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  • 1.
    Collier, Elizabeth S.
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences. Linköping University, Faculty of Medicine and Health Sciences. RISE Res Inst Sweden, Sweden.
    Harris, Kathryn L.
    RISE Res Inst Sweden, Sweden.
    Jecks, Michael
    Independent Scholar, UK.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Dont throw the individual perspective out while waiting for systemic change2023In: Behavioral and Brain Sciences, ISSN 0140-525X, E-ISSN 1469-1825, Vol. 46, article id e154Article in journal (Other academic)
    Abstract [en]

    Although it is clear that i-frame approaches cannot stand alone, the impact of s-frame changes can plateau. Combinations of these approaches may best reflect what we know about behavior and how to support behavioral change. Interactions between i-frame and s-frame thinking are explored here using two examples: alcohol consumption and meat consumption.

  • 2.
    Alexandrou, Christina
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    Henriksson, Hanna
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Henstrom, Maria
    Karolinska Inst, Sweden.
    Henriksson, Pontus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Nystrom, Christine Delisle
    Karolinska Inst, Sweden.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Löf, Marie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    Effectiveness of a Smartphone App (MINISTOP 2.0) integrated in primary child health care to promote healthy diet and physical activity behaviors and prevent obesity in preschool-aged children: randomized controlled trial2023In: International Journal of Behavioral Nutrition and Physical Activity, ISSN 1479-5868, E-ISSN 1479-5868, Vol. 20, no 1, article id 22Article in journal (Refereed)
    Abstract [en]

    Background:Childhood overweight and obesity is a public health priority. We have previously reported the efficacy of a parent-oriented mobile health (mHealth) app-based intervention (MINISTOP 1.0) which showed improvements in healthy lifestyle behaviors. However, the effectiveness of the MINISTOP app in real-world conditions needs to be established. Objective:To evaluate the real-world effectiveness of a 6-month mHealth intervention (MINISTOP 2.0 app) on childrens intake of fruits, vegetables, sweet and savory treats, sweet drinks, moderate-to-vigorous physical activity, and screen time (primary outcomes), and on parental self-efficacy (PSE) for promoting healthy lifestyle behaviors, and childrens body mass index (BMI) (secondary outcomes). Methods:A hybrid type 1 effectiveness-implementation design was utilized. For the effectiveness outcomes, a two-arm, individually randomized controlled trial was conducted. Parents (n = 552) of 2.5-to-3-year-old children were recruited from 19 child health care centers across Sweden, and, randomized to either a control (standard care) or intervention group (MINISTOP 2.0 app). The 2.0 version was adapted and translated into English, Somali and Arabic to increase reach. All recruitment and data collection were conducted by the nurses. Outcomes were assessed at baseline and after six months, using standardized measures (BMI) and a questionnaire (health behaviors, PSE). Results:Among the participating parents (n = 552, age: 34.1 +/- 5.0 years), 79% were mothers and 62% had a university degree. Twenty-four percent (n = 132) of children had two foreign-born parents. At follow-up, parents in the intervention group reported lower intakes of sweet and savory treats (-6.97 g/day; p = 0.001), sweet drinks (-31.52 g/day; p < 0.001), and screen time (-7.00 min/day; p = 0.012) in their children compared to the control group. The intervention group reported higher total PSE (0.91; p = 0.006), PSE for promoting healthy diet (0.34; p = 0.008) and PSE for promoting physical activity behaviors (0.31; p = 0.009) compared to controls. No statistically significant effect was observed for childrens BMI z-score. Overall, parents reported high satisfaction with the app, and 54% reported using the app at least once a week. Conclusion:Children in the intervention group had lower intakes of sweet and savory treats, sweet drinks, less screen time (primary outcomes) and their parents reported higher PSE for promoting healthy lifestyle behaviors. Our results from this real-world effectiveness trial support the implementation of the MINISTOP 2.0 app within Swedish child health care.

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  • 3.
    Blomqvist, Jenny
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Ulfsdotter Gunnarsson, Katarina
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bendtsen, Preben
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Operations management NSV. Dept Med Specialist, Sweden.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Effects of a text messaging smoking cessation intervention amongst online help-seekers and primary health care visitors: findings from a randomised controlled trial2023In: BMC Medicine, E-ISSN 1741-7015, Vol. 21, no 1, article id 382Article in journal (Refereed)
    Abstract [en]

    Background Smoking continues to be a leading risk factor for several diseases globally. We hypothesised that an intervention delivered via text messages could help individuals who were looking to quit.Methods A two-arm, parallel-groups, randomised controlled trial was employed. Both groups received treatment as usual, with the intervention group also receiving a 12-week text messaging intervention. Participants were adult, weekly or more frequent smokers, recruited online and in primary health care centres. Research personnel were blinded, while participants were not. Primary outcomes were prolonged abstinence and point prevalence of abstinence, 3 and 6 months post-randomisation. All randomised participants were included in analyses.Results Between 18 September 2020 and 16 June 2022, we randomised 1012 participants (intervention: 505, control: 507). Outcome data was available for 67% (n = 682) of participants at 3 months and 64% (n = 643) at 6 months. At 3 months, the odds ratio (OR) of prolonged abstinence was 2.15 (95% compatibility interval [CoI] = 1.51; 3.06, probability of effect [POE] > 99.9%, p < 0.0001), and for point prevalence of abstinence, it was 1.70 (95% CoI = 1.18; 2.44, POE = 99.8%, p = 0.0034) in favour of the text messaging intervention. At 6 months, the OR of prolonged abstinence was 2.38 (95% CoI = 1.62; 3.57, POE > 99.9%, p = < 0.0001), and for point prevalence, it was 1.49 (95% CoI = 1.03; 2.14, POE = 98.3%, p = 0.0349) in favour of the text messaging intervention. Analyses with imputed data were not markedly different.Conclusions Amongst general population help-seekers-who on average had smoked for 25 years-access to a 12-week text messaging intervention produced higher rates of self-reported smoking abstinence in comparison to treatment as usual only. The intervention could be part of the societal response to the burden which smoking causes; however, findings are limited by risk of bias due to attrition, self-reported outcomes, and lack of blinding.

  • 4.
    Åsberg, Katarina
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Evaluating the effectiveness of a brief digital procrastination intervention targeting university students in Sweden: study protocol for the Focus randomised controlled trial2023In: BMJ Open, E-ISSN 2044-6055, Vol. 13, no 7, article id e072506Article in journal (Refereed)
    Abstract [en]

    Introduction The concept of procrastination can be described as a conscious, yet irrational, postponement of important tasks or decisions-despite awareness that the delay may lead to negative consequences. Procrastination behaviours are common among university students and is often described as a failure of self-regulation, and the behaviour is associated with stress, symptoms of depression and anxiety, poorer academic performance and negative effects on overall health and well-being.Methods and analysis A two-arm, parallel groups (1:1), single-blind randomised controlled trial will be conducted to assess the effectiveness of a brief digital procrastination intervention (Focus) among university students in Sweden. The intervention consists of a screening and feedback component based on Pure Procrastination Scale (PPS) score, allowing intervention participants to assess their current procrastination behaviours and receive behaviour change advice. Participants in the control group will be shown their total PPS score without any further feedback. Monte Carlo simulations (assuming a standardised effect of 0.35 Cohens d of the intervention on the primary outcome, to at least 80% of the time estimate a posterior probability of effect of at least 95%) indicated that data from 1000 participants are required for analysis, meaning that 2000 participants are required to be randomised when assuming a 50% attrition rate. The primary outcome will be procrastination behaviour measured at 2 months postrandomisation. Secondary outcomes will be anxiety and stress symptoms and lifestyle behaviours. Outcomes will be analysed using multilevel regression models estimated using Bayesian inference.Ethics and dissemination The study was approved by the Swedish Ethical Review Authority on 2022-08-24 (dnr 2022-00353). Students will be asked to give informed consent before participation and after having been given information about the study. The results will be submitted for publication in open access, peer-reviewed journals.

  • 5.
    Shorter, G. W.
    et al.
    Queens Univ Belfast, North Ireland; Queens Univ Belfast, North Ireland.
    Campbell, K. B. D.
    Queens Univ Belfast, North Ireland; Queens Univ Belfast, North Ireland.
    Miller, N. M.
    Univ West London, England.
    Epton, T.
    Univ Manchester, England.
    OHara, L.
    Queens Univ Belfast, North Ireland; Queens Univ Belfast, North Ireland.
    Millen, S.
    Queens Univ Belfast, North Ireland; Queens Univ Belfast, North Ireland.
    Ulfsdotter Gunnarsson, Katarina
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Berry, E.
    Queens Univ Belfast, North Ireland.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Few Interventions Support the Affected Other on Their Own: a Systematic Review of Individual Level Psychosocial Interventions to Support Those Harmed by Others Alcohol Use2023In: International Journal of Mental Health and Addiction, ISSN 1557-1874, E-ISSN 1557-1882Article, review/survey (Refereed)
    Abstract [en]

    Over 100 million individuals worldwide experience negative outcomes as a function of a family member or loved ones substance use. Other reviews have summarized evidence on interventions; however, success often depends on the behavior of the individual causing harm, and they may not be ready or able to change. The aim of this study was to identify and describe evaluations of psychosocial interventions which can support those affected by alcohol harm to others independent of their drinking relative or friend. A systematic review/narrative synthesis of articles from 11 databases pre-registered on PROSPERO (CRD42021203204) was conducted. Those experiencing the harm were spouses/partners or adult children/students who have parents with alcohol problems. Studies (n = 7) were from the UK, the USA, Korea, Sweden, Mexico, and India. Most participants were female (71-100%). Interventions varied from guided imagery, cognitive behavioral therapy, motivational interviewing, and anger management. Independent interventions may support those affected by anothers alcohol use, although there was considerable variation in outcomes targeted by the intervention design. Small-scale studies suggest psychosocial interventions ease suffering from alcohols harm to others, independent of the drinking family member. Understanding affected others experience and need is important given the impact of alcohols harm to others; however, there is a lack of quality evidence and theoretical underpinning informing strategies to support these individuals.

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  • 6.
    Collier, Elizabeth S.
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. RISE Res Inst Sweden, Sweden.
    Harris, Kathryn L.
    RISE Res Inst Sweden, Sweden.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Norman, Cecilia
    RISE Res Inst Sweden, Sweden.
    Niimi, Jun
    RISE Res Inst Sweden, Sweden.
    Just a matter of taste? Understanding rationalizations for dairy consumption and their associations with sensory expectations of plant-based milk alternatives2023In: Food Quality and Preference, ISSN 0950-3293, E-ISSN 1873-6343, Vol. 104, article id 104745Article in journal (Refereed)
    Abstract [en]

    Although knowledge surrounding the obstacles omnivorous consumers face when substituting meat products with plant-based alternatives has increased dramatically, less is known about their perspectives on plant-based alternatives to dairy products. Here, these perspectives are assessed in two survey-based studies. Study 1 (N = 175) adapts an existing scale (the 4Ns of meat consumption) to dairy products in an effort to identify similarities and differences between rationalizations for meat and dairy consumption. This 16-item scale quantifies four factors (Natural, Necessary, Normal, and Nice) describing common rationalizations for meat consumption. The results revealed that the 4Ns transfer well to the dairy category, and that endorsement of dairy products as Nice was the strongest predictor of dairy consumption, relative to the other 3Ns. This is further supported by evaluation of consumers own qualitative descriptions of why they do or do not consume meat/dairy products, where "taste" was the most frequently used word in both categories. Study 2 replicates the relationships between dairy 4Ns scores and reported dairy consumption found in Study 1 and builds upon these results by showing that 4N score could accurately categorize consumers as frequent (N = 192) or infrequent (N = 210) consumers of plant-based milk alternatives (PBMAs). Differences in consumers expectations for the sensory characteristics of cows milk and PBMAs are identified, and the impact of rationalization (total 4N score) on the likelihood of expected sensory attribute associations is described. The role of rationalization in shaping sensory expectations and impacting dietary choices, in particular resistance to adopting PBMAs, is discussed.

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  • 7.
    Hurtig, Caroline
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Nursing Sciences and Reproductive Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Arestedt, Liselott
    Linnaeus Univ, Sweden.
    Uhlin, Fredrik
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Diagnostics and Specialist Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Medicine Center, Department of Nephrology. Tallinn Univ Technol TalTech, Estonia.
    Eldh, Ann Catrine
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Nursing Sciences and Reproductive Health. Linköping University, Faculty of Medicine and Health Sciences. Uppsala Univ, Sweden.
    Patient participation in end-stage kidney disease care: variation over time and effects of staff-directed interventions - a quasi-experimental study2023In: BMC Nephrology, ISSN 1471-2369, E-ISSN 1471-2369, Vol. 24, no 1, article id 265Article in journal (Refereed)
    Abstract [en]

    Background Among those elements establishing decent quality of care from a patient perspective, opportunities to participate in accord with ones individual needs and preferences are central. To date, little is known the extent of preference-based patient participation in kidney care, and what facilitates optimal conditions. This study investigated i) preference-based patient participation in kidney care over time, and ii) the effects of interventions designed to enhance person-centred patient participation.Methods A quasi-experimental study was conducted across nine kidney care sites in southeast Sweden. A cohort of 358 patients with stage IV chronic kidney disease (eGRF 15-19 ml/min) or V (eGRF < 15 mL/min) entered the study. Of these, 245 patients (with kidney replacement therapy or intermittent outpatient visits only) completed a survey on patient participation at four time points: every six months from August 2019 to May 2021, patients reported their preferences for and experiences of participation using the validated Patient Preferences for Patient Participation tool, the 4Ps. Between the first and second data collection points, interventions were provided for designated staff to facilitate person-centred participation, using two strategies for two subgroups at three sites each: the managers receiving a bundle of information via e-mail on patient participation in a standard dissemination procedure (three sites), or an additional half-year support program for implementation offered to 1-2 staff per site (three sites), with no intervention for a control group (three sites). The differences in 4Ps data between groups were analysed using multilevel ordinal regression.Results Over time and across all sites, most patients experiences of participation fully or almost fully matched their engagement preferences (57%-90%). Still, up to 12% of patient reports indicated that their preferences and experiences were insufficiently matched: in these cases, the patients had preferred to be more involved than they had experienced, for example, in making healthcare plans and setting health-related goals. The interventions did not affect the levels of preference-based participation, but patients in the control group sites had slightly more consistent matches.Conclusions Living with kidney failure necessitates patient engagement, but opportunities to participate in accordance with ones preferences are not fully provided for all patients. Additional efforts to support a common understanding and to ensure person-centred patient participation is still needed.

  • 8.
    Ulfsdotter Gunnarsson, Katarina
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    McCambridge, Jim
    Univ York, England.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Reactions to being allocated to a waiting list control group in a digital alcohol intervention trial2023In: Patient Education and Counseling, ISSN 0738-3991, E-ISSN 1873-5134, Vol. 107, article id 107572Article in journal (Refereed)
    Abstract [en]

    Objective: To study reactions of control group participants allocated to two different presentations of basic health information in a digital alcohol intervention trial.Method: Control participants were randomised to wait with one of two different presentations of basic health information. Multiple choice questions and free-text comments assessed reactions, four months post random-isation. Effects of differential health information on responses were estimated, as were associations between responses, baseline characteristics and change in alcohol consumption.Result: Of 1066 control group participants, 572 (54%) responded to the questionnaire. Contrasting two different presentations of basic health information revealed no statistically significant differences. Responses revealed that 38% were interested sufficiently to look at the information while 42% felt frustration, irritation, or disap-pointment about having to wait. Approximately 55% responded that they decided to reduce their drinking whilst 17% stated that they continued to drink as usual, and 11% gave up on the idea of reducing their drinking. The two latter groups reported markedly higher alcohol consumption at follow-up in comparison to the former (probability of association >99.9%).Conclusion: Being made to wait may invite negative research participation effects. Practice implication: Comparator guidance should be updated to reflect the potentially negative consequences which are under researched.

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  • 9.
    Collier, Elizabeth S.
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. RISE Res Inst Sweden, Sweden.
    Blomqvist, Jenny
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Satisfaction with a digital support tool targeting alcohol consumption: perspectives from participants in a randomized control trial2023In: Alcohol and Alcoholism, ISSN 0735-0414, E-ISSN 1464-3502Article in journal (Refereed)
    Abstract [en]

    Aim Intervention design may be improved through evaluating the feedback from those who have been exposed to such interventions. As such, here the perspectives of the intervention group from a recent randomized control trial investigating the effectiveness of a digital alcohol intervention, in terms of perceived suitability and usefulness of the support tool they engaged with, were investigated.Methods Respondents (N=475; 45% of the intervention group) answered five quantitative questions addressing user experience, completed the 10-item System Useability Scale, and were offered the opportunity to write free-text feedback. Quantitative measures were analysed using ordinal and linear regression with baseline characteristics as predictors, and free-text responses were evaluated using content analysis.Results Overall, respondents were positive towards the intervention in terms of it fitting their needs, the usefulness of the tools included, and the usefulness of text message content. The intervention was perceived as more helpful by respondents with lower total weekly alcohol consumption, higher self-reported confidence in their ability to reduce their drinking, and the perceived importance there of, at baseline. The free-text comments revealed the value of reminders as prompts to reflect on ones own drinking behaviour. Nonetheless, criticisms of the intervention were voiced, primarily highlighting the repetitive nature of the reminders and the lack of individuation in advice. Some also feltlike the intervention was impersonal and targeted only a specific drinking pattern.Conclusions Experiences of the intervention group in this trial were generally positive, though there may be demand for more individualised, targeted intervention design. Short Summary: Perspectives from participants in a recent parallel group randomized effectiveness trial of a digital alcohol intervention are investigated. Experiences were generally positive, and the efficacy of the behavioural change mechanisms underpinning the intervention design are supported. Nonetheless, more individualized, targeted intervention design may be beneficial in the future.

  • 10.
    Andersson, Roland
    et al.
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Surgery, Orthopedics and Oncology. Linköping University, Faculty of Medicine and Health Sciences. Cty Hosp Ryhov, Sweden; Acad Hlth & Care, Sweden.
    Agiorgiti, Maria
    Bra Liv Eksjo Primary Care Ctr, Sweden; Univ Ioannina, Greece.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Spontaneous Resolution of Uncomplicated Appendicitis may Explain Increase in Proportion of Complicated Appendicitis During Covid-19 Pandemic: a Systematic Review and Meta-analysis2023In: World Journal of Surgery, ISSN 0364-2313, E-ISSN 1432-2323, Vol. 47, p. 1901-1916Article, review/survey (Refereed)
    Abstract [en]

    BackgroundReports of an increased proportion of complicated appendicitis during the Covid-19 pandemic suggest a worse outcome due to delay secondary to the restrained access to health care, but may be explained by a concomitant decrease in uncomplicated appendicitis. We analyze the impact of the pandemic on the incidences of complicated and uncomplicated appendicitis.MethodWe did a systematic literature search in the PubMed, Embase and Web Of Science databases on December 21, 2022 with the search terms (appendicitis OR appendectomy) AND ("COVID" OR SARS-Cov2 OR "coronavirus"). Studies reporting the number of complicated and uncomplicated appendicitis during identical calendar periods in 2020 and the pre-pandemic year(s) were included. Reports with indications suggesting a change in how the patients were diagnosed and managed between the two periods were excluded. No protocol was prepared in advance. We did random effects meta-analysis of the change in proportion of complicated appendicitis, expressed as the risk ratio (RR), and of the change in number of patients with complicated and uncomplicated appendicitis during the pandemic compared with pre-pandemic periods, expressed as the incidence ratio (IR). We did separate analyses for studies based on single- and multi-center and regional data, age-categories and prehospital delay.ResultsThe meta-analysis of 100,059 patients in 63 reports from 25 countries shows an increase in the proportion of complicated appendicitis during the pandemic period (RR 1.39, 95% confidence interval (95% CI 1.25, 1.53). This was mainly explained by a decreased incidence of uncomplicated appendicitis (incidence ratio (IR) 0.66, 95% CI 0.59, 0.73). No increase in complicated appendicitis was seen in multi-center and regional reports combined (IR 0.98, 95% CI 0.90, 1.07).ConclusionThe increased proportion of complicated appendicitis during Covid-19 is explained by a decrease in the incidence of uncomplicated appendicitis, whereas the incidence of complicated appendicitis remained stable. This result is more evident in the multi-center and regional based reports. This suggests an increase in spontaneously resolving appendicitis due to the restrained access to health care. This has important principal implications for the management of patients with suspected appendicitis.

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  • 11.
    Bendtsen, Marcus
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Garnett, Claire
    UCL, England.
    Toner, Paul
    Queens Univ Belfast, North Ireland.
    Shorter, Gillian W.
    Queens Univ Belfast, North Ireland; Queens Univ Belfast, North Ireland.
    The effect of question order on outcomes in the orbital core outcome set for alcohol brief interventions among online help-seekers (QOBCOS): Findings from a randomised factorial trial2023In: DIGITAL HEALTH, ISSN 2055-2076, Vol. 9Article in journal (Refereed)
    Abstract [en]

    ObjectiveA core outcome set (COS) has been developed in alcohol brief intervention (ABI) research through international consensus. This study aimed to estimate order effects among questions in the COS. MethodsIndividuals aged 18 or older who searched online for alcohol-related help were invited to complete the COS. The order of questions was randomised following a factorial design. Primary outcomes were order effects among the COS items and patterns of attrition. ResultsBetween 21/10/2020 and 26/11/2020, we randomised 7334 participants, of which 5256 responded to at least one question and were available for analyses. Current non-drinkers were excluded. We found evidence of higher self-reported average consumption and odds of harmful and hazardous drinking was found among those who first answered questions on recent consumption and impact of alcohol use. Lower self-reported recent consumption was found among those first asked about average consumption. Quality of life (QoL) was reported lower among those who first responded to when questions on impact of alcohol use were asked first, which in turn was lower among those who first answered question on when average consumption and QoL were asked first. Attrition was lowest when average consumption was asked first, and highest when QoL or impact of alcohol use was asked first. Median completion time for the COS was 4.3 min. ConclusionsQuestion order affects outcomes and attrition. If the aim is to minimize attrition, consumption measures should be asked before QoL and impact of alcohol use; however, this order impacts self-reported alcohol consumption and so researchers should be guided by study priorities. At a minimum, all participants should be asked the same questions in the same order.

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  • 12.
    Åsberg, Katarina
    et al.
    Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Region Östergötland, Regionledningskontoret, Enheten för folkhälsa.
    Eldh, Ann Catrine
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Nursing Sciences and Reproductive Health. Linköping University, Faculty of Medicine and Health Sciences. Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.
    Löf, Marie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Department of Biosciences and Nutrition, Karolinska Institute, Solna, Sweden.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    A balancing act–finding one´s way to health and well-being: A qualitative analysis of interviews with Swedish university students on lifestyle and behavior change2022In: PLOS ONE, E-ISSN 1932-6203, Vol. 17, no 10, article id e0275848Article in journal (Refereed)
    Abstract [en]

    Introduction Unhealthy lifestyle behaviors such as unhealthy diets, low physical activity levels, smoking, and harmful alcohol consumption are common in student populations, which constitute a large group of young adults. As unhealthy lifestyle behaviors are associated with future disease and premature mortality, most commonly from cardiovascular disease and cancers, it is from a public health perspective important to understand such behaviors in young adult populations. The objective of this study was to investigate university students experiences of health, health-related behaviors, and the barriers and facilitators for behavior change in terms of health promotion in everyday life. Materials and methods This qualitative study was conducted at a middle-sized university in Sweden. Students represented different faculties and were recruited via non-probability convenience sampling using means such as the snowball technique and social media. The 21 interviews with 24 students, individually or in groups, were transcribed verbatim prior to a qualitative analysis inspired by phenomenological hermeneutics. Results Our interviews showed that university student life is associated with new health-related challenges, for example study-related stress and procrastination implies a lack of energy to engage in healthy routines such as physical activity, and a limited budget affects food choices. While adapting to a new context, students explore personal strategies such as taking on changes in manageable steps, seeking social support, and avoiding disturbances to maintaining health and quality of life. Conclusions Experiences of health while becoming and being a university student can be described as a transition-a balancing act of walking a slack line-during which students seek to manage a healthy balance. In the past, interventions have to some extent been designed to address university students behaviors; however, our study aids an understanding of their needs. Future interventions should highlight the transitions they are experiencing and the challenges of student life.

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  • 13.
    Andersson, Claes
    et al.
    Malmo Univ, Sweden; Uppsala Univ, Sweden.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Molander, Olof
    Karolinska Inst, Sweden; Stockholm Hlth care Serv, Sweden.
    Lindner, Philip
    Karolinska Inst, Sweden; Stockholm Hlth care Serv, Sweden.
    Granlund, Lilian
    Uppsala Univ, Sweden.
    Topooco, Naira
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Engstroem, Karin
    Karolinska Inst, Sweden.
    Lindfors, Petra
    Stockholm Univ, Sweden.
    Berman, Anne H. H.
    Uppsala Univ, Sweden; Karolinska Inst, Sweden; Stockholm Hlth care Serv, Sweden.
    Academic self-efficacy: Associations with self-reported COVID-19 symptoms, mental health, and trust in universities management of the pandemic-induced university lockdown2022In: Journal of American College Health, ISSN 0744-8481, E-ISSN 1940-3208Article in journal (Refereed)
    Abstract [en]

    Objective: To investigate perceived changes in academic self-efficacy associated with self-reported symptoms of COVID-19, changes in mental health, and trust in universities management of the pandemic and transition to remote education during lockdown of Swedish universities in the spring of 2020. Methods: 4495 participated and 3638 responded to self-efficacy questions. Associations were investigated using multinomial regression. Results: Most students reported self-experienced effects on self-efficacy. Lowered self-efficacy was associated with symptoms of contagion, perceived worsening of mental health and low trust in universities capacity to successfully manage the lockdown and transition to emergency remote education. Increased self-efficacy was associated with better perceived mental health and high trust in universities. Conclusion: The initial phase of the pandemic was associated with a larger proportion of students reporting self-experienced negative effects on academic self-efficacy. Since self-efficacy is a predictor of academic performance, it is likely that students academic performance will be adversely affected.

  • 14.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Avoiding Under- and Overrecruitment in Behavioral Intervention Trials Using Bayesian Sequential Designs: Tutorial2022In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 24, no 12, article id e40730Article in journal (Refereed)
    Abstract [en]

    Reducing research waste and protecting research participants from unnecessary harm should be top priorities for researchers studying interventions. However, the traditional use of fixed sample sizes exposes trials to risks of under- and overrecruitment by requiring that effect sizes be determined a priori. One mitigating approach is to adopt a Bayesian sequential design, which enables evaluation of the available evidence continuously over the trial period to decide when to stop recruitment. Target criteria are defined, which encode researchers’ intentions for what is considered findings of interest, and the trial is stopped once the scientific question is sufficiently addressed. In this tutorial, we revisit a trial of a digital alcohol intervention that used a fixed sample size of 2129 participants. We show that had a Bayesian sequential design been used, the trial could have ended after collecting data from approximately 300 participants. This would have meant exposing far fewer individuals to trial procedures, including being allocated to the waiting list control condition, and the evidence from the trial could have been made public sooner.

  • 15.
    Anne, Berman
    et al.
    Department of Psychology, Uppsala University, Sweden ; Centre for Psychiatry Research, Karolinska Institutet and Stockholm Health Care Services, Sweden.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Molander, Olof
    Centre for Psychiatry Research, Karolinska Institutet and Stockholm Health Care Services, Sweden.
    Lindfors, Petra
    Department of Psychology, Stockholm University, Sweden.
    Lindner, Philip
    Centre for Psychiatry Research, Karolinska Institutet and Stockholm Health Care Services, Sweden.
    Granlund, Lilian
    Department of Psychology, Uppsala University, Sweden.
    Topooco, Naira
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Engström, Karin
    Department of Global Public Health, Karolinska Institutet, Sweden.
    Andersson, Claes
    Department of Psychology, Uppsala University, Sweden ; Department of Criminology, Malmö University, Sweden.
    Compliance with recommendations limiting COVID-19 contagion among university students in Sweden: associations with self-reported symptoms, mental health and academic self-efficacy2022In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 50, no 1, p. 70-84Article in journal (Refereed)
    Abstract [en]

    Aims: The COVID-19 containment strategy in Sweden uses public health recommendations relying on personal responsibilityfor compliance. Universities were one of few public institutions subject to strict closure, meaning that students had toadapt overnight to online teaching. This study investigates the prevalence of self-reported recommendation compliance andassociations with self-reported symptoms of contagion, self-experienced effects on mental health and academic self-efficacyamong university students in Sweden in May–June 2020. Methods: This was a cross-sectional 23 question online survey inwhich data were analysed by multinomial regression, taking a Bayesian analysis approach complemented by null hypothesistesting. Results: A total of 4495 students consented to respond. Recommendation compliance ranged between 70% and 96%.Women and older students reported higher compliance than did men and younger students. Mild to moderate COVID-19symptoms were reported by 30%, severe symptoms by fewer than 2%; 15% reported being uncertain and half of theparticipants reported no symptoms. Mental health effects were reported by over 80%, and changes in academic self-efficacywere reported by over 85%; in both these areas negative effects predominated. Self-reported symptoms and uncertaintyabout contagion were associated with non-compliance, negative mental health effects, and impaired academic self-efficacy.Conclusions: Students generally followed public health recommendations during strict closure of universities,but many reported considerable negative consequences related to mental health and academic self-efficacy.Digital interventions should be developed and evaluated to boost coping skills, build resilience and alleviatestudent suffering during the pandemic and future similar crises.

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  • 16.
    Åsberg, Katarina
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Regionledningskontoret, Enheten för folkhälsa.
    Blomqvist, Jenny
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Lundgren, Oskar
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Children's and Women's Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, H.K.H. Kronprinsessan Victorias barn- och ungdomssjukhus.
    Henriksson, Hanna
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Henriksson, Pontus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bendtsen, Preben
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Löf, Marie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Digital multiple health behaviour change intervention targeting online help seekers: protocol for the COACH randomised factorial trial2022In: BMJ Open, E-ISSN 2044-6055, Vol. 12, no 7, article id e061024Article in journal (Refereed)
    Abstract [en]

    Introduction Unhealthy lifestyle behaviours continue to be highly prevalent, including alcohol consumption, unhealthy diets, insufficient physical activity and smoking. There is a lack of effective interventions which have a large enough reach into the community to improve public health. Additionally, the common co-occurrence of multiple unhealthy behaviours demands investigation of efforts which address more than single behaviours. Methods and analysis The effects of six components of a novel digital multiple health behaviour change intervention on alcohol consumption, diet, physical activity and smoking (coprimary outcomes) will be estimated in a factorial randomised trial. The components are designed to facilitate behaviour change, for example, through goal setting or increasing motivation, and are either present or absent depending on allocation (ie, six factors with two levels each). The study population will be those seeking help online, recruited through search engines, social media and lifestyle-related websites. Included will be those who are at least 18 years of age and have at least one unhealthy behaviour. An adaptive design will be used to periodically make decisions to continue or stop recruitment, with simulations suggesting a final sample size between 1500 and 2500 participants. Multilevel regression models will be used to analyse behavioural outcomes collected at 2 months and 4 months postrandomisation. Ethics and dissemination Approved by the Swedish Ethical Review Authority on 2021-08-11 (Dnr 2021-02855). Since participation is likely motivated by gaining access to novel support, the main concern is demotivation and opportunity cost if the intervention is found to only exert small effects. Recruitment began on 19 October 2021, with an anticipated recruitment period of 12 months.

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  • 17.
    Bendtsen, Marcus
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Åsberg, Katarina
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Regionledningskontoret, Enheten för folkhälsa.
    McCambridge, Jim
    Univ York, England.
    Effectiveness of a digital intervention versus alcohol information for online help-seekers in Sweden: a randomised controlled trial2022In: BMC Medicine, E-ISSN 1741-7015, Vol. 20, no 1, article id 176Article in journal (Refereed)
    Abstract [en]

    Background: The ubiquity of Internet connectivity, and widespread unmet needs, requires investigations of digital interventions for people seeking help with their drinking. The objective of this study was to test the effectiveness of a digital alcohol intervention compared to existing online resources for help seekers. Methods: This parallel randomised controlled trial included 2129 risky drinkers with access to a mobile phone and aged 18 years or older. Randomised sub-studies investigated consent procedures and control group design. Simple computerised randomisation was used. Participants were aware of allocation after randomisation; research personnel were not. The digital intervention was designed around weekly monitoring of alcohol consumption followed by feedback and tools for behaviour change. Primary outcomes were total weekly consumption (TWC) and frequency of heavy episodic drinking (HED), measured 2 and 4 months post-randomisation. Results: Between 25/04/2019 and 26/11/2020, 2129 participants were randomised (intervention: 1063, control: 1066). Negative binomial regression was used to contrast groups, with both Bayesian and maximum likelihood inference. The posterior median incidence rate ratio (IRR) of TWC was 0.89 (95% CI = 0.81;0.99, 98.2% probability of effect, P-value = 0.033) at 2 months among 1557 participants and 0.77 (95% CI = 0.69;0.86, > 99.9% probability of effect, P-value < 0.001) at 4 months among 1429 participants. For HED, the IRR was 0.83 (95% CI = 0.75;0.93, > 99.9% probability of effect, P-value = 0.0009) at 2 months among 1548 participants and 0.71 (95% CI = 0.63;0.79, probability of effect > 99.9%, P-value < 0.0001) at 4 months among 1424 participants. Analyses with imputed data were not markedly different. Conclusions: A digital alcohol intervention produced self-reported behaviour change among online help seekers in the general population. The internal and external validity of this trial is strong, subject to carefully considered study limitations arguably inherent to trials of this nature. Limitations include higher than anticipated attrition to follow-up and lack of blinding.

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  • 18.
    Barticevic, Nicolas A.
    et al.
    Pontificia Univ Catolica Chile, Chile.
    Poblete, Fernando
    Pontificia Univ Catolica Chile, Chile.
    Bradshaw, Laura
    Pontificia Univ Catolica Chile, Chile.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Effectiveness of a health technician-delivered brief intervention for alcohol: a Bayesian reanalysis of a clinical trial2022In: BMC Research Notes, ISSN 1756-0500, E-ISSN 1756-0500, Vol. 15, no 1, article id 182Article in journal (Refereed)
    Abstract [en]

    Objective To reanalyze a clinical trial on the effectiveness of a Brief Intervention (BI) delivered by non-professionals to reduce risky alcohol drinking. Our previous null-hypothesis test of the effects of the BI yielded a non-significant p-value, yet remained uninformative. Here we use the Bayesian paradigm which allows for expressing the probability of different effect sizes to better inform public policy decisions. Results The posterior probability of the odds of risky drinking at follow-up favored a marked effect of the BI, with 96% of the probability mass being less than OR = 1, and 84% being less than OR = 0.8. Our findings show that there is a high probability that the BI delivered by health technicians lowered risky alcohol use. The posterior distributions of the BIs effects are presented to help contextualize the evidence for policy making in Chile.

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  • 19.
    Niimi, Jun
    et al.
    RISE Res Inst Sweden, Sweden.
    Collier, Elizabeth S.
    RISE Res Inst Sweden, Sweden.
    Oberrauter, Lisa-Maria
    RISE Res Inst Sweden, Sweden.
    Sörensen, Victoria
    RISE Res Inst Sweden, Sweden.
    Norman, Cecilia
    RISE Res Inst Sweden, Sweden.
    Normann, Anne
    RISE Res Inst Sweden, Sweden.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bergman, Penny
    RISE Res Inst Sweden, Sweden.
    Sample discrimination through profiling with rate all that apply (RATA) using consumers is similar between home use test (HUT) and central location test (CLT)2022In: Food Quality and Preference, ISSN 0950-3293, E-ISSN 1873-6343, Vol. 95, article id 104377Article in journal (Refereed)
    Abstract [en]

    The impact of testing locations, home use test (HUT) and central location test (CLT) on consumer evaluations of food products using rate all that apply (RATA) was investigated. As a case study, eight cold cuts were evaluated: four vegetarian/vegan and four meat-based products. A between-subjects design was used, whereby consumers were randomly allocated to either HUT or CLT test location (58 and 71 consumers, respectively). To retain as much similarity as possible across locations, consumers in both groups received identical bags of products with palate cleansers and instructions. Consumers evaluated the products using a lexicon consisting of 32 sensory attributes based on similar studies and benchtop tasting, using RATA with 7pt scales. A total of 30 and 31 attributes differed significantly (p < 0.05) across the products for HUT and CLT, respectively. Sample discrimination was similar between the two locations. Location significantly (p < 0.05) affected discrimination of 14 attributes, but a particular location having consistently higher attribute means was not observed. Bootstrapping of the attribute means per product showed no significant differences between the two testing locations, and multilevel regression models using Bayesian inference did not reveal marked differences in expected ratings between locations. Further comparisons of sample discrimination patterns through principal component analysis showed that the two locations were very similar, including the overlap of confidence ellipses. The betweensubjects design strengthens the results: that comparable sensory profiles were obtained from different consumers in different testing locations supports the notion that RATA data from consumers can be reliably collected for relatively sensorially distinct products with minimal data compromise.

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  • 20.
    Andersson, Claes
    et al.
    Malmo Univ, Sweden; Uppsala Univ, Sweden.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Molander, Olof
    Karolinska Inst, Sweden; Reg Stockholm, Sweden.
    Granlund, Lilian
    Uppsala Univ, Sweden.
    Topooco, Naira
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Engstrom, Karin
    Karolinska Inst, Sweden.
    Lindfors, Petra
    Stockholm Univ, Sweden.
    Berman, Anne H.
    Uppsala Univ, Sweden; Karolinska Inst, Sweden; Reg Stockholm, Sweden.
    Symptoms of COVID-19 contagion in different social contexts in association to self-reported symptoms, mental health and study capacity in Swedish university students2022In: BMC Research Notes, ISSN 1756-0500, E-ISSN 1756-0500, Vol. 15, no 1, article id 131Article in journal (Refereed)
    Abstract [en]

    Objective The present study investigates if symptoms of COVID-19 contagion in different social contexts (cohabitants, family, acquaintances, and others) are associated with university students own self-reported symptoms of COVID-19 contagion, mental health, and study capacity. This was investigated by a cross-sectional survey administrated in Sweden during the first wave of the COVID-19 pandemic, at the time when universities were locked down to limit viral spread and contagion. Results Mild to moderate symptoms of COVID-19 in cohabitants and family members were associated with students self-reported symptoms of contagion, while no associations could be seen in relation to mental health and study capacity. Symptoms of COVID-19 contagion in acquaintances and others were not associated with students self-reported symptoms, nor with their mental health and study capacity. To conclude, during the initial lockdown of universities students self-reported symptoms of contagion were mainly associated with cohabitants and family members, while symptoms of contagion in different social contexts were not associated with mental health and study capacity. Findings suggest that lockdown of universities may have contributed to limiting infection pathways, while still allowing students to focus on their studies despite significant contagion among others known to the student.

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  • 21.
    Sandborg, Johanna
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    Henriksson, Pontus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Söderström, Emmie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Hidalgo Migueles, Jairo Hidalgo
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden; Univ Granada, Spain.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Blomberg, Marie
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Children's and Women's Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Linköping.
    Löf, Marie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    The effects of a lifestyle intervention (the HealthyMoms app) during pregnancy on infant body composition: Secondary outcome analysis from a randomized controlled trial2022In: Pediatric Obesity, ISSN 2047-6302, E-ISSN 2047-6310, Vol. 17, no 6, article id e12894Article in journal (Refereed)
    Abstract [en]

    Background Pregnancy has been identified as a window for childhood obesity prevention. Although lifestyle interventions in pregnancy can prevent excessive gestational weight gain (GWG), little is known whether such interventions also affect infant growth and body composition. Objectives To investigate (i) the effects of a 6-month lifestyle intervention (the HealthyMoms app) on infant body composition 1-2 weeks postpartum, and (ii) whether a potential intervention effect on infant body composition is mediated through maternal GWG. Methods This is a secondary outcome analysis of the HealthyMoms randomized controlled trial. Air-displacement plethysmography was used to measure body composition in 305 healthy full-term infants. Results We observed no statistically significant effect on infant weight (beta = -0.004, p = 0.94), length (beta = -0.19, p = 0.46), body fat percentage (beta = 0.17, p = 0.72), or any of the other body composition variables in the multiple regression models (all p >= 0.27). Moreover, we observed no mediation effect through GWG on infant body composition. Conclusions Our findings support that HealthyMoms may be implemented in healthcare to promote a healthy lifestyle in pregnant women without compromising offspring growth. Further research is required to elucidate whether lifestyle interventions in pregnancy also may result in beneficial effects on infant body composition and impact future obesity risk.

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  • 22.
    Andersson, Claes
    et al.
    Malmo Univ, Sweden; Uppsala Univ, Sweden.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Molander, Olof
    Stockholm Hlth Care Serv, Sweden.
    Granlund, Lilian
    Uppsala Univ, Sweden.
    Topooco, Naira
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Engström, Karin
    Karolinska Inst, Sweden.
    Lindfors, Petra
    Stockholm Univ, Sweden.
    Berman, Anne H.
    Uppsala Univ, Sweden; Stockholm Hlth Care Serv, Sweden.
    Associations between compliance with covid-19 public health recommendations and perceived contagion in others: a self-report study in Swedish university students2021In: BMC Research Notes, ISSN 1756-0500, E-ISSN 1756-0500, Vol. 14, no 1, article id 429Article in journal (Refereed)
    Abstract [en]

    Objective: During the COVID pandemic, government authorities worldwide have tried to limit the spread of the virus. Swedens distinctive feature was the use of voluntary public health recommendations. Few studies have evaluated the effectiveness of this strategy. Based on data collected in the spring of 2020, this study explored associations between compliance with recommendations and observed symptoms of contagion in others, using self-report data from university students. Results: Compliance with recommendations ranged between 69.7 and 95.7 percent. Observations of moderate symptoms of contagion in "Someone else I have had contact with" and "Another person"were markedly associated with reported self-quarantine, which is the most restrictive recommendation, complied with by 81.2% of participants. Uncertainty regarding the incidence and severity of contagion in cohabitants was markedly associated with the recommendation to avoid public transportation, a recommendation being followed by 69.7%. It is concluded that students largely followed the voluntary recommendations implemented in Sweden, suggesting that coercive measures were not necessary. Compliance with recommendations were associated with the symptoms students saw in others, and with the perceived risk of contagion in the students immediate vicinity. It is recommended that voluntary recommendations should stress personal relevance, and that close relatives are at risk.

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  • 23.
    Bendtsen, Marcus
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    McCambridge, Jim
    Department of Health Sciences, University of York, UK.
    Causal models accounted for research participation effects when estimating effects in a behavioral intervention trial2021In: Journal of Clinical Epidemiology, ISSN 0895-4356, E-ISSN 1878-5921, Vol. 136, p. 77-83Article in journal (Refereed)
    Abstract [en]

    Objective Participants in intervention studies are asked to take part in activities linked to the conduct of research, including signing consent forms and being assessed. If participants are affected by such activities through mechanisms by which the intervention is intended to work, then there is confounding. We examine how to account for research participation effects analytically.

    Study design and setting Data from a trial of a brief alcohol intervention among Swedish university students is used to show how a proposed causal model can account for assessment effects.

    Results The proposed model can account for research participation effects as long as researchers are willing to use existing data to make assumptions about causal influences, for instance on the magnitude of assessment effects. The model can incorporate several research processes which may introduce bias.

    Conclusions As our knowledge grows about research participation effects, we may move away from asking if participants are affected by study design, toward rather asking by how much they are affected, by which activities and in which circumstances. The analytic perspective adopted here avoids assuming there are no research participation effects.

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  • 24.
    Bendtsen, Marcus
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Garnett, Claire
    UCL, England.
    Toner, Paul
    Queens Univ Belfast, North Ireland.
    Shorter, Gillian W.
    Queens Univ Belfast, North Ireland.
    Correction: The Effect of Question Order on Outcomes in the Core Outcome Set for Brief Alcohol Interventions Among Online Help-Seekers: Protocol for a Factorial Randomized Trial (vol 10, e26578, 2021)2021In: JMIR Research Protocols, ISSN 1929-0748, E-ISSN 1929-0748, Vol. 10, no 2, article id e26578Article in journal (Other academic)
    Abstract [en]

    n/a

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  • 25.
    Andersson, Claes
    et al.
    Malmo Univ, Sweden; Uppsala Univ, Sweden.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Lindfors, Petra
    Stockholm Univ, Sweden.
    Molander, Olof
    Karolinska Inst, Sweden; Stockholm Hlth Care Serv, Sweden.
    Lindner, Philip
    Karolinska Inst, Sweden; Stockholm Hlth Care Serv, Sweden.
    Topooco, Naira
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Engström, Karin
    Karolinska Inst, Sweden.
    Berman, Anne H.
    Uppsala Univ, Sweden; Karolinska Inst, Sweden; Stockholm Hlth Care Serv, Sweden.
    Does the management of personal integrity information lead to differing participation rates and response patterns in mental health surveys with young adults?: A three-armed methodological experiment2021In: International Journal of Methods in Psychiatric Research, ISSN 1049-8931, E-ISSN 1557-0657, Vol. 30, no 4, article id e1891Article in journal (Refereed)
    Abstract [en]

    Objectives This study evaluates whether initiation rates, completion rates, response patterns and prevalence of psychiatric conditions differ by level of personal integrity information given to prospective participants in an online mental health self-report survey. Methods A three-arm, parallel-group, single-blind experiment was conducted among students from two Swedish universities. Consenting participants following e-mail invitation answered the World Health Organization (WHO) World Mental Health-International College Student (WMH-ICS) mental health self-report survey, screening for eight psychiatric conditions. Random allocation meant consenting to respond (1) anonymously; (2) confidentially, or (3) confidentially, where the respondent also gave consent for collection of register data. Results No evidence was found for overall between-group differences with respect to (1) pressing a hyperlink to the survey in the invitation email; and (2) abandoning the questionnaire before completion. However, participation consent and self-reported depression were in the direction of higher levels for the anonymous group compared to the two confidential groups. Conclusions Consent to participate is marginally affected by different levels of personal integrity information. Current standard participant information procedures may not engage participants to read the information thoroughly, and online self-report mental health surveys may reduce stigma and thus be less subject to social desirability bias.

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  • 26.
    Sandborg, Johanna
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    Söderström, Emmie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Henriksson, Pontus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Henström, Maria
    Karolinska Inst, Sweden.
    Leppänen, Marja H.
    Karolinska Inst, Sweden; Folkhalsan Res Ctr, Finland; Univ Helsinki, Finland.
    Maddison, Ralph
    Deakin Univ, Australia.
    Hidalgo Migueles, Jairo Hidalgo
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Univ Granada, Spain.
    Blomberg, Marie
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Children's and Women's Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Linköping.
    Löf, Marie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden; Deakin Univ, Australia.
    Effectiveness of a Smartphone App to Promote Healthy Weight Gain, Diet, and Physical Activity During Pregnancy (HealthyMoms): Randomized Controlled Trial2021In: JMIR mhealth and uhealth, E-ISSN 2291-5222, Vol. 9, no 3, article id e26091Article in journal (Refereed)
    Abstract [en]

    Background: Excessive gestational weight gain (GWG) during pregnancy is a major public health concern associated with negative health outcomes for both mother and child. Scalable interventions are needed, and digital interventions have the potential to reach many women and promote healthy GWG. Most previous studies of digital interventions have been small pilot studies or have not included women from all BMI categories. We therefore examined the effectiveness of a smartphone app in a large sample (n=305) covering all BMI categories. Objective: To investigate the effectiveness of a 6-month intervention (the HealthyMoms app) on GWG, body fatness, dietary habits, moderate-to-vigorous physical activity (MVPA), glycemia, and insulin resistance in comparison to standard maternity care. Methods: A 2-arm parallel randomized controlled trial was conducted. Women in early pregnancy at maternity clinics in Ostergotland, Sweden, were recruited. Eligible women who provided written informed consent completed baseline measures, before being randomized in a 1:1 ratio to either an intervention (n=152) or control group (n=153). The control group received standard maternity care while the intervention group received the HealthyMoms smartphone app for 6 months (which includes multiple features, eg, information; push notifications; self-monitoring; and feedback features for GWG, diet, and physical activity) in addition to standard care. Outcome measures were assessed at Linkoping University Hospital at baseline (mean 13.9 [SD 0.7] gestational weeks) and follow-up (mean 36.4 [SD 0.4] gestational weeks). The primary outcome was GWG and secondary outcomes were body fatness (Bod Pod), dietary habits (Swedish Healthy Eating Index) using the web-based 3-day dietary record Riksmaten FLEX, MVPA using the ActiGraph wGT3x-BT accelerometer, glycemia, and insulin resistance. Results: Overall, we found no statistically significant effect on GWG (P=.62); however, the data indicate that the effect of the intervention differed by pre-pregnancy BMI, as women with overweight and obesity before pregnancy gained less weight in the intervention group as compared with the control group in the imputed analyses (-1.33 kg; 95% CI -2.92 to 0.26; P=.10) and completers-only analyses (-1.67 kg; 95% CI -3.26 to -0.09; P=.031]). Bayesian analyses showed that there was a 99% probability of any intervention effect on GWG among women with overweight and obesity, and an 81% probability that this effect was over 1 kg. The intervention group had higher scores for the Swedish Healthy Eating Index at follow-up than the control group (0.27; 95% CI 0.05-0.50; P=.017). We observed no statistically significant differences in body fatness, MVPA, glycemia, and insulin resistance between the intervention and control group at follow up (P=.21). Conclusions: Although we found no overall effect on GWG, our results demonstrate the potential of a smartphone app (HealthyMoms) to promote healthy dietary behaviors as well as to decrease weight gain during pregnancy in women with overweight and obesity.

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  • 27.
    Bendtsen, Marcus
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Ulfsdotter Gunnarsson, Katarina
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    McCambridge, Jim
    Univ York, England.
    Effects of a waiting list control design on alcohol consumption among online help-seekers: protocol for a randomised controlled trial2021In: BMJ Open, E-ISSN 2044-6055, Vol. 11, no 8, article id e049810Article in journal (Refereed)
    Abstract [en]

    Introduction Sparse attention has been given to the design of control conditions in trials, despite their important role as contrasts for novel treatments, and thus as a key determinant of effect sizes. This undermines valid inferences on effect estimates in trials, which are fundamentally comparative in nature. Such challenges to understanding also makes generalisation of effect estimates complex, for example, it may not be clear to what degree real-world alternatives to the novel treatments in pragmatic trials are similar to the control conditions studied. The present study aims to estimate the effects of being allocated to a waiting list control condition. Methods and analysis Individuals searching online for help to reduce their drinking will be invited to take part in a study. Individuals aged 18 years or older, who in the past month consumed six or more drinks on one occasion, or consumed 10 or more drinks the past week, will be eligible to participate. Both groups will receive identical feedback and advice on behaviour change; however, one group will be informed that they have to wait 1 month for the intervention materials. One month postrandomisation, participants will receive an email with the follow-up questionnaire measuring the primary outcomes: (1) frequency of heavy episodic drinking (defined as at study entry) in the past month; and (2) overall past week alcohol consumption. Differences between groups will be analysed using negative binomial regression models estimated using Bayesian inference. Recruitment will begin in October 2021. A Bayesian group sequential design will be employed to determine when to end enrolment (expected to be between 500 and 1500 individuals). Ethics and dissemination The study was approved by the Swedish Ethical Review Authority on 2021-01-25 (Dnr 2020-06267). Findings will be disseminated in open access peer-reviewed journals no later than 2023.

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  • 28.
    Bendtsen, Marcus
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Thomas, Kristin
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Mental health promotion among university students using a mobile health intervention: longitudinal findings from a randomized controlled trial2021In: European Journal of Applied Positive Psychology, ISSN 2397-7116, Vol. 5, article id 12Article in journal (Refereed)
    Abstract [en]

    Background: Research shows that positive psychology interventions have a small to medium effect on wellbeing, depression, anxiety, and stress. However, few studies have investigated long-term mental health outcomes.

    Methods: This paper reports on the 6- and 12-month effects of a mobile phone based positive psychology intervention on wellbeing among university students in Sweden. A 2-arm, single blind (researchers), parallel groups, randomized controlled trial was employed.

    Results: In total 654 individuals (25 years median age, 78% female) were randomized to the intervention (n=348) or control group (n=306). Primary outcome was positive mental health (Mental Health Continuum-Short Form).  Secondary outcomes were depression and anxiety symptomatology (Hospital Anxiety and Depression Scale). A lasting effect on wellbeing was observed. An immediate positive effect was observed on anxiety and depression outcomes which waned over time.

    Discussion and conclusions: The findings suggest that mobile phone-based interventions could be an important tool in a wider strategy for mental health promotion. Future research could improve on the effects observed in this study by finding ways to optimise person-activity fit and tailor the intervention content.

  • 29.
    Bendtsen, Marcus
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Seiterö, Anna
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bendtsen, Preben
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Olsson, Hanna
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Henriksson, Pontus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Thomas, Kristin
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Löf, Marie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Müssener, Ulrika
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    mHealth intervention for multiple lifestyle behaviour change among high school students in Sweden (LIFE4YOUth): Protocol for a randomised controlled trial2021In: Public Health Nursing, ISSN 0737-1209, E-ISSN 1525-1446, Vol. 21, no 1Article in journal (Refereed)
    Abstract [en]

    BackgroundNational surveys in Sweden demonstrate that the majority of young people do not engage in health promoting behaviours at levels recommended by the Public Health Agency of Sweden. The objective of this study is to estimate the effectiveness of a novel mHealth intervention named LIFE4YOUth, which targets multiple lifestyle behaviours (alcohol, diet, physical activity, and smoking) among high school students in Sweden.MethodsA 2-arm parallel groups single blind randomised controlled trial (1:1) will be employed to estimate the effectiveness of the novel mHealth intervention. Students will be recruited at high schools throughout Sweden, and will be included if they fulfil one of six criteria relating to unhealthy behaviours with respect to alcohol, diet, physical activity and smoking. Eligible participants will be randomised to either receive the novel intervention immediately, or to be placed on a waiting list for 4 months. The intervention consists of a combination of recurring screening, text messages, and an interactive platform which is adaptable to individual preferences. Outcome measures with respect to alcohol, diet, physical activity and smoking will be assessed through questionnaires at 2 and 4 months post randomisation.DiscussionThe findings of this trial could be generalised to a diverse high-school student population as our recruitment encompass a large proportion of schools throughout Sweden with various educational profiles. Furthermore, if effective, the mHealth intervention has good potential to be able to be scaled up and disseminated at high schools nationally.Trial registrationRegistered prospectively on 2020-05-20 in ISRCTN (ISRCTN34468623).

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  • 30.
    Åsberg, Katarina
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Regionledningskontoret, Enheten för folkhälsa.
    Lundgren, Oskar
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Children's and Women's Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, H.K.H. Kronprinsessan Victorias barn- och ungdomssjukhus.
    Henriksson, Hanna
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Henriksson, Pontus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bendtsen, Preben
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Löf, Marie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Multiple lifestyle behaviour mHealth intervention targeting Swedish college and university students: protocol for the Buddy randomised factorial trial2021In: BMJ Open, E-ISSN 2044-6055, Vol. 11, no 12, article id e051044Article in journal (Refereed)
    Abstract [en]

    Introduction The time during which many attend college or university is an important period for developing health behaviours, with potentially major implications for future health. Therefore, it is concerning that many Swedish students excessively consume alcohol, have unhealthy diets, are not physical active and smoke. The potential of digital interventions which integrate support for change of all of these behaviours is largely unexplored, as are the dismantled effects of the individual components that make up digital lifestyle behaviour interventions. Methods and analysis A factorial randomised trial (six factors with two levels each) will be employed to estimate the effects of the components of a novel mHealth multiple lifestyle intervention on alcohol consumption, diet, physical activity and smoking among Swedish college and university students. A Bayesian group sequential design will be employed to periodically make decisions to continue or stop recruitment, with simulations suggesting that between 1500 and 2500 participants will be required. Multilevel regression models will be used to analyse behavioural outcomes collected at 2 and 4 months postrandomisation. Ethics and dissemination The study was approved by the Swedish Ethical Review Authority on 2020-12-15 (Dnr 2020-05496). The main concern is the opportunity cost if the intervention is found to only have small effects. However, considering the lack of a generally available evidence-based multiple lifestyle behaviour support to university and college students, this risk was deemed acceptable given the potential benefits from the study. Recruitment will begin in March 2021, and it is expected that recruitment will last no more than 24 months. A final data set will, therefore, be available in July 2023, and findings will be reported no later than December 2023.

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  • 31.
    Åsberg, Katarina
    et al.
    Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Region Östergötland, Regionledningskontoret, Enheten för folkhälsa.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Perioperative digital behaviour change interventions for reducing alcohol consumption, improving dietary intake, increasing physical activity and smoking cessation: a scoping review2021In: Perioperative Medicine, E-ISSN 2047-0525, Vol. 10, article id 18Article, review/survey (Refereed)
    Abstract [en]

    Background: Evidence suggests that unhealthy lifestyle behaviours are modifiable risk factors for postoperativecomplications. Digital behaviour change interventions (DBCIs), for instance text messaging programs and smartphoneapps, have shown promise in achieving lifestyle behaviour change in a wide range of clinical populations, and it maytherefore be possible to reduce postoperative complications by supporting behaviour change perioperatively usingdigital interventions. This scoping review was conducted in order to identify existing research done in the area ofperioperative DBCIs for reducing alcohol consumption, improving dietary intake, increasing physical activity andsmoking cessation.Main text: This scoping review included eleven studies covering a range of surgeries: bariatric, orthopaedic, cancer,transplantation and elective surgery. The studies were both randomised controlled trials and feasibility studies andinvestigated a diverse set of interventions: one game, three smartphone apps, one web-based program and five textmessage interventions. Feasibility studies reported user acceptability and satisfaction with the behaviour changesupport. Engagement data showed participation rates ranged from 40 to 90%, with more participants being activelyengaged early in the intervention period. In conclusion, the only full-scale randomised controlled trial (RCT), textmessaging ahead of bariatric surgery did not reveal any benefits with respect to adherence to preoperative exerciseadvice when compared to a control group. Two of the pilot studies, one text message intervention, one game,indicated change in a positive direction with respect to alcohol and tobacco outcomes, but between groupcomparisons were not done due to small sample sizes. The third pilot-study, a smartphone app, found between groupchanges for physical activity and alcohol, but not with respect to smoking cessation outcomes.

    Conclusion: This review found high participant satisfaction, but shows recruitment and timing-delivery issues, as wellas low retention to interventions post-surgery. Small sample sizes and the use of a variety of feasibility outcomemeasures prevent the synthesis of results and makes generalisation difficult. Future research should focus on definingstandardised outcome measures, enhancing patient engagement and improving adherence to behaviour change priorto scheduled surgery.

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  • 32.
    Bendtsen, Marcus
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bendtsen, Preben
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Müssener, Ulrika
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Six-Month Outcomes from the NEXit Junior Trial of a Text Messaging Smoking Cessation Intervention for High School Students: Randomized Controlled Trial With Bayesian Analysis2021In: JMIR mhealth and uhealth, E-ISSN 2291-5222, Vol. 9, no 10, article id e29913Article in journal (Refereed)
    Abstract [en]

    Background: The prevalence of daily or occasional smoking among high school students in Sweden was approximately 20% in 2019, which is problematic since lifestyle behaviors are established in adolescence and track into adulthood. The Nicotine Exit (NEXit) Junior trial was conducted in response to a lack of evidence for the effects of text message smoking cessation interventions among high school students in Sweden. Objective: The aim of this study was to estimate the 3-and 6-month effects of a text messaging intervention among high school students in Sweden on smoking cessation outcomes. Methods: A 2-arm, single-blind randomized controlled trial was employed to estimate the effects of the intervention on smoking cessation in comparison to treatment as usual. Participants were recruited from high schools in Sweden using advertising and promotion by school staff from January 10, 2018, to January 10, 2019. Weekly or daily smokers who were willing to make a quit attempt were eligible for inclusion. Prolonged abstinence and point prevalence of smoking cessation were measured at 3 and 6 months after randomization. Results: Complete case analysis was possible on 57.9% (310/535) of the participants at 6 months, with no observed statistically significant effect on 5-month prolonged abstinence (odds ratio [OR] 1.27, 95% CI 0.73-2.20; P=.39) or 4-week smoking cessation (OR 1.42; 95% CI 0.83-2.46; P=.20). Sensitivity analyses using imputation yielded similar findings. Unplanned Bayesian analyses showed that the effects of the intervention were in the anticipated direction. The findings were limited by the risk of bias induced by high attrition (42.1%). The trial recruited high school students in a pragmatic setting and included both weekly and daily smokers; thus, generalization to the target population is more direct compared with findings obtained under more strict study procedures. Conclusions: Higher than expected attrition rates to follow-up 6 months after randomization led to null hypothesis tests being underpowered; however, unplanned Bayesian analyses found that the effects of the intervention were in the anticipated direction. Future trials of smoking cessation interventions targeting high school students should aim to prepare strategies for increasing retention to mid-and long-term follow-up. Trial Registration: IRCTN Registry ISRCTN15396225; https://www.isrctn.com/ISRCTN15396225 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-018-3028-2

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  • 33.
    Bendtsen, Marcus
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    McCambridge, Jim
    Univ York, England.
    Åsberg, Katarina
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Regionledningskontoret, Enheten för folkhälsa.
    Bendtsen, Preben
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Text messaging interventions for reducing alcohol consumption among risky drinkers: systematic review and meta-analysis2021In: Addiction, ISSN 0965-2140, E-ISSN 1360-0443, Vol. 116, no 5, p. 1021-1033Article, review/survey (Refereed)
    Abstract [en]

    Background and Aims The global growth of mobile phone use has led to new opportunities for health interventions, including through text messaging. We aimed to estimate the effects of text messaging interventions on alcohol consumption among risky drinkers. Methods Systematic review and meta-analysis of reports on randomized controlled trials (RCTs) published in English. Searches were conducted on 23 May 2019 in PubMed; PubMed Central; CENTRAL; CDSR; DARE; NHS-EED; Scopus; PsycINFO; PsycARTICLES; CINAHL; and Web of Science. Measurements included number of episodes of heavy drinking (HED) per month and weekly alcohol consumption (WAC) in grams. Trials among risky drinkers who were not receiving co-interventions were included in the review (n = 3481, mean age 29 years, 41% female). Data were extracted from reports and authors were contacted for additional data. Results Ten trials were included and all analyses were based on random-effects models. Primary analyses, including seven trials (n = 2528) for HED and five trials (n = 2236) for WAC, found that the interventions may reduce self-reported HED [-0.33 episodes per month; 95% confidence interval (CI) = -0.79, 0.12] and WAC (-18.62 g per week; 95% CI = -39.61, 2.38), although both estimates included the null. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) quality of evidence was judged to be low for both HED and WAC, primarily due to risk of attrition and performance bias, heterogeneity and influence of pilot trials on estimates. Conclusions Text messaging alcohol interventions may reduce alcohol consumption compared with no or basic health information; however, there are doubts about the overall quality of the evidence.

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  • 34.
    Bendtsen, Marcus
    et al.
    Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health.
    Müssener, Ulrika
    Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health.
    Linderoth, Catharina
    Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health.
    Thomas, Kristin
    Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health.
    A Mobile Health Intervention for Mental Health Promotion Among University Students: Randomized Controlled Trial2020In: JMIR mhealth and uhealth, E-ISSN 2291-5222, Vol. 8, no 3, article id e17208Article in journal (Refereed)
    Abstract [en]

    Background: High positive mental health, including the ability to cope with the normal stresses of life, work productively, and be able to contribute to one’s community, has been associated with various health outcomes. The role of positive mental health is therefore increasingly recognized in national mental health promotion programs and policies. Mobile health (mHealth) interventions could be a cost-effective way to disseminate positive psychological interventions to the general population.

    Objective: The aim of this study was to estimate the effect of a fully automated mHealth intervention on positive mental health, and anxiety and depression symptomology among Swedish university students using a randomized controlled trial design.

    Methods: A 2-arm, single-blind (researchers), parallel-groups randomized controlled trial with an mHealth positive psychology program intervention group and a relevant online mental health information control group was employed to estimate the effect of the novel intervention. Participants were recruited using digital advertising through student health care centers in Sweden. Inclusion criteria were (1) university students, (2) able to read and understand Swedish, (3) and have access to a mobile phone. Exclusion criteria were high positive mental health, as assessed by the Mental Health Continuum Short Form (MHC-SF), or high depression and anxiety symptomology, as assessed by the Hospital Anxiety Depression Scale (HADS). The primary outcome was positive mental health (MHC-SF), and the secondary outcomes were depression and anxiety symptomatology (HADS). The subscales of MHC-SF were also analyzed as exploratory outcomes. Outcomes were measured 3 months after randomization through questionnaires completed on the participants’ mobile phones.

    Results: A total of 654 participants (median age 25 years), including 510 (78.0%) identifying as female, were randomized to either the intervention (n=348) or control group (n=306). At follow-up, positive mental health was significantly higher in the intervention group compared with the control group (incidence rate ratio [IRR]=1.067, 95% CI 1.024-1.112, P=.002). For both depression and anxiety symptomatology, the intervention group showed significantly lower scores at follow-up compared with the control group (depression: IRR=0.820, 95% CI 0.714-0.942, P=.005; anxiety: IRR=0.899, 95% CI 0.840-0.962, P=.002). Follow-up rates were lower than expected (58.3% for primary outcomes and 52.3% for secondary outcomes); however, attrition analyses did not identify any systematic attrition with respect to baseline variables.

    Conclusions: The mHealth intervention was estimated to be superior to usual care in increasing positive mental health among university students. A protective effect of the intervention was also found on depressive and anxiety symptoms. These findings demonstrate the feasibility of using an automated mobile phone format to enhance positive mental health, which offers promise for the use of mHealth solutions in public mental health promotion.

    Trial Registration: International Standard Randomized Controlled Trial Registry ISRCTN54748632; http://www.isrctn.com/ISRCTN54748632

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  • 35.
    Henriksson, Pontus
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    Sandborg, Johanna
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    Blomberg, Marie
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Children's and Women's Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Linköping.
    Nowicka, Paulina
    Uppsala Univ, Sweden.
    Petersson, Kerstin
    Umea Univ, Sweden.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Rosell, Magdalena
    Karolinska Inst, Sweden.
    Löf, Marie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    Body mass index and gestational weight gain in migrant women by birth regions compared with Swedish-born women: A registry linkage study of 0.5 million pregnancies2020In: PLOS ONE, E-ISSN 1932-6203, Vol. 15, no 10, article id e0241319Article in journal (Refereed)
    Abstract [en]

    Introduction Women migrating to high-income countries may have increased risks of adverse pregnancy outcomes as compared with native-born women. However, little is known whether migrant women are more likely to have unhealthy body mass index (BMI) or gestational weight gain (GWG), which is of importance considering the well-established links between unhealthy BMI and GWG with adverse pregnancy outcomes. Hence, the aim of the study was to examine the prevalence and estimate odds ratios (ORs) of underweight and obesity in the first trimester as well as inadequate and excessive GWG across birth regions in migrant (first-generation) and Swedish-born women in a population-based sample of pregnant women in Sweden. Methods This population-based study included 535 609 pregnancies from the Swedish Pregnancy Register between the years 2010-2018. This register has a coverage of approximately 90% and includes data on body weight, height, birth country and educational attainment. BMI in the first trimester of pregnancy was classified as underweight, normal weight, overweight and obesity whereas GWG was classified as inadequate, adequate and excessive according to the recommendations from the National Academy of Medicine, USA. BMI and GWG were examined according to 7 birth regions and the 100 individual birth countries. Adjusted ORs of underweight, obesity as well as inadequate or excessive GWG by birth regions were estimated using multinomial logistic regression. Results There were large disparities in unhealthy BMI and GWG across birth regions. For instance, women born in North Africa and Middle East and Sub-Saharan Africa had 1.40 (95% CI 1.35-1.44) and 2.13 (95% CI 2.03-2.23) higher odds of obesity compared with women born in Sweden. However, women born in Sub-Saharan Africa had also considerably higher odds of underweight (OR, 2.93 [95% CI 2.70-3.18]) and inadequate GWG (OR, 1.97 [95% CI 1.87-2.07]). The limitations of the study include the lack of a validated measure of acculturation and that the study only had data on first-generation migration. Conclusions The large differences across the 7 regions and 100 countries highlights the importance of considering birth region and country-specific risks of unhealthy BMI and GWG in first-generation migrant women. Furthermore, inadequate GWG was common among pregnant first-generation migrant women, especially in women born in Sub-Saharan Africa, which demonstrates the need to promote adequate GWG, not only the avoidance of excessive GWG. Thus, our findings also indicate that additional support and interventions may be needed for first-generation migrant women from certain birth regions and countries in order to tackle the observed disparities in unhealthy BMI and GWG. Although further studies are needed, our results are useful for identifying groups of women at increased risk of unhealthy BMI and weight gain during pregnancy.

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  • 36.
    Müssener, Ulrika
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Thomas, Kristin
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Linderoth, Catharina
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Löf, Marie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    Åsberg, Katarina
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Henriksson, Pontus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Development of an Intervention Targeting Multiple Health Behaviors Among High School Students: Participatory Design Study Using Heuristic Evaluation and Usability Testing2020In: JMIR mhealth and uhealth, E-ISSN 2291-5222, Vol. 8, no 10, article id e17999Article in journal (Refereed)
    Abstract [en]

    Background: Mobile electronic platforms provide exciting possibilities for health behavior promotion. For instance, they can promote smoking cessation, moderate alcohol consumption, healthy eating, and physical activity. Young adults in Sweden are proficient in the use of technology, having been exposed to computers, smartphones, and the internet from an early age. However, with the high availability of mobile health (mHealth) interventions of varying quality, it is critical to optimize the usability of mHealth interventions to ensure long-term use of these health promotion interventions. Objective: This study aims to investigate the usability of an mHealth intervention (LIFE4YOUth) targeting health behaviors among high school students through heuristic evaluation and usability testing. Methods: A preliminary version of the LIFE4YOUth mHealth intervention, which was aimed at promoting healthy eating, physical activity, smoking cessation, and nonrisky drinking among high school students, was developed in early 2019. We completed a total of 15 heuristic evaluations and 5 usability tests to evaluate the usability of the mHealth intervention prototype to improve its functioning, content, and design. Results: Heuristic evaluation from a total of 15 experts (10 employees and 5 university students, both women and men, aged 18-25 years) revealed that the major usability problems and the worst ratings, a total of 17 problems termed usability catastrophes, concerned shortcomings in displaying easy-to-understand information to the users or technical errors. The results of the usability testing including 5 high school students (both girls and boys, aged 15-18 years) showed that the design, quality, and quantity of content in the intervention may impact the users level of engagement. Poor functionality was considered a major barrier to usability. Of the 5 participants, one rated the LIFE4YOUth intervention as poor, 2 rated as average, and 2 assessed it as good, according to the System Usability Scale. Conclusions: High school students have high expectations of digital products. If an mHealth intervention does not offer optimal functions, they may cease to use it. Optimizing the usability of mHealth interventions is a critical step in the development process. Heuristic evaluation and usability testing in this study provided valuable knowledge about the prototype from a users perspective. The findings may lead to the development of similar interventions targeting the high school population.

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  • 37.
    Ek, Anna
    et al.
    Karolinska Inst, Sweden.
    Alexandrou, Christina
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Söderström, Emmie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bergman, Patrick
    Linnaeus Univ, Sweden.
    Nystrom, Christine Delisle
    Karolinska Inst, Sweden.
    Direito, Artur
    Natl Univ Singapore, Singapore.
    Eriksson, Ulf
    Stromstad Acad, Sweden.
    Henriksson, Pontus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Maddison, Ralph
    Deakin Univ, Australia.
    Lagerros, Ylva Trolle
    Karolinska Inst, Sweden; Stockholm Hlth Serv, Sweden.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Löf, Marie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    Effectiveness of a 3-Month Mobile Phone-Based Behavior Change Program on Active Transportation and Physical Activity in Adults: Randomized Controlled Trial2020In: JMIR mhealth and uhealth, E-ISSN 2291-5222, Vol. 8, no 6, article id e18531Article in journal (Refereed)
    Abstract [en]

    yyy Background: Active transportation (AT; ie, walking and cycling as a mode for transportation) has been associated with decreased morbidity and mortality; however, low-cost and scalable intervention programs are lacking. Objective: The goal of the research was to determine the effectiveness of a 3-month behavior change program delivered via a mobile phone app to promote AT (TravelVu Plus) on time spent in moderate-to-vigorous physical activity (MVPA). Methods: For this 2-arm parallel randomized controlled trial, we recruited a population-based sample of 254 adults from Stockholm County who were aged 20 to 65 years and had access to a smartphone. On completion of 1-week baseline measures, the 254 participants were randomized to either the control or intervention group (1:1 ratio). Both groups had access to the standard TravelVu app (Trivector AB) for monitoring their AT for 6 months. The intervention group also received a 3-month behavior change program to promote AT (TravelVu Plus app). Assessors of outcomes were blinded to group allocation. Outcomes were objectively measured MVPA at 3 (primary) and 6 months. Secondary outcomes were AT, attitudes toward AT, and health-related quality of life at 3 and 6 months. Results: No effect on MVPA was observed after 3 months (P=.29); however, at 6 months the intervention group had a greater improvement in MVPA than the controls (6.05 minutes per day [95% CI 0.36 to 11.74; P=.04]). A Bayesian analyses showed that there was a 98% probability that the intervention had any effect at 6 months, and a 63% probability that this effect was >5 minute MVPA per day. Conclusions: No effect on MVPA immediately after the intervention period (at 3 months) was observed; however, there was a delayed effect on MVPA (6 minutes per day) at 6 months, which corresponds to approximately 30% of the weekly MVPA recommendation. Our findings suggest that a behavior change program promoting AT delivered via an app may have a relevant effect on PA.

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  • 38.
    Bendtsen, Marcus
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Thomas, Kristin
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Linderoth, Catharina
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bendtsen, Preben
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Effects of a Text Messaging Smoking Cessation Intervention Among Online Help Seekers and Primary Health Care Visitors in Sweden: Protocol for a Randomized Controlled Trial Using a Bayesian Group Sequential Design2020In: JMIR Research Protocols, ISSN 1929-0748, E-ISSN 1929-0748, Vol. 9, no 12, article id e23677Article in journal (Refereed)
    Abstract [en]

    Background: A steady decline of the smoking prevalence in Sweden has been recorded over the past decade; however, people still start and continue to smoke. There is a need for effective smoking cessation interventions that can scale to a national level and that are designed to reach individuals requiring smoking cessation support in the general population. Objective: Previous randomized controlled trials of smoking cessation interventions among high school and university students in Sweden have found consistent evidence that text messaging interventions are effective in helping students quit smoking. However, there are no studies that investigate the effects of text messaging interventions in a more general population. The objective of this study is to estimate the effects of a text messaging intervention on individuals seeking help to quit online and individuals visiting primary health care units. Methods: A 2-arm, parallel-group (1:1), randomized controlled trial will be employed to address the study objectives. The trial will follow a Bayesian group sequential design. Recruitment will be conducted using online advertisement (Google, Bing, and Facebook) and through health care professionals at primary health care units. All participants will receive treatment as usual; however, participants who are allocated to the intervention arm will also be given access to a 12-week text message smoking cessation intervention. Primary outcomes are 8-week prolonged abstinence and 4-week point prevalence, measured 3 months and 6 months postrandomization. Mediator variables (self-efficacy, importance, and know-how) will be measured to estimate causal mediation models. Results: Recruitment commenced in September 2020 and will not exceed 24 months. This means that a complete dataset will be available at the latest towards the end of 2022. We expect to publish the findings from this trial by June 2023. Conclusions: This trial will further our understanding of the effects of text messaging interventions among a more general population than has previously been studied. We also aim to learn about differential effects between those who seek support online and those who are given facilitated support at primary health care units. Trial recruitment is limited to the Swedish population; however, a strength of this study is the pragmatic way in which participants are recruited. Through online advertisements, individuals are recruited in reaction to their own interest in seeking help to quit. At primary health care units, individuals who were not necessarily looking for smoking cessation support are given information about the trial. This closely mimics the way the intervention would be disseminated in a real-world setting and may therefore strengthen the argument of generalizability of findings.

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  • 39.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Heterogeneous treatment effects of a text messaging smoking cessation intervention among university students2020In: PLOS ONE, E-ISSN 1932-6203, Vol. 15, no 3, article id e0229637Article in journal (Refereed)
    Abstract [en]

    Introduction

    Despite tobacco being an important preventable factor with respect to ill health and death, it is a legal substance that harms and kills many of those who use it. Text messaging smoking cessation interventions have been evaluated in a variety of contexts, and are generally considered to have a positive effect on smoking cessation success. In order for text messaging interventions to continue to be useful as prevalence of smoking decreases, it may be necessary to tailor the interventions to specific individuals. However, little is known with regard to who benefits the most and least from existing interventions.

    Methods

    In order to identify heterogenous treatment effects, we analyzed data from a randomized controlled trial of a text messaging smoking cessation intervention targeting university students in Sweden. We used a Bayesian hierarchical model where the outcome was modelled using logistic regression, and so-called horseshoe priors were used for coefficients. Predictive performance of the model, and heterogeneous treatment effects, were calculated using cross-validation over the trial data.

    Results

    Findings from the study of heterogenous treatment effects identified less effect of the intervention among university students with stronger dependence of nicotine and students who smoke a greater quantity of cigarettes per week. No heterogeneity was found with respect to sex, number of years smoking, or the use of snuff.

    Discussion

    Results emphasize that individuals with a more developed dependence of nicotine may have a harder time quitting smoking even with support. This questions the dissemination and development of text messaging interventions to university students in the future, as they may not be the optimal choice of intervention for those with a more developed dependence. On the other hand, text messaging interventions may be useful to disseminate among university students that are at risk of developing a strong dependence.

    Trial registration

    International Standard Randomized Controlled Trial Number (ISRCTN): 75766527; http://www.controlled-trials.com/ISRCTN75766527.

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  • 40.
    Müssener, Ulrika
    et al.
    Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health.
    Thomas, Kristin
    Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health.
    Bendtsen, Preben
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Operations management NSV.
    Bendtsen, Marcus
    Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health.
    High School Students’ Preferences and Design Recommendations for a Mobile Phone–Based Intervention to Improve Psychological Well-Being: Mixed Methods Study2020In: JMIR Pediatrics and Parenting, ISSN 2561-6722, Vol. 3, no 2, article id e17044Article in journal (Refereed)
    Abstract [en]

    Background:Young adults’ mental health is characterized by relatively high rates of stress and anxiety and low levels of help-seeking behavior. Mobile health (mHealth) interventions could offer a cost-effective and readily available avenue to provide personalized support to young adults. More research needs to be directed at the development of mHealth interventions targeting youths specifically, as well as at determining how to reach young people and how to effectively intervene to improve psychological well-being.

    Objective:The objective was to gather perceptions from high school students to inform the development of a prototype mHealth intervention aiming to promote psychological well-being.

    Methods:A mixed methods design was used to (1) investigate high school students’ perceptions about stress and its consequences in daily life, as well as their ability to cope with stress, and (2) explore their preferences and design recommendations for an mHealth intervention to improve psychological well-being. Students from two high schools in the southeast of Sweden were invited to take part in the study. Recruitment of high school students was completed over a 6-week period, between October 25 and December 7, 2018. Recruitment entailed inviting students to complete a stress test (ie, screening and feedback) on their mobile phones. After completing the stress test, all participants were invited to complete a follow-up questionnaire and take part in telephone interviews.

    Results:A total of 149 high school students completed the stress test, of which 68 completed the questionnaire. There were 67 free-text comments distributed across the items. The majority of participants (55/68, 81%) stated that they coped with stress better or in the same way after engaging in the stress test, due to time management, dialogue with others, and self-refection. A total of 4 out of 68 participants (6%)—3 female students (75%) and 1 male student (25%)—took part in telephone interviews. Three main themes were identified from the interview data: perceptions about stress, design features, and intervention features.

    Conclusions:Stress was described by the students as a condition caused by high demands set by oneself and the social environment that impacted their physical health, personal relationships, school performance, and emotional well-being. Participants claimed that mHealth interventions need to be clearly tailored to a young age group, be evidence based, and offer varied types of support, such as information about stress, exercises to help organize tasks, self-assessment, coping tools, and recommendations of other useful websites, literature, blogs, self-help books, or role models. Mobile phones seemed to be a feasible and acceptable platform for the delivery of an intervention.

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  • 41.
    Thomas, Kristin
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Linderoth, Catharina
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bendtsen, Preben
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Operations management NSV.
    Implementing Facilitated Access to a Text Messaging, Smoking Cessation Intervention Among Swedish Patients Having Elective Surgery: Qualitative Study of Patients and Health Care Professionals Perspectives2020In: JMIR mhealth and uhealth, E-ISSN 2291-5222, Vol. 8, no 9, article id e17563Article in journal (Refereed)
    Abstract [en]

    Background: There is strong evidence that short-term smoking cessation before surgery can reduce postoperative morbidity. There are, however, several structural problems in health care systems concerning how to implement smoking cessation interventions in routine practice for preoperative patients. Objective: This study aimed to analyze the implementation of a text messaging, smoking cessation intervention targeting patients having elective surgery. Implementation of facilitated access (ie, referral from practitioners) and the perceived usefulness among patients were investigated. Elective surgery is defined as scheduled, nonacute surgery. Methods: A qualitative study was carried out at two medium-sized hospitals in the south of Sweden. The implementation of facilitated access was investigated during a 12-month period from April 2018 to April 2019. Facilitated access was conceptualized as specialists recommending the text messaging intervention to patients having elective surgery. Implementation was explored in terms of perceptions about the intervention and behaviors associated with implementation; that is, how patients used the intervention and how specialists behaved in facilitating usage among patients. Two focus groups with smoking cessation specialists and 10 individual interviews with patients were carried out. Qualitative content analysis was used to analyze the data. Results: Two main categories were identified from the focus group data with smoking cessation specialists: implementation approach and perceptions about the intervention. The first category, implementation approach, referred to how specialists adapted their efforts to situational factors and to the needs and preferences of patients, and how building of trust with patients was prioritized. The second category, perceptions about the intervention, showed that specialists thought the content and structure of the text messaging intervention felt familiar and worked well as a complement to current practice. Two categories were identified from the patient interview data: incorporating new means of support from health care and determinants of use. The first category referred to how patients adopted and incorporated the intervention into their smoking cessation journey. Patients were receptive, shared the text messages with friends and family, humanized the text messages, and used the messages as a complement to other strategies to quit smoking. The second category, determinants of use, referred to aspects that influenced how and when patients used the intervention and included the following: timing of the intervention and text messages, motivation to change, and perceptions of the mobile phone medium. Conclusions: Smoking cessation specialists adopted an active role in implementing the intervention by adapting their approach and fitting the intervention into existing routines. Patients showed strong motivation to change and openness to incorporate the intervention into their behavior change journey; however, the timing of the intervention and messages were important in optimizing the support. A text messaging, smoking cessation intervention can be a valuable and feasible way to reach smoking patients having elective surgery.

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  • 42.
    Müssener, Ulrika
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Linderoth, Catharina
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Thomas, Kristin
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    mHealth smoking cessation intervention among high school students: 3-month primary outcome findings from a randomized controlled trial2020In: PLOS ONE, E-ISSN 1932-6203, Vol. 15, no 3, article id e0229411Article in journal (Refereed)
    Abstract [en]

    Background

    Smoking among adolescents remains a global public health issue as youth continue to maintain high prevalence rates. The evidence for the efficacy of text messaging interventions to reduce smoking behavior is well established, yet there is still a need for studies targeting high school students. The aim of the study was to determine the effectiveness of a text-based smoking cessation intervention among high school students in Sweden.

    Methods

    The study was a two-arm randomized trial conducted from January 10 2018 to January 11 2019, data were analysed from April 12 2019 to May 21 2019. Inclusion criteria were high school students who were daily or weekly smokers willing to attempt to quit smoking and owned a mobile phone. The study invited all students at 630 high schools units throughout Sweden. The intervention group received text messages based on components of effective smoking cessation interventions for 12 weeks. The control group were offered treatment as usual. The primary outcomes were self-reported prolonged abstinence (not having smoked more than 5 cigarettes over the last 8 weeks) and 4-week point prevalence of smoking abstinence.

    Findings

    A total of 535 participants, with a median age of 17 (IQR 16–18), were randomized into the study; 276 (164 [59.4%] women) were allocated to the intervention and 259 (162 [62.5%] women) to the control group. The outcomes of the trial were analyzed on a total of 212 (76.8%) participants in the intervention group and 201 (77.6%) participants in the control group. Prolonged abstinence at the 3-month follow-up was reported by 49 (23.1%) individuals in the intervention group and 39 (19.4%) individuals in the control group (adjusted OR, 1.21; 95% CI, 0.73–2.01; P value, .46). Four-week point prevalence of complete smoking cessation was reported by 53 (25.0%) individuals in the intervention group and 31 (15.4%) individuals in the control group (adjusted OR, 1.87; 95% CI, 1.12–3.17; P value, .018).

    Conclusions

    Estimates of 4-week point prevalence of complete cessation was 10 percentage points higher in the group that were given access to the intervention compared to the control. Findings provide confirmation that text messaging-based smoking cessation programs can affect quit rates among adolescents.

    Trial registration

    ISRCTN15396225; registration date October 13, 2017, https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-018-3028-2.

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  • 43.
    Henriksson, Hanna
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Alexandrou, Christina
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    Henriksson, Pontus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Henstrom, Maria
    Karolinska Inst, Sweden.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Thomas, Kristin
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Müssener, Ulrika
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Nilsen, Per
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Löf, Marie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    MINISTOP 2.0: a smartphone app integrated in primary child health care to promote healthy diet and physical activity behaviours and prevent obesity in preschool-aged children: protocol for a hybrid design effectiveness-implementation study2020In: BMC Public Health, E-ISSN 1471-2458, Vol. 20, no 1, article id 1756Article in journal (Refereed)
    Abstract [en]

    BackgroundChildhood obesity is still a major health problem in many countries, including Sweden. Childhood obesity and obesity-related behaviours in childhood, such as low physical activity and unhealthy eating habits, tend to track into adulthood, which highlights the need for early prevention. Our aims are to evaluate whether a parent-oriented mobile health app (the MINISTOP 2.0 app) integrated into primary child health care can improve diet and physical activity behaviours and reduce the prevalence of overweight and obesity in preschool-aged children as well as to evaluate the implementation among child health care nurses and parents.MethodsThis trial uses a hybrid type 1 effectiveness-implementation design. Families (n=500) who attend a routine visit to one of 15-20 primary child health care centres throughout Sweden, when their child is 2.5years, are offered participation in a randomised controlled trial (effectiveness evaluation). After acceptance, families will be randomised (1:1) to control or intervention groups. The intervention group receives a 6-month parent-oriented smartphone intervention aimed at improving the dietary and activity behaviours of their child (the MINISTOP 2.0 app) and the control group receives routine child health care. Dietary habits, physical activity and screen time (primary outcomes), body weight and height in children, and parental self-efficacy (secondary outcomes) are measured at baseline and at 6months post randomisation. Implementation outcomes (i.e. perceived acceptability, appropriateness, and feasibility) of the intervention will be assessed among primary child health care nurses and parents in the trial through questionnaires and qualitative interviews.DiscussionThis trial will evaluate whether the MINISTOP 2.0 app can be used in primary child health care to improve diet and physical activity behaviours, and prevent overweight and obesity, in preschool-aged children. If effectiveness is proven, and the MINISTOP 2.0 app is considered acceptable, appropriate and feasible, it can be implemented nationally as part of the preventive strategies to combat childhood obesity provided by routine child health care.Trial registrationThe trial was registered at the Clinicaltrials.gov register platform (ID NCT04147039) on 31 October 2019.

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  • 44.
    Henriksson, Pontus
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Söderström, Emmie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Blomberg, Marie
    Linköping University, Department of Biomedical and Clinical Sciences, Division of Children's and Women's Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Linköping.
    Nowicka, Paulina
    Uppsala Univ, Sweden.
    Petersson, Kerstin
    Umea Univ, Sweden.
    Thomas, Kristin
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Esteyez-Lopez, Fernando
    Erasmus MC Univ Med Ctr, Netherlands.
    Löf, Marie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    Self-Rated Health in Migrant and Non-Migrant Women before, during and after Pregnancy: A Population-Based Study of 0.5 Million Pregnancies from the Swedish Pregnancy Register2020In: Journal of Clinical Medicine, E-ISSN 2077-0383, Vol. 9, no 6, article id 1764Article in journal (Refereed)
    Abstract [en]

    Self-rated health is a strong health marker. Migrants have been suggested to have poorer self-rated health than non-migrants (i.e., native-born). However, little is known about whether there are disparities in self-reported health in relation to pregnancy. Therefore, the aim of the current study was to examine the odds of poor self-rated health before, during and after pregnancy in migrant women as compared to women born in Sweden. We utilized population-based data from the Swedish Pregnancy Register containing 0.5 million women born in Sweden (i.e., non-migrant women) and migrant women between 2010 and 2018. Self-rated health was reported on a 5-point scale (from very poor to very good). Very poor and poor health were categorized as poor self-rated health. Logistic regression was utilized to calculate odds ratios (ORs) that were unadjusted and adjusted for covariates (age, parity, educational attainment and body mass index). The results demonstrate disparities in self-rated health across birth regions. In comparison to women born in Sweden, women born in Latin America and the Caribbean, South Asia as well as North Africa and the Middle East had consistently higher odds of poor self-rated health before, during and after pregnancy (ORs ranging from 1.14 to 1.96 in both unadjusted and adjusted models). Although women born in Sub-Saharan Africa did have comparable self-rated health as to women born in Sweden before pregnancy, after accounting for covariates, they had lower odds of poor self-rated health during and after pregnancy (ORs: 0.71 and 0.80 respectively). Therefore, additional measures and support may be needed to tackle disparities in health between migrant and non-migrant women before, during and after pregnancy.

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  • 45.
    Bendtsen, Marcus
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Garnett, Claire
    UCL, England.
    Toner, Paul
    Queens Univ Belfast, North Ireland.
    Shorter, Gillian W.
    Queens Univ Belfast, North Ireland.
    The Effect of Question Order on Outcomes in the Core Outcome Set for Brief Alcohol Interventions Among Online Help-Seekers: Protocol for a Factorial Randomized Trial2020In: JMIR Research Protocols, ISSN 1929-0748, E-ISSN 1929-0748, Vol. 9, no 11, article id e24175Article in journal (Refereed)
    Abstract [en]

    Background: A core outcome set (COS) for trials and evaluations of the effectiveness and efficacy of alcohol brief interventions (ABIs) has recently been established through international consensus to address the variability of outcomes evaluated. Objective: This is a protocol for studies to assess if there are order effects among the questions included in the COS. Methods: The 10 items of the COS are organized into 4 clusters. A factorial design will be used with 24 arms, where each arm represents 1 order of the 4 clusters. Individuals searching online for help will be asked to complete a questionnaire, and consenting participants will be randomized to 1 of the 24 arms (double-blind with equal allocation). Participants will be included if they are 18 years or older. The primary analyses will (1) estimate how the order of the clusters of outcomes affects how participants respond and (2) investigate patterns of abandonment of the questionnaire. Results: Data collection is expected to commence in November 2020. A Bayesian group sequential design will be used with interim analyses planned for every 50 participants completing the questionnaire Data collection will end no more than 24 months after commencement, and the results are expected to be published no later than December 2023. Conclusions: Homogenizing the outcomes evaluated in studies of ABIs is important to support synthesis, and the COS is an important step toward this goal. Determining whether there may be issues with the COS question order may improve confidence in using it and speed up its dissemination in the research community We encourage others to adopt the protocol as a study within their trial as they adopt the ORBITAL (Outcome Reporting in Brief Intervention Trials: Alcohol) COS to build a worldwide repository and provide materials to support such analysis.

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  • 46.
    Bendtsen, Marcus
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Bendtsen, Preben
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Henriksson, Hanna
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Henriksson, Pontus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Müssener, Ulrika
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Thomas, Kristin
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Löf, Marie
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Karolinska Inst, Sweden.
    The Mobile Health Multiple Lifestyle Behavior Interventions Across the Lifespan (MoBILE) Research Program: Protocol for Development, Evaluation, and Implementation2020In: JMIR Research Protocols, ISSN 1929-0748, E-ISSN 1929-0748, Vol. 9, no 4, article id e14894Article in journal (Refereed)
    Abstract [en]

    Background: Clustering of multiple lifestyle risk behaviors has been associated with a greater risk of noncommunicable diseases and mortality than one lifestyle risk behavior or no lifestyle risk behaviors. The National Board of Health and Welfare in Sweden reported in 2018 that it is important to provide additional support to individuals with multiple lifestyle risk behaviors, as risks from these behaviors are multiplicative rather than additive. However, the same report emphasized that there is a lack of knowledge regarding interventions that support changes to unhealthy lifestyle behaviors.

    Objective: The MoBILE (Mobile health Multiple lifestyle Behavior Interventions across the LifEspan) research program has brought together two Swedish research groups supported by international collaborators. Through this collaboration, we aim to design and evaluate a number of novel and tailored mobile health (mHealth) multiple lifestyle behavior interventions across the life span of different health care populations. In addition, the MoBILE research program will extend ongoing research to include mHealth interventions for migrant pregnant women and children.

    Methods: Each project within the MoBILE program will focus on a specific group: pregnant women, preschool children, high school and university students, and adults in primary and clinical care. All the projects will follow the same 4 phases: requirements, development, evaluation, and implementation. During the requirements phase, implementers and end users will aid the design of content and functionality of the interventions. In the development phase, findings from the first phase will be synthesized with expert domain knowledge and theoretical constructs to create interventions tailored to the target groups. The third phase, evaluation, will comprise randomized controlled trials conducted to estimate the effects of the interventions on multiple lifestyle risk behaviors (eg, alcohol, nutrition, physical activity, and smoking). The final phase will investigate how the interventions, if found effective, can be disseminated into different health care contexts.

    Results: The research program commenced in 2019, and the first results will be available in 2020. Projects involving pregnant women, preschool children, and high school and university students will be completed in the first 3 years, with the remaining projects being planned for the program’s final 3 years.

    Conclusions:The development of evidence-based digital tools is complex, as they should be guided by theoretical frameworks, and requires large interdisciplinary teams with competence in technology, behavioral science, and lifestyle-specific areas. Individual researchers or smaller research groups developing their own tools is not the way forward, as it means reinventing the wheel over and over again. The MoBILE research program therefore aims to join forces and learn from the past 10 years of mHealth research to maximize scientific outcomes, as well as the use of financial resources to expand the growing body of evidence for mHealth lifestyle behavior interventions.

     

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  • 47.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    The P Value Line Dance: When Does the Music Stop?2020In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 22, no 8, article id e21345Article in journal (Refereed)
    Abstract [en]

    When should a trial stop? Such a seemingly innocent question evokes concerns of type I and II errors among those who believe that certainty can be the product of uncertainty and among researchers who have been told that they need to carefully calculate sample sizes, consider multiplicity, and not spend P values on interim analyses. However, the endeavor to dichotomize evidence into significant and nonsignificant has led to the basic driving force of science, namely uncertainty, to take a back seat. In this viewpoint we discuss that if testing the null hypothesis is the ultimate goal of science, then we need not worry about writing protocols, consider ethics, apply for funding, or run any experiments at all—all null hypotheses will be rejected at some point—everything has an effect. The job of science should be to unearth the uncertainties of the effects of treatments, not to test their difference from zero. We also show the fickleness of P values, how they may one day point to statistically significant results; and after a few more participants have been recruited, the once statistically significant effect suddenly disappears. We show plots which we hope would intuitively highlight that all assessments of evidence will fluctuate over time. Finally, we discuss the remedy in the form of Bayesian methods, where uncertainty leads; and which allows for continuous decision making to stop or continue recruitment, as new data from a trial is accumulated.

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  • 48.
    Müssener, Ulrika
    et al.
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Löf, Marie
    Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, Sweden.
    Bendtsen, Preben
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Bendtsen, Marcus
    Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences.
    Using Mobile Devices to Deliver Lifestyle Interventions Targeting At-Risk High School Students: Protocol for a Participatory Design Study2020In: JMIR Research Protocols, ISSN 1929-0748, E-ISSN 1929-0748, Vol. 1, no 9Article in journal (Refereed)
    Abstract [en]

    Background: Unhealthy lifestyle behaviors such as insufficient physical activity, unhealthy diet, smoking, and harmful use of alcohol tend to cluster (ie, individuals may be at risk from more than one lifestyle behavior that can be established in early childhood and adolescence and track into adulthood). Previous research has underlined the potential of lifestyle interventions delivered via mobile phones. However, there is a need for deepened knowledge on how to design mobile health (mHealth) interventions taking end user views into consideration in order to optimize the overall usability of such interventions. Adolescents are early adopters of technology and frequent users of mobile phones, yet research on interventions that use mobile devices to deliver multiple lifestyle behavior changes targeting at-risk high school students is lacking.

    Objective: This protocol describes a participatory design study with the aim of developing an mHealth lifestyle behavior intervention to promote healthy lifestyles among high school students.

    Methods: Through an iterative process using participatory design, user requirements are investigated in terms of technical features and content. The procedures around the design and development of the intervention, including heuristic evaluations, focus group interviews, and usability tests, are described.

    Results: Recruitment started in May 2019. Data collection, analysis, and scientific reporting from heuristic evaluations and usability tests are expected to be completed in November 2019. Focus group interviews were being undertaken with high school students from October through December, and full results are expected to be published in Spring 2020. A planned clinical trial will commence in Summer 2020. The study was funded by a grant from the Swedish Research Council for Health, Working Life, and Welfare.

    Conclusions: The study is expected to add knowledge on how to design an mHealth intervention taking end users’ views into consideration in order to develop a novel, evidence-based, low-cost, and scalable intervention that high school students want to use in order to achieve a healthier lifestyle.

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  • 49.
    Bendtsen, Marcus
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    An Electronic Screening and Brief Intervention for Hazardous and Harmful Drinking Among Swedish University Students: Reanalysis of Findings From a Randomized Controlled Trial Using a Bayesian Framework2019In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 21, no 12, article id e14420Article in journal (Refereed)
    Abstract [en]

    Background: Due to a resurgent debate on the misuse of P values, the Journal of Medical Internet Research is hosting a standing theme issue inviting the reanalysis of (primarily digital health) trial data using a Bayesian framework. This first paper in this series focuses on an electronic screening and brief intervention (eSBI), targeting harmful and hazardous alcohol consumption, which student health care centers across Sweden have routinely administerd to all students during the past decade. The second Alcohol Email Assessment and Feedback Study Dismantling Effectiveness for University Students (AMADEUS-2) trial aimed to assess the effect of the eSBI on alcohol consumption among students who were harmful and hazardous drinkers. A two-arm randomized controlled trial design was employed, randomizing eligible participants to either a waiting list or direct access to an eSBI. Follow-up assessments were conducted 2 months after randomization. Subsequent analysis of the trial followed the conventional null hypothesis approach, and no statistical significance was found between groups at follow-up with respect to the number of standard drinks consumed weekly. However, in an unspecified sensitivity analysis, it was discovered that removing three potential outliers made the difference between the groups significant.

    Objective: The objective of this study is to reperform the primary and sensitivity analysis of the AMADEUS-2 trial using a Bayesian framework and to compare the results with those of the original analysis.

    Methods: The same regression models used in the original analysis were employed in this reanalysis (negative binomial regression). Model parameters were given uniform priors. Markov chain Monte Carlo was used for Bayesian inference, and posterior probabilities were calculated for prespecified thresholds of interest.

    Results: Null hypothesis tests did not identify a statistically significant difference between the intervention and control groups, potentially due to a few extreme data points. The Bayesian analysis indicated a 93.6% probability that there was a difference in grams of alcohol consumed at follow-up between the intervention and control groups and a 71.5% probability that the incidence rate ratio was <0.96. Posterior probabilities increased when excluding three potential outliers, yet such post hoc analyses were not necessary to show the preference toward offering an eSBI to harmful and hazardous drinkers among university students.

    Conclusions: The null hypothesis framework relies on point estimates of parameters. P values can therefore swing heavily, depending on a single or few data points alone, casting doubt on the value of the analysis. Bayesian analysis results in a distribution over parameter values and is therefore less sensitive to outliers and extreme values. Results from analyses of trials of interventions where small-to-modest effect sizes are expected can be more robust in a Bayesian framework, making this a potentially better approach for analyzing digital health research data.

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  • 50.
    Bendtsen, Marcus
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Electronic Screening for Alcohol Use and Brief Intervention by Email for University Students: Reanalysis of Findings From a Randomized Controlled Trial Using a Bayesian Framework2019In: Journal of Medical Internet Research, ISSN 1438-8871, E-ISSN 1438-8871, Vol. 21, no 11, article id e14419Article in journal (Refereed)
    Abstract [en]

    Background: Almost a decade ago, Sweden became the first country to implement a national system enabling student health care centers across all universities to routinely administer (via email) an electronic alcohol screening and brief intervention to their students. The Alcohol email assessment and feedback study dismantling effectiveness for university students (AMADEUS-1) trial aimed to assess the effect of the student health care centers routine practices by exploiting the lack of any standard timing for the email invitation and by masking trial participation from students. The original analyses adopted the conventional null hypothesis framework, and the results were consistently in the expected direction. However, since for some tests the P values did not pass the conventional .05 threshold, some of the analyses were necessarily inconclusive. Objective: The outcomes of the AMADEUS-1 trial were derived from the first 3 items of the Alcohol Use Disorders Identification Test (AUDIT-C). The aim of this paper was to reanalyze the two primary outcomes of the AMADEUS-1 trial (AUDIT-C scores and prevalence of risky drinking), using the same models used in the original publication but applying a Bayesian inference framework and interpretation. Methods: The same regression models used in the original analysis were employed in this reanalysis (linear and logistic regression). Model parameters were given uniform priors. Markov chain Monte Carlo was used for Bayesian inference, and posterior probabilities were calculated for prespecified thresholds of interest. Results: Where the null hypothesis tests showed inconclusive results, the Bayesian analysis showed that offering an intervention at baseline was preferable compared to offering nothing. At follow-up, the probability of a lower AUDIT-C score among those who had been offered an intervention at baseline was greater than 95%, as was the case when comparing the prevalence of risky drinking. Conclusions: The Bayesian analysis allows for a more consistent perspective of the data collected in the trial, since dichotomization of evidence is not looked for at some arbitrary threshold. Results are presented that represent the data collected in the trial rather than trying to make conclusions about the existence of a population effect. Thus, policy makers can think about the value of keeping the national system without having to navigate the treacherous landscape of statistical significance.

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