Identifying barriers and facilitators for using a smartwatch to monitor health among older adults.

Smartwatches are a type of wearable device that enable continuous monitoring of an individual's activities and critical health metrics. As the number of older adults age 65+ continues to grow in the U.S., so does their usage of smartwatches, making it necessary to understand the real-world uptake and use of these devices to monitor health. In this study, older adults with a relatively high level of education and digital skills were provided with a smartwatch equipped with a mobile application (ROAMM) that was worn for a median of 14 days. Usability surveys were distributed, and a qualitative analysis was performed about participants' experience using the smartwatch and ROAMM application. Constructs from the Technology Acceptance Model and Consolidated Framework for Implementation Research were incorporated into in-depth interviews, which were recorded and transcribed. Data were analyzed using the constant comparative method. Interviews among 30 older adults revealed the following main themes: 1) familiarization with the device and adoption and acceptance, 2) factors encouraging usage, such as a doctor's endorsement or the appeal of tracking one's health, and 3) barriers to usage, such as insufficient education and training and the desire for additional functionality. Overall, participants found the smartwatch easy to use and were likely to continue using the device in a long-term study. Data generated from smartwatches have the potential to engage individuals about their health and could inspire them to participate more actively during clinical encounters.

Tele-Oncology Use During the COVID-19 Pandemic: Patient Experiences and Communication Behaviors with Clinicians.

Background: Tele-oncology became a widely used tool during the COVID-19 pandemic, but there was limited understanding of how patient-clinician communication occurred using the technology. Our goal was to identify how communication transpired during tele-oncology consultations compared with in-person appointments. Methods: A convergent parallel mixed-method design was utilized for the web-based survey, and follow-up interviews were conducted with cancer patients from March to December 2020. Participants were recruited from the University of Florida Health Cancer Center and two national cancer organizations. During the survey, participants rated their clinician's patient-centered communication behaviors. Open-ended survey responses and interview data were combined and analyzed thematically using the constant comparative method. Results: A total of 158 participants completed the survey, and 33 completed an interview. Ages ranged from 19 to 88 years (mean = 64.2; standard deviation = 13.0); 53.2% identified as female and 44.9% as male. The majority of respondents (76%) considered communication in tele-oncology equal to in-person visits. Preferences for tele-oncology included the ability to get information from the clinician, with 13.5% rating tele-oncology as better than in-person appointments. Tele-oncology was considered worse than in-person appointments for eye contact (n = 21, 12.4%) and virtual waiting room times (n = 50, 29.4%). The following qualitative themes corresponded with several quantitative variables: (1) commensurate to in-person appointments, (2) uncertainty with the digital platform, (3) lack of a personal connection, and (4) enhanced patient experience. Conclusion: Patient-centered communication behaviors were mostly viewed as equally prevalent during tele-oncology and in-person appointments. Addressing the challenges of tele-oncology is necessary to improve the patient experience.

Understanding the Design of Fear Appeals by Applying the Extended Parallel Process Model: A Qualitative Analysis of COVID-19 Public Service Announcements.

PURPOSE: Identify how early COVID-19 public health messages incorporated in the tenets of the extended parallel process model (EPPM). SETTING: YouTube videos developed by governmental departments, medical institutions, news organizations, and non-profit organizations in the United States were aggregated. METHOD: This qualitative study conducted a keyword search to identify public service announcements (PSAs). The sample was further refined after searching PSAs that contained fear appeals. A thematic analysis was performed by using the constant comparative method. SAMPLE: A total of forty-three videos was included in the final analysis. RESULT: Two themes emerged regarding messages aimed at arousing the perceived severity of threat. These themes include emphasizing the consequences of being infected and utilizing personal narratives. Perceived susceptibility of threat was aroused by emphasizing that some groups have higher risks than others. Two themes emerged around arousing perceived response efficacy: (1) the authority of professionals; and (2) altruism and personal responsibility. One way was identified to arouse perceived self-efficacy, which is informing the protective measures. CONCLUSION: Multiple strategies were used in PSAs about COVID-19 to arouse fear during the early stages of the pandemic. The utilization of self-efficacy was oversimplified, by not providing details about the rationale for the recommended behavior.

A systematic scoping review of patient and caregiver self-report measures of satisfaction with clinicians' communication.

OBJECTIVE: We conducted a systematic scoping review of self-report tools used to measure patient and/or caregiver satisfaction with clinician communication. Aims included identifying: 1) instruments that have been used to measure communication satisfaction, and 2) content of the communication items on measures. METHODS: Two databases (PubMed and CINAHL) were searched for relevant studies. Eligibility included patient or caregiver self-report tools assessing satisfaction with clinicians' communication in a biomedical healthcare setting; and the stated purpose for using the measurement involved evaluating communication satisfaction and measures included more than one question about this. All data were charted in a form created by the authors. RESULTS: Our search yielded a total of 4531 results screened as title and abstracts; 228 studies were screened in full text and 85 studies were included in the review. We found 53 different tools used to measure communication satisfaction among those 85 studies, including 29 previously used measures (e.g., FS-ICU-24, CAHPS), and 24 original measures developed by authors. Content of communication satisfaction items included satisfaction with content-specific communication, interpersonal communication skills of clinicians, communicating to set the right environment, and global communication satisfaction items. CONCLUSION: There was high variability in the number of items and types of content on measures. Communication satisfaction should be better conceptualized to improve measurement, and more robust measures should be created to capture complex factors of communication satisfaction. PRACTICE IMPLICATIONS: Creating a rigorous evaluation of satisfaction with clinician communication may help strengthen communication research and the assessment of communication interventions.

Identifying the mechanisms of patient-centred communication in secure messages between clinicians and cancer patients.

Objective: Identify how patients and clinicians incorporate patient-centered communication (PCC) within secure messaging. Methods: A random sample of 199 secure messages from patient portal communication between patients and clinicians were collected and analyzed. Via manual annotation, the task of tagging target words/phrases in text, we identified five components of PCC: information giving, information seeking, emotional support, partnership, and shared decision-making. Textual analysis was also performed to understand the context of PCC expressions within messages. Results: Information-giving was the predominant (n = 346, 68.1%) PCC category used in secure messaging, more than double of the other four PCC codes, information-seeking (n = 82, 16.1%), emotional support (n = 52, 10.2%), shared decision making (n = 5, 1.0%), combined. The textual analysis revealed that clinicians informed patients about appointment reminders and new protocols while patients reminded clinicians about upcoming procedures and outcomes of test results conducted by other clinicians. Although less common, patients expressed statements of concern, uncertainty, and fear; enabling clinicians to provide support. Conclusion: Secure messaging is mainly used for exchanging information, but other aspects of PCC emerge using this channel of communication. Innovation: Meaningful discussions can occur via secure messaging, and clinicians should be mindful of incorporating PCC when communicating with patients through secure messaging.

Feasibility of a Smartwatch Platform to Assess Ecological Mobility: Real-Time Online Assessment and Mobility Monitor.

BACKGROUND: Early detection of mobility decline is critical to prevent subsequent reductions in quality of life, disability, and mortality. However, traditional approaches to mobility assessment are limited in their ability to capture daily fluctuations that align with sporadic health events. We aim to describe findings from a pilot study of our Real-time Online Assessment and Mobility Monitor (ROAMM) smartwatch application, which uniquely captures multiple streams of data in real time in ecological settings. METHODS: Data come from a sample of 31 participants (Mage = 74.7, 51.6% female) who used ROAMM for approximately 2 weeks. We describe the usability and feasibility of ROAMM, summarize prompt data using descriptive metrics, and compare prompt data with traditional survey-based questionnaires or other established measures. RESULTS: Participants were satisfied with ROAMM's function (87.1%) and ranked the usability as "above average." Most were highly engaged (average adjusted compliance = 70.7%) and the majority reported being "likely" to enroll in a 2-year study (77.4%). Some smartwatch features were correlated with their respective traditional measurements (eg, certain GPS-derived life-space mobility features (r = 0.50-0.51, p < .05) and ecologically measured pain (r = 0.72, p = .01), but others were not (eg, ecologically measured fatigue). CONCLUSIONS: ROAMM was usable, acceptable, and effective at measuring mobility and risk factors for mobility decline in our pilot sample. Additional work with a larger and more diverse sample is necessary to confirm associations between smartwatch-measured features and traditional measures. By monitoring multiple data streams simultaneously in ecological settings, this technology could uniquely contribute to the evolution of mobility measurement and risk factors for mobility loss.

Clinician Communication With Patients About Cancer Misinformation: A Qualitative Study.

PURPOSE: Clinicians regularly face conversations about information that patients have found online. Given the prevalence of misinformation, these conversations can include cancer-related misinformation, which is often harmful. Clinicians are in a key position as trusted sources of information to educate patients. However, there is no research on clinician-patient conversations about cancer-related misinformation. As a first step, the objective of this study was to describe how cancer clinicians report communicating with patients about online cancer misinformation. METHODS: We used convenience and snowball sampling to contact 59 cancer clinicians by e-mail. Contacted clinicians predominately worked at academic centers across the United States. Clinicians who agreed participated in semistructured interviews about communication in health care. For this study, we focused specifically on clinicians' experiences discussing online cancer-related misinformation with patients. We conducted a thematic analysis using a constant comparative approach to identify how clinicians address misinformation during clinical visits. RESULTS: Twenty-one cancer clinicians participated in the study. Nineteen were physicians, one was a physician assistant, and one was a nurse practitioner. The majority (62%) were female. We identified four themes that describe how cancer clinicians address misinformation: (1) work to understand the misinformation; (2) correct misinformation through education; (3) advise about future online searches, and (4) preserve the clinician-patient relationship. CONCLUSION: Our study identified four strategies that clinicians use to address online cancer-related misinformation with their patients. These findings provide a foundation for future research, allowing us to test these strategies in larger samples to examine their effectiveness.

Barriers and Facilitators of Obtaining Social Determinants of Health of Patients With Cancer Through the Electronic Health Record Using Natural Language Processing Technology: Qualitative Feasibility Study With Stakeholder Interviews.

BACKGROUND: Social determinants of health (SDoH), such as geographic neighborhoods, access to health care, education, and social structure, are important factors affecting people's health and health outcomes. The SDoH of patients are scarcely documented in a discrete format in electronic health records (EHRs) but are often available in free-text clinical narratives such as physician notes. Innovative methods like natural language processing (NLP) are being developed to identify and extract SDoH from EHRs, but it is imperative that the input of key stakeholders is included as NLP systems are designed. OBJECTIVE: This study aims to understand the feasibility, challenges, and benefits of developing an NLP system to uncover SDoH from clinical narratives by conducting interviews with key stakeholders: (1) oncologists, (2) data analysts, (3) citizen scientists, and (4) patient navigators. METHODS: Individuals who frequently work with SDoH data were invited to participate in semistructured interviews. All interviews were recorded and subsequently transcribed. After coding transcripts and developing a codebook, the constant comparative method was used to generate themes. RESULTS: A total of 16 participants were interviewed (5 data analysts, 4 patient navigators, 4 physicians, and 3 citizen scientists). Three main themes emerged, accompanied by subthemes. The first theme, importance and approaches to obtaining SDoH, describes how every participant (n=16, 100%) regarded SDoH as important. In particular, proximity to the hospital and income levels were frequently relied upon. Communication about SDoH typically occurs during the initial conversation with the oncologist, but more personal information is often acquired by patient navigators. The second theme, SDoH exists in numerous forms, exemplified how SDoH arises during informal communication and can be difficult to enter into the EHR. The final theme, incorporating SDoH into health services research, addresses how more informed SDoH can be collected. One strategy is to empower patients so they are aware about the importance of SDoH, as well as employing NLP techniques to make narrative data available in a discrete format, which can provide oncologists with actionable data summaries. CONCLUSIONS: Extracting SDoH from EHRs was considered valuable and necessary, but obstacles such as narrative data format can make the process difficult. NLP can be a potential solution, but as the technology is developed, it is important to consider how key stakeholders document SDoH, apply the NLP systems, and use the extracted SDoH in health outcome studies.

Integrating patient-centeredness into online patient-clinician communication: a qualitative analysis of clinicians' secure messaging usage.

PURPOSE: Patient-centered communication (PCC) in cancer care is helpful to nurture the patient-clinician relationship and respond to patients' emotions. However, it is unknown how PCC is incorporated into electronic patient-clinician communication. METHODS: In-depth, semi-structured qualitative interviews with clinicians were conducted to understand how PCC was integrated into asynchronous communication between patients and clinicians; otherwise, known as secure messaging. The constant comparative method was used to develop a codebook and formulate themes. RESULTS: Twenty clinicians in medical and radiation oncology participated in audio-recorded interviews. Three main themes addressed how clinicians incorporate PCC within messages: (1) being mindful of the patient-clinician relationship, (2) encouraging participation and partnership, and (3) responding promptly suggests accessibility and approachability. Clinicians recommended that patients could craft more effective messages by being specific, expressing concern, needs, and directness, summarized by the acronym S.E.N.D. CONCLUSIONS: Clinicians value secure messaging to connect with patients and demonstrate their accessibility. They acknowledge that secure messaging can influence the patient-clinician relationship and make efforts to include considerate and supportive language. As secure messaging is increasingly relied upon for patient-clinician communication, patients' message quality must improve to assist clinicians in being able to provide prompt responses inclusive of PCC.

Comparing Transactional eHealth Literacy of Individuals With Cancer and Surrogate Information Seekers: Mixed Methods Study.

BACKGROUND: The number of adults entering higher-risk age groups for receiving a cancer diagnosis is rising, with predicted numbers of cancer cases expected to increase by nearly 50% by 2050. Living with cancer puts exceptional burdens on individuals and families during treatment and survivorship, including how they navigate their relationships with one another. One role that a member of a support network may enact is that of a surrogate seeker, who seeks information in an informal capacity on behalf of others. Individuals with cancer and surrogate seekers often use the internet to learn about cancer, but differences in their skills and strategies have received little empirical attention. OBJECTIVE: This study aimed to examine the eHealth literacy of individuals with cancer and surrogate information seekers, including an investigation of how each group evaluates the credibility of web-based cancer information. As a secondary aim, we sought to explore the differences that exist between individuals with cancer and surrogate seekers pertaining to eHealth literacies and sociodemographic contexts. METHODS: Between October 2019 and January 2020, we conducted a web-based survey of 282 individuals with cancer (n=185) and surrogate seekers (n=97). We used hierarchical linear regression analyses to explore differences in functional, communicative, critical, and translational eHealth literacy between individuals with cancer and surrogate seekers using the Transactional eHealth Literacy Instrument. Using a convergent, parallel mixed methods design, we also conducted a thematic content analysis of an open-ended survey response to qualitatively examine how each group evaluates web-based cancer information. RESULTS: eHealth literacy scores did not differ between individuals with cancer and surrogate seekers, even after adjusting for sociodemographic variables. Individuals with cancer and surrogate seekers consider the credibility of web-based cancer information based on its channel (eg, National Institutes of Health). However, in evaluating web-based information, surrogate seekers were more likely than individuals with cancer to consider the presence and quality of scientific references supporting the information. Individuals with cancer were more likely than surrogate seekers to cross-reference other websites and web-based sources to establish consensus. CONCLUSIONS: Web-based cancer information accessibility and evaluation procedures differ among individuals with cancer and surrogate seekers and should be considered in future efforts to design web-based cancer education interventions. Future studies may also benefit from more stratified recruitment approaches and account for additional contextual factors to better understand the unique circumstances experienced within this population.

Cancer patients' satisfaction with telehealth during the COVID-19 pandemic.

OBJECTIVE: To examine factors associated with cancer patients' satisfaction using telehealth during COVID-19, including video conferencing platforms and secure messaging systems. METHOD: Patients with cancer participated in a cross-sectional, web-based survey was conducted with patients with cancer. The survey included questions about satisfaction with video-conferencing and secure messaging platforms to interact with clinicians during the COVID-19 pandemic. Logistic regression analyses were conducted to examine predictors of satisfaction for each telehealth platform. RESULTS: Participants generally reported positive satisfaction with each telehealth platform. Both platforms were commonly used to review medical results and discuss symptoms or treatment. Participants identifying as a man were most satisfied with their video-conferencing session, especially if they had a comfortable place to sit. Patients were more satisfied with secure messaging because they could ask a question without scheduling an appointment. DISCUSSION: When strategically used together, video-conferencing platforms and secure messaging may increase patient satisfaction in cancer care during the remainder of the pandemic and beyond. Attention must be paid to optimizing factors that promote satisfaction for each telehealth platform.

Clinicians' Attitudes and Behaviors Towards Communicating Electronically with Patients: A Grounded Practical Theory Approach.

Secure messaging (SM), asynchronous communication between patients and clinicians, is an increasingly popular tool among patients to contact clinicians about their care. Despite patients' enthusiasm, clinicians have been hesitant to embrace the technology to communicate with patients. Using the theoretical and methodological framework of Grounded Practical Theory (GPT), we analyzed and interpreted clinicians' perceptions, attitudes, and approaches toward SM to communicate with patients. Twenty clinicians in medical oncology and radiation oncology participated in audio-recorded, semi-structured interviews. Findings revealed the problems with using SM, such as difficulty interpreting low-quality messages, the amount of time needed to devote to responding, and its potential to negatively affect the patient-clinician relationship. Techniques employed to manage such problems consisted of using different forms of communication and utilizing messaging to expedite workloads. The philosophical rationale of clinicians toward SM was that it can improve patient care and this form of communication is already embedded within existing patient care. Overall, this article clarifies how clinicians can re-conceptualize how they think about SM so that it becomes a productive, informative, and useful aspect of patient care.

Practicing Mindfulness through mHealth Applications: Emerging Adults' Health-Enhancing and Inhibiting Experiences.

Mindfulness-based interventions (MBIs) and practices (MBPs) can promote better health outcomes. Although MBIs and MBPs were developed to be delivered in-person, mobile health (mHealth) tools such as apps have made these more accessible. Mindfulness apps (MAs) are popular among emerging adults (EAs) who have the highest ownership of smartphones and who are also at risk for distress. While adverse effects have been observed with MBIs/MBPs, this has not been examined when mindfulness is practiced using apps. We interviewed EAs (n = 22) to capture their motivations for using these apps and identified health-inhibiting and enhancing experiences. Data were thematically analyzed using the constant comparative method. Motivations for app use included accessibility, convenience, and stress/health management. EAs described health-enhancing outcomes (reduced distress, improved physical symptoms, increased focus) and health-inhibiting outcomes (worsened distress, performance uncertainty, dependency development, worsened physical health). They provided suggestions for improving apps (e.g., feedback option). These findings illustrate benefits and risks that EAs may encounter when practicing mindfulness using apps, which can inform the best practices for app design.

Clinicians' Perceptions of the Benefits and Challenges of Teleoncology as Experienced Through the COVID-19 Pandemic: Qualitative Study.

BACKGROUND: COVID-19 thrust both patients and clinicians to use telemedicine in place of traditional in-person visits. Prepandemic, limited research had examined clinician-patient communication in telemedicine visits. The shift to telemedicine in oncology, or teleoncology, has placed attention on how the technology can be utilized to provide care for patients with cancer. OBJECTIVE: Our objective was to describe oncology clinicians' experiences with teleoncology and to uncover its benefits and challenges during the first 10 months of the COVID-19 pandemic. METHODS: In-depth, semistructured qualitative interviews were conducted with oncology clinicians. Using an inductive, thematic approach, the most prevalent themes were identified. RESULTS: In total, 21 interviews with oncology clinicians revealed the following themes: benefits of teleoncology, such as (1) reducing patients' travel time and expenses, (2) limiting COVID-19 exposure, and (3) enabling clinicians to "see" a patients' lifestyle and environment, and challenges, such as (1) technological connection difficulties, (2) inability to physically examine patients, and (3) patients' frustration related to clinicians being late to teleoncology appointments. CONCLUSIONS: Teleoncology has many benefits and is well suited for specific types of appointments. Challenges could be addressed through improved communication when scheduling appointments to make patients aware about what to expect. Ensuring patients have the proper technology to participate in teleoncology and an understanding about how it functions are necessary.

Secure Messaging and COVID-19: A Content Analysis of Patient-Clinician Communication During the Pandemic.

Background: Coronavirus disease 2019 (COVID-19) immediately impacted patient-clinician communication, particularly in the oncology setting. Relatedly, secure messaging (SM) usage greatly increased, yet it is unknown what was discussed and whether the technology was utilized to disseminate information. Aims: This study aimed at identifying the most frequently discussed topics using SM as well as at understanding how the communication process transpired during the early stages of the pandemic. Materials and Methods: A mixed-methods design was utilized, consisting of a content analysis of more than 4,200 secure messages, aggregated into 1,454 patient-clinician discussions. Data were collected from February 2020 to May 2020. Discussions were from various oncology departments and included physicians, physician assistants, and nurses. Based on the identified categories, a thematic analysis was conducted to understand the nuances occurring within discussions. Results: Out of the 1,454 discussions, 26% (n = 373) related to COVID-19. Of the COVID-19 discussion, the most frequently coded category was "changes, adjustments, and re-arranging care" (65%, n = 241), followed by "risk for COVID-19" (24%, n = 90), "precautions inside the hospital" (18%, n = 66), and "precautions outside the hospital" (14%, n = 52). Natural language processing techniques were used to confirm the validity of the results. Thematic analysis revealed that patients were proactive in rescheduling appointments, expressed anxiety about being immunocompromised, and clinicians were uncertain about providing recommendations related to COVID-19. Conclusions: The COVID-19 outbreak revealed the need for responsive and effective public health communication. The SM can disseminate information from trusted sources, clinicians, but can be better utilized to deliver tailored information for specific patient populations.

Streaming mindfulness: Well-being and mindfulness among subscribers to a video streaming service.

OBJECTIVE: Internet and smartphone technology have advanced the dissemination of mindfulness practices and philosophy. This study explored how individuals interact with Spectiv, a subscription-based video streaming service (VSS) that advertises content for meditation, and measured levels of mindfulness and well-being. We hypothesized that users engaging with Spectiv for longer sessions and on a regular basis would report higher levels of mindfulness and well-being. METHOD: A 46-question online survey was developed and distributed to all active subscribers of Spectiv (N = 119). The survey included two validated scales: (1) The Cognitive and Affective Mindfulness Scale, and (2) The Warwick-Edinburgh Mental Well-being Scale. A series of one-way ANOVAs were performed, along with a simple linear regression and descriptive statistics. RESULTS: Users reported relaxation as the most common activity. Levels of mindfulness and well-being were significantly higher for users whose session-duration lasted 2 hours (p = .01) and 3 hours (p = .03). Users engaging with the VSS daily had significant levels of both mindfulness (p < .001) and well-being (p < .001). There was no difference between subscription length and mindfulness and well-being. Mindfulness was found to be a significant positive predictor of well-being (p < .0001). CONCLUSION: VSS could be valuable to facilitating mindfulness. Users engaging with a VSS for longer durations and more frequently may be more likely to experience benefits. Future research using controlled designs such as randomized control trials and feasibility studies should be conducted to determine if VSS can maintain or increase levels of mindfulness and well-being.

When text simplification is not enough: could a graph-based visualization facilitate consumers' comprehension of dietary supplement information?

OBJECTIVE: Dietary supplements are widely used. However, dietary supplements are not always safe. For example, an estimated 23 000 emergency room visits every year in the United States were attributed to adverse events related to dietary supplement use. With the rapid development of the Internet, consumers usually seek health information including dietary supplement information online. To help consumers access quality online dietary supplement information, we have identified trustworthy dietary supplement information sources and built an evidence-based knowledge base of dietary supplement information-the integrated DIetary Supplement Knowledge base (iDISK) that integrates and standardizes dietary supplement related information across these different sources. However, as information in iDISK was collected from scientific sources, the complex medical jargon is a barrier for consumers' comprehension. The objective of this study is to assess how different approaches to simplify and represent dietary supplement information from iDISK will affect lay consumers' comprehension. MATERIALS AND METHODS: Using a crowdsourcing platform, we recruited participants to read dietary supplement information in 4 different representations from iDISK: (1) original text, (2) syntactic and lexical text simplification (TS), (3) manual TS, and (4) a graph-based visualization. We then assessed how the different simplification and representation strategies affected consumers' comprehension of dietary supplement information in terms of accuracy and response time to a set of comprehension questions. RESULTS: With responses from 690 qualified participants, our experiments confirmed that the manual approach, as expected, had the best performance for both accuracy and response time to the comprehension questions, while the graph-based approach ranked the second outperforming other representations. In some cases, the graph-based representation outperformed the manual approach in terms of response time. CONCLUSIONS: A hybrid approach that combines text and graph-based representations might be needed to accommodate consumers' different information needs and information seeking behavior.

Vaping and Instagram: A Content Analysis of e-Cigarette Posts Using the Content Appealing to Youth (CAY) Index.

BACKGROUND: The promotion of flavors, perceptions of "coolness," and general curiosity are characteristics of electronic nicotine delivery systems (ENDS) that have appealed to young adults. However, little is known about the characteristics of popular social media posts related to ENDS on the social media network, Instagram. Methods: Content analysis was performed using the Content Appealing to Youth (CAY) index. Over 700 posts were collected from August 2019 - December 2019 by searching the Instagram hashtags, #vape and #vapelife. Frequencies and percentages were calculated for each of the six major categories and 35 sub-categories. Results: Nearly all of the images were color photographs and 84% featured an ENDS device (mod) as the focal point. The style of the device was often matte (75%) in only one or two main colors (55%). Warnings about age restrictions and nicotine were included in 28% of images, but commonly used promotional tactics, such as humor, presence of vapor puffs, and flavors were rarely utilized. Conclusions: Instagram posts featuring ENDS are visually appealing and like cigarette packaging, may have the capacity to influence perceptions about the product. Since it is culturally normative for appealing images to be shared on Instagram, greater attention should be placed on media literacy skills to educate young adults about ENDS viewed on social media.

The Causal Relationship Between Portal Usage and Self-Efficacious Health Information-Seeking Behaviors: Secondary Analysis of the Health Information National Trends Survey Data.

BACKGROUND: Patient portals have drawn much attention, as they are considered an important tool for health providers in facilitating patient engagement. However, little is known about whether the intensive use of patient portals contributes to improved management of patients' health in terms of their confidence in acquiring health information and exercising self-care. There is a lack of randomized trials with these outcomes measured both pre- and postadoption of patient portals. OBJECTIVE: The aim of this study was to examine the causal relationship between the usage of patient portals and patients' self-efficacy toward obtaining health information and performing self-care. METHODS: This study was a secondary data analysis that used data from a US national survey, the National Cancer Institute's Health Information National Trends Survey 5 Cycle 1. Patient portal usage frequency was used to define the treatment. Survey items measuring self-efficacy on a Likert-type scale were selected as the main outcomes, including patients' confidence in obtaining health information and performing self-care. To establish causality using survey data, we adopted the instrumental variables method. To determine the direction of the causal relationship in the presence of high-dimensional confounders, we further proposed a novel testing framework that employs conditional independence tests in a directed acyclic graph. The average causal effect was measured using the two-stage least squares regression method. RESULTS: We showed that frequently using patient portals improves patients' confidence in obtaining health information. The estimand of the weighted average causal effect was 0.14 (95% CI 0.06-0.23; P<.001). This means that when increasing the portal usage intensity, for instance, from 1-2 times to 3-5 times per year, the expected average increase in confidence level measured on a Likert-type scale would be 0.14. However, we could not conclusively determine the causal effect between patient portal usage and patients' confidence in exercising self-care. CONCLUSIONS: The results support the use of patient portals and encourage better support and education to patients. The proposed statistical method can be used to exploit the potential of national survey data for causal inference studies.