Development of Web-Based Education Modules to Improve Carer Engagement in Cancer Care: Design and User Experience Evaluation of the e-Triadic Oncology (eTRIO) Modules for Clinicians, Patients, and Carers.

BACKGROUND: Carers often assume key roles in cancer care. However, many carers report feeling disempowered and ill-equipped to support patients. Our group published evidence-based guidelines (the Triadic Oncology [TRIO] Guidelines) to improve oncology clinician engagement with carers and the management of challenging situations involving carers. OBJECTIVE: To facilitate implementation of the TRIO Guidelines in clinical practice, we aimed to develop, iteratively refine, and conduct user testing of a suite of evidence-based and interactive web-based education modules for oncology clinicians (e-Triadic Oncology [eTRIO]), patients with cancer, and carers (eTRIO for Patients and Carers [eTRIO-pc]). These were designed to improve carer involvement, communication, and shared decision-making in the cancer management setting. METHODS: The eTRIO education modules were based on extensive research, including systematic reviews, qualitative interviews, and consultation analyses. Guided by the person-based approach, module content and design were reviewed by an expert advisory group comprising academic and clinical experts (n=13) and consumers (n=5); content and design were continuously and iteratively refined. User experience testing (including "think-aloud" interviews and administration of the System Usability Scale [SUS]) of the modules was completed by additional clinicians (n=5), patients (n=3), and carers (n=3). RESULTS: The final clinician module comprises 14 sections, requires approximately 1.5 to 2 hours to complete, and covers topics such as carer-inclusive communication and practices; supporting carer needs; and managing carer dominance, anger, and conflicting patient-carer wishes. The usability of the module was rated by 5 clinicians, with a mean SUS score of 75 (SD 5.3), which is interpreted as good. Clinicians often desired information in a concise format, divided into small "snackable" sections that could be easily recommenced if they were interrupted. The carer module features 11 sections; requires approximately 1.5 hours to complete; and includes topics such as the importance of carers, carer roles during consultations, and advocating for the patient. The patient module is an adaptation of the relevant carer module sections, comprising 7 sections and requiring 1 hour to complete. The average SUS score as rated by 6 patients and carers was 78 (SD 16.2), which is interpreted as good. Interactive activities, clinical vignette videos, and reflective learning exercises are incorporated into all modules. Patient and carer consumer advisers advocated for empathetic content and tone throughout their modules, with an easy-to-read and navigable module interface. CONCLUSIONS: The eTRIO suite of modules were rigorously developed using a person-based design methodology to meet the unique information needs and learning requirements of clinicians, patients, and carers, with the goal of improving effective and supportive carer involvement in cancer consultations and cancer care.

An online intervention to improve oncology health professional self-efficacy in communicating with carers: Hybrid effectiveness-implementation evaluation of the eTRIO program.

OBJECTIVES: Many oncology health professionals (HPs) report communicating with carers as complex; and receive limited carer-relevant training. We developed an online HP education program for supporting and managing carer involvement (eTRIO). We aimed to assess whether HPs' self-efficacy in carer communication, knowledge, and decision-making preferences improve following eTRIO. Satisfaction and implementation potential were assessed. METHODS: This type 1 hybrid effectiveness-implementation study used a pre-post single arm intervention design. HPs completed baseline measures, the eTRIO online module, and measures at 1- and 12-weeks post-intervention. Measures included: self-efficacy in carer communication (13-items), applied knowledge (7-items), preference for carer involvement in decisions (1-item). Fifteen of participants completed feedback interviews which underwent thematic analysis. User analytics were collected and analysed. RESULTS: Fifty-six HPs completed baseline measures, 42 completed post- and follow-up measures. At baseline mean self-efficacy score was 88. HPs showed a statistically significant increase in self-efficacy post-intervention (mean = 105.8, CI [12.99, 20.47]), maintained at 12-weeks (mean = 101.1, CI [8.00, 15.72]). There were no changes in knowledge or decision-making preferences. Program engagement and satisfaction were high, 86.7% participants rated eTRIO as very/extremely helpful. CONCLUSIONS AND PRACTICE IMPLICATIONS: eTRIO provided HPs with confidence to effectively engage with carers and manage complex situations such as family dominance. These gains are noteworthy, as conflict with families/carers contributes to HP burnout.

Thought Leader Perspectives on the Benefits, Barriers, and Enablers for Routinely Collected Electronic Health Data to Support Professional Development: Qualitative Study.

BACKGROUND: Hospitals routinely collect large amounts of administrative data such as length of stay, 28-day readmissions, and hospital-acquired complications; yet, these data are underused for continuing professional development (CPD). First, these clinical indicators are rarely reviewed outside of existing quality and safety reporting. Second, many medical specialists view their CPD requirements as time-consuming, having minimal impact on practice change and improving patient outcomes. There is an opportunity to build new user interfaces based on these data, designed to support individual and group reflection. Data-informed reflective practice has the potential to generate new insights about performance, bridging the gap between CPD and clinical practice. OBJECTIVE: This study aims to understand why routinely collected administrative data have not yet become widely used to support reflective practice and lifelong learning. METHODS: We conducted semistructured interviews (N=19) with thought leaders from a range of backgrounds, including clinicians, surgeons, chief medical officers, information and communications technology professionals, informaticians, researchers, and leaders from related industries. Interviews were thematically analyzed by 2 independent coders. RESULTS: Respondents identified visibility of outcomes, peer comparison, group reflective discussions, and practice change as potential benefits. The key barriers included legacy technology, distrust with data quality, privacy, data misinterpretation, and team culture. Respondents suggested recruiting local champions for co-design, presenting data for understanding rather than information, coaching by specialty group leaders, and timely reflection linked to CPD as enablers to successful implementation. CONCLUSIONS: Overall, there was consensus among thought leaders, bringing together insights from diverse backgrounds and medical jurisdictions. We found that clinicians are interested in repurposing administrative data for professional development despite concerns with underlying data quality, privacy, legacy technology, and visual presentation. They prefer group reflection led by supportive specialty group leaders, rather than individual reflection. Our findings provide novel insights into the specific benefits, barriers, and benefits of potential reflective practice interfaces based on these data sets. They can inform the design of new models of in-hospital reflection linked to the annual CPD planning-recording-reflection cycle.

The Contribution of Nutrients of Concern to the Diets of 18-to-30-Year-Old Australians from Food Prepared Outside Home Differs by Food Outlet Types: The MYMeals Cross-Sectional Study.

Young adults are frequent consumers of food prepared outside the home (FOH). In a cross-sectional survey, the MYMeals study, we showed FOH provided one-third of meals and snacks for young Australian adults, yet it contributed higher proportions of energy and nutrients of concern, such as saturated fat and sodium. This study aimed to determine the detailed proportional contribution of nutrients of concern from the nine food outlet types captured in the MYMeals study. Young adults residing in New South Wales (NSW), Australia, (n = 1001) used a validated smartphone app to report all types and amounts of food and beverages consumed for three consecutive days, as well as their preparation location. The proportions of daily energy, macronutrients, sodium, total sugars, and saturated fat were calculated for each of the nine following outlet types: bakeries or patisseries, coffee chains, cold-drink chains, fast-food chains, ice creamery or frozen yoghurt outlets, independent cafes or restaurants, pubs (hotels) and clubs, service stations or convenience stores, and others not fitting the above categories. Of all FOH outlet types, independent cafes or restaurants contributed the most energy (17.5%), sodium (20.0%) and saturated fat (17.8%) to the total diet, followed by fast-food chains (12.0% energy, 15.8% sodium, and 12.0% saturated fat) and other outlets, with smaller proportions. For males, the proportion of energy and nutrients contributed by fast-food outlets was higher than for females (14.8% versus 9.8% energy). Menu labelling at independent cafes and restaurants is recommended, comprising, in addition to the energy labels already in use in fast-food restaurants, the labelling of nutrients of concern. The feasibility of this recommendation warrants further exploration.

State-of-the-art Dashboards on Clinical Indicator Data to Support Reflection on Practice: Scoping Review.

BACKGROUND: There is an increasing interest in using routinely collected eHealth data to support reflective practice and long-term professional learning. Studies have evaluated the impact of dashboards on clinician decision-making, task completion time, user satisfaction, and adherence to clinical guidelines. OBJECTIVE: This scoping review aims to summarize the literature on dashboards based on patient administrative, medical, and surgical data for clinicians to support reflective practice. METHODS: A scoping review was conducted using the Arksey and O'Malley framework. A search was conducted in 5 electronic databases (MEDLINE, Embase, Scopus, ACM Digital Library, and Web of Science) to identify studies that met the inclusion criteria. Study selection and characterization were performed by 2 independent reviewers (BB and CP). One reviewer extracted the data that were analyzed descriptively to map the available evidence. RESULTS: A total of 18 dashboards from 8 countries were assessed. Purposes for the dashboards were designed for performance improvement (10/18, 56%), to support quality and safety initiatives (6/18, 33%), and management and operations (4/18, 22%). Data visualizations were primarily designed for team use (12/18, 67%) rather than individual clinicians (4/18, 22%). Evaluation methods varied among asking the clinicians directly (11/18, 61%), observing user behavior through clinical indicators and use log data (14/18, 78%), and usability testing (4/18, 22%). The studies reported high scores on standard usability questionnaires, favorable surveys, and interview feedback. Improvements to underlying clinical indicators were observed in 78% (7/9) of the studies, whereas 22% (2/9) of the studies reported no significant changes in performance. CONCLUSIONS: This scoping review maps the current literature landscape on dashboards based on routinely collected clinical indicator data. Although there were common data visualization techniques and clinical indicators used across studies, there was diversity in the design of the dashboards and their evaluation. There was a lack of detail regarding the design processes documented for reproducibility. We identified a lack of interface features to support clinicians in making sense of and reflecting on their personal performance data.

Electronic Health Records That Support Health Professional Reflective Practice: a Missed Opportunity in Digital Health.

A foundational component of digital health involves collecting and leveraging electronic health data to improve health and wellbeing. One of the central technologies for collecting these data are electronic health records (EHRs). In this commentary, the authors explore intersection between digital health and data-driven reflective practice that is described, including an overview of the role of EHRs underpinning technology innovation in healthcare. Subsequently, they argue that EHRs are a rich but under-utilised source of information on the performance of health professionals and healthcare teams that could be harnessed to support reflective practice and behaviour change. EHRs currently act as systems of data collection, not systems of data engagement and reflection by end users such as health professionals and healthcare organisations. Further consideration should be given to supporting reflective practice by health professionals in the design of EHRs and other clinical information systems.

Exploring the Intersection Between Health Professionals' Learning and eHealth Data: Protocol for a Comprehensive Research Program in Practice Analytics in Health Care.

BACKGROUND: There is an increasing amount of electronic data sitting within the health system. These data have untapped potential to improve clinical practice if extracted efficiently and harnessed to change the behavior of health professionals. Furthermore, there is an increasing expectation from the government and peak bodies that both individual health professionals and health care organizations will use electronic data for a range of applications, including improving health service delivery and informing clinical practice and professional accreditation. OBJECTIVE: The aim of this research program is to make eHealth data captured within tertiary health care organizations more actionable to health professionals for use in practice reflection, professional development, and other quality improvement activities. METHODS: A multidisciplinary approach was used to connect academic experts from core disciplines of health and medicine, education and learning sciences, and engineering and information communication technology with government and health service partners to identify key problems preventing the health care industry from using electronic data to support health professional learning. This multidisciplinary approach was used to design a large-scale research program to solve the problem of making eHealth data more accessible to health professionals for practice reflection. The program will be delivered over 5 years by doctoral candidates undertaking research projects with discrete aims that run in parallel to achieving this program's objectives. RESULTS: The process used to develop the research program identified 7 doctoral research projects to answer the program objectives, split across 3 streams. CONCLUSIONS: This research program has the potential to successfully unpack electronic data siloed within clinical sites and enable health professionals to use them to reflect on their practice and deliver informed and improved care. The program will contribute to current practices by fostering stronger connections between industry and academia, interlinking doctoral research projects to solve complex problems, and creating new knowledge for clinical sites on how data can be used to understand and improve performance. Furthermore, the program aims to affect policy by developing insights on how professional development programs may be strengthened to enhance their alignment with clinical practice. The key contributions of this paper include the introduction of a new conceptualized research program, Practice Analytics in Health care, by describing the foundational academic disciplines that the program is formed of and presenting scientific methods for its design and development. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/27984.

Computer-Based Decision Tools for Shared Therapeutic Decision-making in Oncology: Systematic Review.

BACKGROUND: Therapeutic decision-making in oncology is a complex process because physicians must consider many forms of medical data and protocols. Another challenge for physicians is to clearly communicate their decision-making process to patients to ensure informed consent. Computer-based decision tools have the potential to play a valuable role in supporting this process. OBJECTIVE: This systematic review aims to investigate the extent to which computer-based decision tools have been successfully adopted in oncology consultations to improve patient-physician joint therapeutic decision-making. METHODS: This review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 checklist and guidelines. A literature search was conducted on February 4, 2021, across the Cochrane Database of Systematic Reviews (from 2005 to January 28, 2021), the Cochrane Central Register of Controlled Trials (December 2020), MEDLINE (from 1946 to February 4, 2021), Embase (from 1947 to February 4, 2021), Web of Science (from 1900 to 2021), Scopus (from 1969 to 2021), and PubMed (from 1991 to 2021). We used a snowball approach to identify additional studies by searching the reference lists of the studies included for full-text review. Additional supplementary searches of relevant journals and gray literature websites were conducted. The reviewers screened the articles eligible for review for quality and inclusion before data extraction. RESULTS: There are relatively few studies looking at the use of computer-based decision tools in oncology consultations. Of the 4431 unique articles obtained from the searches, only 10 (0.22%) satisfied the selection criteria. From the 10 selected studies, 8 computer-based decision tools were identified. Of the 10 studies, 6 (60%) were conducted in the United States. Communication and information-sharing were improved between physicians and patients. However, physicians did not change their habits to take advantage of computer-assisted decision-making tools or the information they provide. On average, the use of these computer-based decision tools added approximately 5 minutes to the total length of consultations. In addition, some physicians felt that the technology increased patients' anxiety. CONCLUSIONS: Of the 10 selected studies, 6 (60%) demonstrated positive outcomes, 1 (10%) showed negative results, and 3 (30%) were neutral. Adoption of computer-based decision tools during oncology consultations continues to be low. This review shows that information-sharing and communication between physicians and patients can be improved with the assistance of technology. However, the lack of integration with electronic health records is a barrier. This review provides key requirements for enhancing the chance of success of future computer-based decision tools. However, it does not show the effects of health care policies, regulations, or business administration on physicians' propensity to adopt the technology. Nevertheless, it is important that future research address the influence of these higher-level factors as well. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42021226087; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021226087.

The Contribution of Foods Prepared Outside the Home to the Diets of 18- to 30-Year-Old Australians: The MYMeals Study.

Young adults are the highest consumers of food prepared outside home (FOH) and gain most weight among Australian adults. One strategy to address the obesogenic food environment is menu labelling legislation whereby outlets with >20 stores in one state and >50 Australia-wide must display energy content in kJ. The aim of this study was to assess the contribution of FOH to the energy and macronutrients, saturated fat, total sugars and sodium intakes of young Australians. One thousand and one 18 to 30-year-olds (57% female) residing in Australia's most populous state recorded all foods and beverages consumed and the location of preparation for three consecutive days using a purpose-designed smartphone application. Group means for the daily consumption of energy, percentage energy (%E) for protein, carbohydrate, total sugars, total and saturated fats, and sodium density (mg/1000 kJ) and proportions of nutrients from FOH from menu labelling and independent outlets were compared. Overall, participants consumed 42.4% of their energy intake from FOH with other nutrients ranging from 39.8% (sugars) to 47.3% (sodium). Independent outlets not required to label menus, contributed a greater percentage of energy (23.6%) than menu labelling outlets (18.7%, p < 0.001). Public health policy responses such as public education campaigns, extended menu labelling, more detailed nutrition information and reformulation targets are suggested to facilitate healthier choices.

eTRIO trial: study protocol of a randomised controlled trial of online education modules to facilitate effective family caregiver involvement in oncology.

OBJECTIVE: Informal family caregivers play a crucial role in cancer care. Effective caregiver involvement in cancer care can improve both patient and caregiver outcomes. Despite this, interventions improving the caregiver involvement are sparse. This protocol describes a randomised controlled trial evaluating the combined effectiveness of novel online caregiver communication education modules for: (1) oncology clinicians (eTRIO) and (2) patients with cancer and caregivers (eTRIO-pc). METHODS AND ANALYSIS: Thirty medical/radiation/surgical oncology or haematology doctors and nurses will be randomly allocated to either intervention (eTRIO) or control (an Australian State Government Health website on caregivers) education conditions. Following completion of education, each clinician will recruit nine patient-caregiver pairs, who will be allocated to the same condition as their recruiting clinician. Eligibility includes any new adult patient diagnosed with any type/stage cancer attending consultations with a caregiver. Approximately 270 patient-caregiver pairs will be recruited. The primary outcome is caregiver self-efficacy in triadic (clinician-patient-caregiver) communication. Patient and clinician self-efficacy in triadic communication are secondary outcomes. Additional secondary outcomes for clinicians include preferences for caregiver involvement, perceived module usability/acceptability, analysis of module use, satisfaction with the module, knowledge of strategies and feedback interviews. Secondary outcomes for caregivers and patients include preferences for caregiver involvement, satisfaction with clinician communication, distress, quality of life, healthcare expenditure, perceived module usability/acceptability and analysis of module use. A subset of patients and caregivers will complete feedback interviews. Secondary outcomes for caregivers include preparedness for caregiving, patient-caregiver communication and caring experience. Assessments will be conducted at baseline, and 1 week, 12 weeks and 26 weeks post-intervention. ETHICS AND DISSEMINATION: Ethical approval has been received by the Sydney Local Health District Human Research Ethics Committee (REGIS project ID number: 2019/PID09787), with site-specific approval from each recruitment site. Protocol V.7 (dated 1 September 2020) is currently approved and reported in this manuscript. Findings will be disseminated via presentations and peer-reviewed publications. Engagement with clinicians, media, government, consumers and peak cancer groups will facilitate widespread dissemination and long-term availability of the educational modules. TRIAL REGISTRATION NUMBER: ACTRN12619001507178.

Developing an Intranet-Based Lymphedema Dashboard for Breast Cancer Multidisciplinary Teams: Design Research Study.

BACKGROUND: A large quantity of data is collected during the delivery of cancer care. However, once collected, these data are difficult for health professionals to access to support clinical decision making and performance review. There is a need for innovative tools that make clinical data more accessible to support health professionals in these activities. One approach for providing health professionals with access to clinical data is to create the infrastructure and interface for a clinical dashboard to make data accessible in a timely and relevant manner. OBJECTIVE: This study aimed to develop and evaluate 2 prototype dashboards for displaying data on the identification and management of lymphedema. METHODS: The study used a co-design framework to develop 2 prototype dashboards for use by health professionals delivering breast cancer care. The key feature of these dashboards was an approach for visualizing lymphedema patient cohort and individual patient data. This project began with 2 focus group sessions conducted with members of a breast cancer multidisciplinary team (n=33) and a breast cancer consumer (n=1) to establish clinically relevant and appropriate data for presentation and the visualization requirements for a dashboard. A series of fortnightly meetings over 6 months with an Advisory Committee (n=10) occurred to inform and refine the development of a static mock-up dashboard. This mock-up was then presented to representatives of the multidisciplinary team (n=3) to get preliminary feedback about the design and use of such dashboards. Feedback from these presentations was reviewed and used to inform the development of the interactive prototypes. A structured evaluation was conducted on the prototypes, using Think Aloud Protocol and semistructured interviews with representatives of the multidisciplinary team (n=5). RESULTS: Lymphedema was selected as a clinically relevant area for the prototype dashboards. A qualitative evaluation is reported for 5 health professionals. These participants were selected from 3 specialties: surgery (n=1), radiation oncology (n=2), and occupational therapy (n=2). Participants were able to complete the majority of tasks on the dashboard. Semistructured interview themes were categorized into engagement or enthusiasm for the dashboard, user experience, and data quality and completeness. CONCLUSIONS: Findings from this study constitute the first report of a co-design process for creating a lymphedema dashboard for breast cancer health professionals. Health professionals are interested in the use of data visualization tools to make routinely collected clinical data more accessible. To be used effectively, dashboards need to be reliable and sourced from accurate and comprehensive data sets. While the co-design process used to develop the visualization tool proved effective for designing an individual patient dashboard, the complexity and accessibility of the data required for a cohort dashboard remained a challenge.

Attitudes of health professionals to using routinely collected clinical data for performance feedback and personalised professional development.

OBJECTIVES: To learn the attitudes of health professionals, health informaticians and information communication technology professionals to using data in electronic health records (eHRs) for performance feedback and professional development. DESIGN: Qualitative research in a co-design framework. Health professionals' perceptions of the accessibility of data in eHRs, and barriers to and enablers of using these data in performance feedback and professional development were explored in co-design workshops. Audio recordings of the workshops were transcribed, de-identified, and thematically analysed. SETTING, PARTICIPANTS: A total of nine co-design workshops were held in two major public hospitals in Sydney: three for nursing staff (ten participants), three for doctors (15 participants), and one each for information communication technology professionals (six participants), health informaticians (four participants), and allied health professionals (13 participants). MAIN OUTCOME MEASURES: Key themes related to attitudes of participants to the secondary use of eHR data for improving health care practice. RESULTS: Six themes emerged from the discussions in the workshops: enthusiasm for feeding back clinical data; formative rather than punitive use; peer comparison, benchmarking, and collaborative learning; data access and use; capturing complex clinical narratives; and system design challenges. Barriers to secondary use of eHR data included access to information, measuring performance on the basis of eHR data, and technical questions. CONCLUSIONS: Our findings will inform the development of programs designed to utilise routinely collected eHR data for performance feedback and professional development.

A Tool to Measure Young Adults' Food Intake: Design and Development of an Australian Database of Foods for the Eat and Track Smartphone App.

BACKGROUND: Dietary assessment is reliant on the collection of accurate food and beverage consumption data. Technology has been harnessed to standardize recording and provide automatic nutritional analysis to reduce cost and researcher burden. OBJECTIVE: To better assess the diet of young adults, especially relating to the contribution of foods prepared outside the home, a database was needed to support a mobile phone data collection app. The app also required usability testing to assure ease of entry of foods and beverages. This paper describes the development of the Eat and Track app (EaT app) and the database underpinning it. METHODS: The Australian Food and Nutrient Database 2011-13, consisting of 5740 food items was modified. Four steps were undertaken: (1) foods not consumed by young adults were removed, (2) nutritionally similar foods were merged, (3) foods available from the 30 largest ready-to-eat food chains in Australia were added, and (4) long generic food names were shortened and simplified. This database was used to underpin the EaT app. Qualitative, iterative usability testing of the EaT app was conducted in three phases using the "Think Aloud" method. Responses were sorted and coded using content analysis. The System Usability Scale (SUS) was administered to measure the EaT app's perceived usability. RESULTS: In total, 1694 (29.51%) foods were removed from the Australian Food and Nutrient Database, including 608 (35.89%) ingredients, 81 (4.78%) foods already captured in the fast food chain information, 52 (3.07%) indigenous foods, 25 (1.48%) nutrients/dietary supplements, and 16 (0.94%) child-specific foods. The remaining 912 (53.84%) foods removed were not consumed by young adults in previous surveys or were "not defined" in the Australian Food and Nutrient Database. Another 220 (3.83%) nutritionally similar foods were combined. The final database consisted of 6274 foods. Fifteen participants completed usability testing. Issues identified by participants fell under six themes: keywords for searching, history list of entered foods, amounts and units, the keypad, food names, and search function. Suggestions for improvement were collected, incorporated, and tested in each iteration of the app. The SUS of the final version of the EaT app was rated 69. CONCLUSIONS: A food and beverage database has been developed to underpin the EaT app, enabling data collection on the eating-out habits of 18- to 30-year-old Australians. The development process has resulted in a database with commonly used food names, extensive coverage of foods from ready-to-eat chains, and commonly eaten portion sizes. Feedback from app usability testing led to enhanced keyword searching and the addition of functions to enhance usability such as adding brief instructional screens. There is potential for the features of the EaT app to facilitate the collection of more accurate dietary intake data. The database and the app will be valuable dietary assessment resources for researchers.

It's the deceiver and the receiver: Individual differences in phishing susceptibility and false positives with item profiling.

Phishing email is one of the biggest risks to online information security due to its ability to exploit human trust and naivety. Prior research has examined whether some people are more susceptible to phishing than others and what characteristics may predict this susceptibility. Given that there are no standardised measures or methodologies to detect phishing susceptibility, results have conflicted. To address this issue, the current study created a 40-item phishing detection task to measure both cognitive and behavioural indicators of phishing susceptibility and false positives (misjudged genuine email). The task is based on current real-life email stimuli (i.e., phishing and genuine) relevant to the student and general population. Extending previous literature we also designed a methodology for assessing phishing susceptibility by allowing participants to indicate perception of maliciousness of each email type and the actions they would take (keep it, trash it or seek further information). This enabled us to: (1) examine the relationships that psychological variables share with phishing susceptibility and false positives-both captured as consistent tendencies; (2) determine the relationships between perceptions of maliciousness with behavioural outcomes and psychological variables; and (3) determine the relationships between these tendencies and email characteristics. In our study, 150 undergraduate psychology students participated in exchange for partial course credit (98 Females; Mean age = 19.70, SD = 2.27). Participants also completed a comprehensive battery of psychometric tests assessing intelligence, pre- and on-task confidence, Big 6 personality, and familiarity/competence in computing and phishing. Results revealed that people showed distinct and robust tendencies for phishing susceptibility and false positives. A series of regression analyses looking at the accuracy of both phishing and false positives detection revealed that human-centred variables accounted for a good degree of variance in phishing susceptibility (about 54%), with perceptions of maliciousness, intelligence, knowledge of phishing, and on-task confidence contributing significantly, directly and/or indirectly via perception of maliciousness. A regression model looking at discriminating false positives has also shown that human-centred variables accounted for a reasonable degree of variance (41%), with perceptions of maliciousness, intelligence and on-task confidence contributing significantly, directly and/or indirectly via perception of maliciousness. Furthermore, the characteristics of the most effective phishing and misjudged genuine email items were profiled. Based on our findings, we suggest that future research should investigate these significant variables in more detail. We also recommend that future research should capture consistent response tendencies to determine vulnerability to phishing and false positives (rather than a one off response to a single email), and use the collection of the most current phishing email obtained from relevant sources to the population. It is important to capture perceptions of maliciousness of email because it is a key predictor of the action taken on the email. It directly predicts accuracy detection of phishing and genuine email, as well as mediating the relationships between some other predictors whose role would have been overlooked if the perceptions were not captured. The study provides the framework of human-centred variables which predict phishing and false positive susceptibility as well as the characteristics of email which most deceive people.

Examining the Frequency and Contribution of Foods Eaten Away From Home in the Diets of 18- to 30-Year-Old Australians Using Smartphone Dietary Assessment (MYMeals): Protocol for a Cross-Sectional Study.

BACKGROUND: Young Australians aged between 18 and 30 years have experienced the largest increase in the body mass index and spend the largest proportion of their food budget on fast food and eating out. Frequent consumption of foods purchased and eaten away from home has been linked to poorer diet quality and weight gain. There has been no Australian research regarding quantities, type, or the frequency of consumption of food prepared outside the home by young adults and its impact on their energy and nutrient intakes. OBJECTIVES: The objective of this study was to determine the relative contributions of different food outlets (eg, fast food chain, independent takeaway food store, coffee shop, etc) to the overall food and beverage intake of young adults; to assess the extent to which food and beverages consumed away from home contribute to young adults' total energy and deleterious nutrient intakes; and to study social and physical environmental interactions with consumption patterns of young adults. METHODS: A cross-sectional study of 1008 young adults will be conducted. Individuals are eligible to participate if they: (1) are aged between 18 and 30 years; (2) reside in New South Wales, Australia; (3) own or have access to a smartphone; (4) are English-literate; and (5) consume at least one meal, snack, or drink purchased outside the home per week. An even spread of gender, age groups (18 to 24 years and 25 to 30 years), metropolitan or regional geographical areas, and high and low socioeconomic status areas will be included. Participants will record all food and drink consumed over 3 consecutive days, together with location purchased and consumed in our customized smartphone app named Eat and Track (EaT). Participants will then complete an extensive demographics questionnaire. Mean intakes of energy, nutrients, and food groups will be calculated along with the relative contribution of foods purchased and eaten away from home. A subsample of 19.84% (200/1008) of the participants will complete three 24-hour recall interviews to compare with the data collected using EaT. Data mining techniques such as clustering, decision trees, neural networks, and support vector machines will be used to build predictive models and identify important patterns. RESULTS: Recruitment is underway, and results will be available in 2018. CONCLUSIONS: The contribution of foods prepared away from home, in terms of energy, nutrients, deleterious nutrients, and food groups to young people's diets will be determined, as will the impact on meeting national recommendations. Foods and consumption behaviors that should be targeted in future health promotion efforts for young adults will be identified.

Dietary contribution of foods and beverages sold within a university campus and its effect on diet quality of young adults.

OBJECTIVE: Tertiary education institutions have been linked with excessive weight in young adults. However, few data are available on the effect of foods from the university food environment on the diet quality of young adults. The aim of this study was to describe the association of a number of foods and beverages consumed at university food outlets with the diet quality of young adults. METHODS: This was a cross-sectional survey in which the 103 university student participants, aged 19 to 24 y, contributed 5 d of dietary data. A purposely designed, validated smartphone application was used to collect the data. Diet quality was assessed by adherence to the 2013 dietary guidelines for food groups and nutrients, and the validated Healthy Eating Index for Australians (HEIFA-2013) was applied. Individual HEIFA-2013 scores were compared with the frequency of food purchase and consumption from university outlets to assess a dose-response effect of the food environment. Comparisons by tertiles of diet quality for body mass index, waist circumference, and takeaway food consumption (university and other) were computed using a one-way analysis of variance and post hoc Tukey test. RESULTS: There was a statistically significant difference between the number of university foods and beverages consumed in 5 d and the HEIFA-2013 scores: More on-campus purchases resulted in a poor-quality diet (P = 0.001). As the HEIFA-2013 tertile scores increased, there was a significant decrease in the number of university campus and other takeaway foods consumed; body mass index and waist circumference showed a decrease in trend. CONCLUSIONS: Efforts to improve the diet quality of young adults attending university may benefit from approaches to improve the campus food environment.

Electronic Dietary Intake Assessment (e-DIA): relative validity of a mobile phone application to measure intake of food groups.

Automation of dietary assessment can reduce limitations of established methodologies, by alleviating participant and researcher burden. Designed as a research tool, the electronic Dietary Intake Assessment (e-DIA) is a food record in mobile phone application format. The present study aimed to examine the relative validity of the e-DIA with the 24-h recall method to estimate intake of food groups. A sample of eighty university students aged 19-24 years recorded 5 d of e-DIA and 3 d of recall within this 5-d period. The three matching days of dietary data were used for analysis. Food intake data were disaggregated and apportioned to one of eight food groups. Median intakes of food groups were similar between the methods, and strong correlations were found (mean: 0·79, range: 0·69-0·88). Cross-classification by tertiles produced a high level of exact agreement (mean: 71 %, range: 65-75 %), and weighted κ values were moderate to good (range: 0·54-0·71). Although mean differences (e-DIA-recall) were small (range: -13 to 23 g), limits of agreement (LOA) were relatively large (e.g. for vegetables, mean difference: -4 g, LOA: -159 to 151 g). The Bland-Altman plots showed robust agreement, with minimum bias. This analysis supports the use of e-DIA as an alternative to the repeated 24-h recall method for ranking individuals' food group intake.

Electronic Dietary Intake Assessment (e-DIA): Comparison of a Mobile Phone Digital Entry App for Dietary Data Collection With 24-Hour Dietary Recalls.

BACKGROUND: The electronic Dietary Intake Assessment (e-DIA), a digital entry food record mobile phone app, was developed to measure energy and nutrient intake prospectively. This can be used in monitoring population intakes or intervention studies in young adults. OBJECTIVE: The objective was to assess the relative validity of e-DIA as a dietary assessment tool for energy and nutrient intakes using the 24-hour dietary recall as a reference method. METHODS: University students aged 19 to 24 years recorded their food and drink intake on the e-DIA for five days consecutively and completed 24-hour dietary recalls on three random days during this 5-day study period. Mean differences in energy, macro-, and micronutrient intakes were evaluated between the methods using paired t tests or Wilcoxon signed-rank tests, and correlation coefficients were calculated on unadjusted, energy-adjusted, and deattenuated values. Bland-Altman plots and cross-classification into quartiles were used to assess agreement between the two methods. RESULTS: Eighty participants completed the study (38% male). No significant differences were found between the two methods for mean intakes of energy or nutrients. Deattenuated correlation coefficients ranged from 0.55 to 0.79 (mean 0.68). Bland-Altman plots showed wide limits of agreement between the methods but without obvious bias. Cross-classification into same or adjacent quartiles ranged from 75% to 93% (mean 85%). CONCLUSIONS: The e-DIA shows potential as a dietary intake assessment tool at a group level with good ranking agreement for energy and all nutrients.