foods; mood; lack of motivation, awareness, knowledge, and skills; high availability and low cost of unhealthful foods; peers and social influences; ineffective school policies; high density of fast-food outlets; unhealthful food advertising; digital influences; and time constraints. Social, behavioral, digital, and food environmental factors should be considered from an adolescent perspective in the design of education, health promotion, and policy interventions.

Developing the DIGIFOOD Dashboard to Monitor the Digitalization of Local Food Environments: Interdisciplinary Approach.

BACKGROUND: Online food delivery services (OFDS) enable individuals to conveniently access foods from any deliverable location. The increased accessibility to foods may have implications on the consumption of healthful or unhealthful foods. Concerningly, previous research suggests that OFDS offer an abundance of energy-dense and nutrient-poor foods, which are heavily promoted through deals or discounts. OBJECTIVE: In this paper, we describe the development of the DIGIFOOD dashboard to monitor the digitalization of local food environments in New South Wales, Australia, resulting from the proliferation of OFDS. METHODS: Together with a team of data scientists, we designed a purpose-built dashboard using Microsoft Power BI. The development process involved three main stages: (1) data acquisition of food outlets via web scraping, (2) data cleaning and processing, and (3) visualization of food outlets on the dashboard. We also describe the categorization process of food outlets to characterize the healthfulness of local, online, and hybrid food environments. These categories included takeaway franchises, independent takeaways, independent restaurants and cafes, supermarkets or groceries, bakeries, alcohol retailers, convenience stores, and sandwich or salad shops. RESULTS: To date, the DIGIFOOD dashboard has mapped 36,967 unique local food outlets (locally accessible and scraped from Google Maps) and 16,158 unique online food outlets (accessible online and scraped from Uber Eats) across New South Wales, Australia. In 2023, the market-leading OFDS operated in 1061 unique suburbs or localities in New South Wales. The Sydney-Parramatta region, a major urban area in New South Wales accounting for 28 postcodes, recorded the highest number of online food outlets (n=4221). In contrast, the Far West and Orana region, a rural area in New South Wales with only 2 postcodes, recorded the lowest number of food outlets accessible online (n=7). Urban areas appeared to have the greatest increase in total food outlets accessible via online food delivery. In both local and online food environments, it was evident that independent restaurants and cafes comprised the largest proportion of food outlets at 47.2% (17,437/36,967) and 51.8% (8369/16,158), respectively. However, compared to local food environments, the online food environment has relatively more takeaway franchises (2734/16,158, 16.9% compared to 3273/36,967, 8.9%) and independent takeaway outlets (2416/16,158, 14.9% compared to 4026/36,967, 10.9%). CONCLUSIONS: The DIGIFOOD dashboard leverages the current rich data landscape to display and contrast the availability and healthfulness of food outlets that are locally accessible versus accessible online. The DIGIFOOD dashboard can be a useful monitoring tool for the evolving digital food environment at a regional scale and has the potential to be scaled up at a national level. Future iterations of the dashboard, including data from additional prominent OFDS, can be used by policy makers to identify high-priority areas with limited access to healthful foods both online and locally.

Exploring reasons for high levels of food insecurity and low fruit and vegetable consumption among university students post-COVID-19.

High rates of food insecurity and low consumption of fruit and vegetables among university students have been observed prior to the COVID-19 pandemic and intensified during the pandemic. This study aimed to investigate food insecurity among university students and its associations with sociodemographic factors, fruit and vegetable consumption behaviours, and preferred campus programs to address these issues. A convenience sample of 237 Australian university students completed a cross-sectional online survey from October to December 2022. Food insecurity was assessed using the 10-item US Adult Food Security Module, applying the Canadian classification scheme. Sociodemographic variables, fruit and vegetable consumption behaviours, and perceptions of fruit and vegetable access and their affordability were included in the survey. Students were also asked to select the most suitable program(s) and provide reasons for their choice using open-ended questions. Approximately half of respondents (46.4%) were identified as food insecure. The proportion of students meeting the recommended intake of vegetables as specified in the Australian Dietary Guidelines was very low (5.1%) compared with fruit (46.2%). Low fruit consumption was significantly associated with food insecurity (OR = 1.81; 95%CI 1.03, 3.18, p = 0.038). Factors such as the perceived lower accessibility and higher price of fruit and vegetables were significantly associated with higher odds of food insecurity. In terms of potential programs, a free fruit and vegetable campaign was the most popular program, with affordability and physical access being the most frequently cited reasons. These findings suggest that food insecurity is associated with low fruit and vegetable consumption in university students. Therefore, transforming campus food environments and developing food policies at the university level must be considered to address food and nutrition security in university students.

"What concerns me or what is most interesting to me": A qualitative study about what influences adolescent engagement with public health issues.

ISSUES ADDRESSED: Promoting public health messages in adolescence may influence future health outcomes. A better understanding of what influences adolescent engagement with public health issues is needed. METHODS: Adolescents aged 13-19 years from New South Wales, Australia, were recruited via study advertisements to participate in an online focus group. All provided informed consent and completed a short survey including demographics and selection of leading public health issues of concern. Participants attended a 75-90 min focus group conducted through Zoom teleconference that explored top public health issues of concern to participants, and barriers/enablers to engage with these issues. Qualitative data was thematically analysed using NVivo. A working group reached consensus on final themes. RESULTS: Out of 18 participants (mean 15.4 [SD: 2.2] years; 50% female), most attended high school (83%), spoke predominantly English at home (89%), and resided in metropolitan areas (94%). The top public health issues of concern selected were mental health (56%) and the environment/climate change (56%). From the thematic analysis, underlying drivers of adolescent engagement with public health issues included: personal connection to these issues, broader societal impact, and exposure to public health issues on digital media. Barriers included feeling unempowered, and a lack of support and opportunities. CONCLUSIONS: This study provides insights on the barriers and enablers of adolescents engaging with public health issues of concern to them. SO WHAT?: Understanding this may help health professionals and researchers to design more influential public health campaigns and interventions, including through co-design processes, which may improve future health outcomes.

The association of diet quality and physical activity with cardiovascular disease and mortality in 85,545 older Australians: A longitudinal study.

BACKGROUND: A quality diet and an active lifestyle are both important cornerstones of cardiovascular disease (CVD) prevention. However, despite their interlinked effects on metabolic health, the 2 behaviors are rarely considered jointly, particularly within the context of CVD prevention. We examined the independent, interactive, and joint associations of diet and physical activity with CVD hospitalization, CVD mortality, and all-cause mortality. METHODS: CVD-free Australian participants aged 45-74 years (n = 85,545) reported physical activity, diet, sociodemographic, and lifestyle characteristics at baseline (2006-2009) and follow-up (2012-2015), and data were linked to hospitalization and death registries (03/31/2019 for CVD hospitalization and all-cause mortality and 12/08/2017 for CVD mortality). Diet quality was categorized as low, medium, and high based on meeting dietary recommendations. Physical activity was operationalized as (a) total moderate-to-vigorous physical activity (MVPA) as per guidelines, and (b) the composition of MVPA as the ratio of vigorous-intensity physical activity (VPA) to total MVPA. We used a left-truncated cause-specific Cox proportional hazards model using time-varying covariates. RESULTS: During a median of 10.7 years of follow-up, 6576 participants were admitted to the hospital for CVD and 6581 died from all causes (876 from CVD during 9.3 years). A high-quality diet was associated with a 17% lower risk of all-cause mortality than a low-quality diet, and the highest MVPA category (compared with the lowest) was associated with a 44% and 48% lower risk of CVD and all-cause mortality, respectively. Multiplicative interactions between diet and physical activity were non-significant. For all outcomes, the lowest risk combinations involved a high-quality diet and the highest MVPA categories. Accounting for total MVPA, some VPA was associated with further risk reduction of CVD hospitalization and all-cause mortality. CONCLUSION: For CVD prevention and longevity, one should adhere to both a healthy diet and an active lifestyle and incorporate some VPA when possible.

Accelerating implementation of adolescent digital health prevention programs: analysis of insights from Australian stakeholders.

Background: Chronic disease risk factors are increasing amongst adolescents, globally. Digital health prevention programs, which provide education and information to reduce chronic disease risk factors need to be equitable and accessible for all. For their success, multiple highly engaged stakeholders should be involved in development and implementation. This study aimed to evaluate stakeholders' support for, and perspectives on potential public health impact of digital health prevention programs for adolescents and potential pathways for future implementation. Methods: Qualitative semi-structured online interviews with stakeholders. Stakeholder mapping identified key individuals, groups and organizations across Australia that may influence the implementation of digital health prevention programs for adolescents. Recorded and transcribed interviews were analyzed within the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) Framework, using deductive content analysis. Findings: Nineteen interviews were conducted in 2023 with stakeholders from government, health, non-government organizations, youth services, education, community settings and others. Four overarching themes were identified: (i) existing digital health initiatives are not fit for purpose; (ii) the co-creation of digital health prevention programs is critical for successful implementation; (iii) digital health prevention programs must address equity and the unique challenges raised by technology and; (iv) system level factors must be addressed. Interpretation: Stakeholders broadly supported digital health prevention programs, yet raised unique insights to ensure that future programs create public health impact by improving chronic disease risk factors among adolescents. These insights can be applied in future development of digital health prevention programs for adolescents to strengthen widespread implementation.

Benchmarking online food delivery applications against menu labelling laws: a cross-sectional observational analysis.

OBJECTIVE: It is unknown how well menu labelling schemes that enforce the display of kilojoule (kJ) labelling at point-of-sale have been implemented on online food delivery (OFD) services in Australia. This study aimed to examine the prevalence of kJ labelling on the online menus of large food outlets with more than twenty locations in the state or fifty locations nationally. A secondary aim was to evaluate the nutritional quality of menu items on OFD from mid-sized outlets that have fewer locations than what is specified in the current scheme. DESIGN: Cross-sectional analysis. Prevalence of kJ labelling by large food outlets on OFD from August to September 2022 was examined. Proportion of discretionary ('junk food') items on menus from mid-sized outlets was assessed. SETTING: Forty-three unique large food outlets on company (e.g. MyMacca's) and third party OFD (Uber Eats, Menulog, Deliveroo) within Sydney, Australia. Ninety-two mid-sized food outlets were analysed. PARTICIPANTS: N/A. RESULTS: On company OFD apps, 35 % (7/23) had complete kJ labelling for each menu item. In comparison, only 4·8 % (2/42), 5·3 % (2/38) and 3·6 % (1/28) of large outlets on Uber Eats, Menulog and Deliveroo had complete kJ labelling at all locations, respectively. Over three-quarters, 76·3 % (345/452) of menu items from mid-sized outlets were classified as discretionary. CONCLUSIONS: Kilojoule labelling was absent or incomplete on a high proportion of online menus. Mid-sized outlets have abundant discretionary choices and yet escape criteria for mandatory menu labelling laws. Our findings show the need to further monitor the implementation of nutrition policies on OFD.

Empowering Young Women: A Qualitative Co-Design Study of a Social Media Health Promotion Programme.

Social media platforms may be promising intervention tools to address the nutrition literacy and associated health behaviours of young women. We aimed to co-design a lifestyle intervention on social media targeting eating, physical activity, and social wellbeing that is evidence-based, acceptable, and engaging for young women aged 18-24 years. The study used a participatory design framework and previously published iterative mixed methods approach to intervention development. Matrices for workshop objectives were constructed using expert discussions and insights were sought from young women in participatory workshops. A 10-step qualitative data analysis process resulted in relevant themes, which guided intervention development. The resulting intervention, the Daily Health Coach, uses multiple features of Instagram to disseminate health information. Co-created nutrition content considers themes such as holism, food relationships, and food neutrality and acknowledges commonly experienced barriers associated with social media use such as nutrition confusion, body image concerns, and harmful comparison. This study may guide other researchers or health professionals seeking to engage young women in the co-design of women's health promotion or intervention content on social media.

Use of online food retail platforms throughout the COVID-19 pandemic and associated diet-related chronic disease risk factors: A systematic review of emerging evidence.

Food accessibility was considerably impacted by restrictions during the coronavirus disease 2019 (COVID-19) pandemic, leading to growth in the online food retail sector, which offered contact-free delivery. This systematic review aimed to assess the change in use of online food retail platforms during COVID-19. The secondary aim was to identify diet-related chronic disease risk factors including dietary intake, eating behaviors, and/or weight status associated with the use of online food retail platforms during the pandemic. The review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42022320498) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Nine electronic databases were searched between January 2020 and October 2023. Studies that reported the frequency or change in use of online groceries, meal delivery applications, and/or meal-kit delivery services before and during the pandemic were included. A total of 53 studies were identified, including 46 cross-sectional studies, 4 qualitative studies, 2 longitudinal cohort studies, and 1 mixed-methods study. Overall, 96% (43/45) of outcomes showed an increase in the use of online groceries during COVID-19, while 55% (22/40) of outcomes showed a decrease in meal delivery applications. Eight of nine outcomes associated the use of online food retail with weight gain and emotional eating. Further research is needed to investigate the links between online food retail and obesity.

Engaging adolescents in chronic disease prevention research: insights from researchers about establishing and facilitating a youth advisory group.

Our comment discusses our experience establishing a youth advisory group focused on chronic disease prevention research. The comment highlights three key learnings: the need for researchers to adapt their working style, the importance of redefining the power dynamics, and disrupting traditional research structures to align with co-researcher engagement models.

In this comment, we share our insights from working with a youth advisory group in adolescent health research. Our comment supports our research paper on co-designing an online health study, "Health4Me." The youth advisors worked with us for a year, during which we also studied leadership and other outcomes.Adolescent health is gaining worldwide attention. Health researchers see the value of working with young people on issues that affect them. To address this need, we formed the Health Advisory Panel for Youth at the University of Sydney. We motivated young people through building new skills and leadership training, rather than only focusing on improved health outcomes or health knowledge.Here are our key lessons as researchers: Flexibility: We changed our approach to support online teamwork with young people, offered payment and worked around their schedules. Changing power dynamics: We empowered young people by engaging them in decisions and involved them in co-authoring papers and presentations. Challenging traditional structures: To support youth- as co-researchers, we used existing sources of funding and offered mentoring. In conclusion, we highlight practical ways of working with a youth advisory group in health research. Our teamwork led to a youth digital health program, published essays, and future research ideas. It is important for researchers to actively involve and support young people in shaping research that affects them.

Determining the feasibility of a codesigned and personalised intervention (Veg4Me) to improve vegetable intake in young adults living in rural Australian communities: protocol for a randomised controlled trial.

INTRODUCTION: Diets low in vegetables are a main contributor to the health burden experienced by young adults in rural communities. Digital health interventions provide an accessible delivery model that can be personalised to meet the diverse preferences of young adults. A personalisable digital vegetable intake intervention (Veg4Me) was codesigned to meet the needs of young adults living in rural communities. This study will determine the feasibility of delivering a personalised Veg4Me programme and compare preliminary effects with a non-personalised Veg4Me (control). METHODS AND ANALYSIS: A 12-week assessor-blinded, two-arm, parallel randomised controlled trial will be undertaken from August 2023 until April 2024. A total of 150 eligible and consenting young adults (18-35 years; eat<5 serves of vegetables/day; have an internet connected mobile device/computer) living in Loddon Campaspe or Colac Otway Shire in Victoria, Australia, will be randomised to receive 12 weeks of personalised (intervention) or non-personalised (control) support to increase vegetable intake via a free web application (app; Veg4Me). The primary outcome is feasibility (recruitment, participation and retention rates). Secondary outcomes are user engagement, usability and experience, as well as vegetable intake, eating habits and digital health equity. Process evaluation will be conducted in a subsample of participants using semistructured interviews. Descriptive statistics will be presented for the personalised and non-personalised groups at baseline and 12 weeks. Generalised linear models will be used to evaluate group differences in outcomes. Interviews will be transcribed and analysed thematically. ETHICS AND DISSEMINATION: All procedures involving human subjects were approved by Deakin University's Human Ethics Advisory Group-Health (HEAG-H 06_2023) on 6 March 2023. Dissemination events will be held in the City of Greater Bendigo and the Colac Otway Shire. Summaries of the results will be disseminated to participants via email. Results will be disseminated to the scientific community through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: Australia New Zealand Clinical Trials Registry, ACTRN12623000179639p, prospectively registered on 21 February 2023, according to the World Health Organizational Trial Registration Data Set. Universal Trial Number U1111-1284-9027.

Co-design of a personalised digital intervention to improve vegetable intake in adults living in Australian rural communities.

BACKGROUND: Diets low in vegetables are a main contributor to the health burden experienced by Australians living in rural communities. Given the ubiquity of smartphones and access to the Internet, digital interventions may offer an accessible delivery model for a dietary intervention in rural communities. However, no digital interventions to address low vegetable intake have been co-designed with adults living in rural areas. This paper describes the co-design of a digital intervention to improve vegetable intake with rural community members and research partners. METHODS: Active participants in the co-design process were adults ≥ 18 years living in three rural Australian communities (total n = 57) and research partners (n = 4) representing three local rural governments and one peak non-government health organisation. An iterative co-design process was undertaken to understand the needs (pre-design phase) and ideas (generative phase) of the target population. Eight online workshops and a community survey were conducted between July and December 2021. The MoSCoW prioritisation method was used to help participants identify the 'Must-have, Should-have, Could-have, and Won't-have or will not have right now' features and functions of the digital intervention. Workshops were transcribed and inductively analysed using NVivo. Convergent and divergent themes were identified between the workshops and community survey to identify how to implement the digital intervention in the community. RESULTS: Consensus was reached on a concept for a digital intervention that addressed individual and food environment barriers to vegetable intake, specific to rural communities. Implementation recommendations centred on (i) food literacy approaches to improve skills via access to vegetable-rich recipes and healthy eating resources, (ii) access to personalisation options and behaviour change support, and (iii) improving the community food environment by providing information on and access to local food initiatives. CONCLUSIONS: Rural-dwelling adults expressed preferences for personalised intervention features that can enhance food literacy and engagement with community food environments. This research will inform the development of the prototyping (evaluation phase) and feasibility testing (post-design phase) of this intervention.

Integrated Text Messaging (ITM) for people attending cardiac and pulmonary rehabilitation: A multicentre randomised controlled trial.

BACKGROUND: People living with cardiac and respiratory disease require improved post-hospital support that is readily available and efficient. OBJECTIVES: To 1) test the effectiveness of an automated, semi-personalised text message support program on clinical and lifestyle outcomes amongst people attending cardiac and pulmonary rehabilitation. Also, 2) to evaluate the program's acceptability and utility using patient-reported outcome and experience measures. METHODS: Multicentre randomised controlled trial (3:1, intervention:control) amongst cardiac and pulmonary rehabilitation attendees. Control received usual care (no message program). Intervention also received a 6-month text message lifestyle and support program. Primary outcome was 6-minute walk distance (6MWD). Secondary outcomes included clinical measures, lifestyle, patient-reported outcome and experience measures, medication adherence and rehabilitation attendance. RESULTS: A total of 316 participants were recruited. They had a mean age of 66.7 (SD 10.1) years. Sixty percent were male (190/316) and 156 were cardiac rehabilitation participants. The cohort's mean baseline 6MWD was higher in the intervention than the control group. At 6 months, 6MWD improved in both groups; it was significantly greater amongst intervention than control participants (unadjusted mean difference of 43.4 m, 95 % CI 4.3 to 82.4; P = 0.0296). After adjustment for baseline values, there was no significant difference between intervention and control groups for 6MWD (adjusted mean difference 2.2 m, -21.2 to 25.6; P = 0·85), medication adherence, or cardiovascular risk factors. At 6-month follow-up, intervention participants reported significantly lower depression scores (adjusted mean difference -1.3, 95 % CI -2.2 to -0.3; P = 0.0124) and CAT scores (adjusted mean difference -3.9, 95 % CI -6.6 to -1.3; P = 0.0038), and significantly lower anxiety (adjusted mean difference -1.1, 95 %CI -2.1 to 0; P = 0.0456). Most participants (86 %) read most of their messages and strongly/agreed that the intervention was easy to understand (99 %) and useful (86 %). CONCLUSIONS: An educational and supportive text message program for cardiac and pulmonary rehabilitation attendees improved anxiety and depression plus program attendance. The program was acceptable to, and useful for, participants and would be suitable for implementation alongside rehabilitation programs. TRIAL REGISTRATION NUMBER: ACTRN12616001167459.

Striking the right balance: co-designing the Health4Me healthy lifestyle digital health intervention with adolescents.

BACKGROUND: Adolescents are navigating a period of rapid growth and development within an era of digitalization. Mobile phone ownership among adolescents is nearly ubiquitous, and this provides an opportunity to harness text messaging to promote a healthy lifestyle and reduce chronic disease risk factors. Inclusion of adolescents throughout the design process has been recognized as essential for engagement and future implementation of such interventions. This study aimed to co-design a bank of text messages to promote a healthy lifestyle which are useful, acceptable, and engaging for adolescents aged 12-18 years old. METHODS: Iterative, mixed-methods design with consumer partnership. Co-design occurred over three stages: text message development, text message review and final refinement and testing. The text message development included literature searches and consumer partnership with an established youth advisory group (n = 16). Participants who gave e-consent participated in text message review. Demographic characteristics were collected, and quantitative surveys were distributed to adolescents (n = up to 50) and health professionals (n = up to 30), who rated text message content for understanding, usefulness and appropriateness (total score out of 15). Final refinement was completed by the research team to edit or remove messages which had low scores and to assess readability and interactivity of the text messages. RESULTS: The Heath Advisory Panel for Youth at the University of Sydney (HAPYUS) identified the top six lifestyle health issues for young people today in relation to chronic disease prevention, which became the key content areas for the text message bank and drafted new text messages. Following text message development, 218 messages were available for review. Adolescents (n = 18, mean age 16.3 [SD 1.4]) and healthcare professionals (n = 16) reviewed the text messages. On average, all reviewers found that the text messages were easy to understand (mean = 13.4/15) and useful (mean = 12.7/15). Based on scoring and open ended-feedback, 91 text messages were edited and 42 deleted. The final text message bank included 131 text messages. The overall program is suitable for a seventh-grade reading level, and interactive. CONCLUSIONS: This study describes the process of effectively engaging adolescents to co-design a text message bank intervention, which are useful, acceptable and engaging for an adolescent audience. The effectiveness of the co-designed text message bank is currently being tested in the Health4Me RCT.

Today's adolescents are growing and developing through a period of increased technology use. Most adolescents have access to a mobile phone which can be used to deliver healthy lifestyle information to them through text messages. However, it is important that researchers engage with adolescents as collaborators to develop any information which may be sent to them, to ensure that it is acceptable and engaging. We aimed to co-design a bank of text messages to promote a healthy lifestyle which are useful, acceptable and engaging for adolescents 12­18 years old. We engaged with 16 adolescents from an established youth advisory group who advised on top health issues they face today in terms of leading a healthy lifestyle, which became key content areas for the text message program. They also drafted text messages around these content areas (218 total). Next, the text messages underwent review with 34 adolescents and healthcare professionals to ensure they were useful, easy to understand and appropriate. After the review, the research team edited, deleted and replaced text messages which did not score well. This resulted in a text message bank to promote a healthy lifestyle with 131 text messages which were useful, acceptable and engaging for adolescents 12­18 years old.