Background:Digital interventions have shown promise in supporting healthy behaviors among university students; however, few interventions support simultaneous change across multiple health behaviors. Moreover, behavioral interventions are typically evaluated as a whole, making it challenging to disentangle the contribution of individual components to the overall effects.

Objective:This study estimated the effects of the components of a digital behavior intervention on alcohol, diet, physical activity, and smoking outcomes among university students in Sweden.

Methods:A double-blind randomized factorial trial with 6 two-level factors was conducted. University students in Sweden were proactively recruited through student health care centers and social media. Participants were eligible if they were aged 18 years or older and had at least one health behavior classified as unhealthy. The effects of 6 components were estimated: screening and feedback; goal-setting and planning; motivation; skills and know-how; mindfulness; and self-authored SMS text messages. Primary outcomes were weekly alcohol consumption and frequency of heavy episodic drinking, average daily fruit and vegetable consumption, weekly sugary drink consumption, weekly moderate-to-vigorous physical activity (MVPA), and 4-week point prevalence of smoking.

Results:A total of 1704 students were randomized. The effectiveness of individual and pairwise components was estimated using available data from 1118 (65.61%) participants at 2 months and 874 (51.29%) at 4 months, with sensitivity analyses conducted using imputed missing data. Most consistently, the evidence indicated that screening and feedback affected fruit and vegetable consumption (2-month mean difference 0.11, compatibility interval [CoI] –0.02 to 0.24; probability of effect [POE] 94.7% and 4-month mean difference 0.12, CoI –0.03 to 0.26; POE 94.4%), as did skills and know-how (2-month mean difference 0.19, CoI 0.06-0.33; POE 99.8% and 4-month mean difference 0.14, CoI 0.01-0.28; POE 96.9%). The combination of these 2 components was even more effective (2-month mean difference 0.30, CoI 0.11-0.48; POE 99.9% and 4-month mean difference 0.26, CoI 0.05-0.46; POE 99.4%). The motivation and mindfulness components, both individually and in combination, increased MVPA at 2 months (combined mean difference 78.0, CoI 28.3-128.2; POE 99.9%); however, this effect was not observed at 4 months. Combining screening and feedback with skills and know-how increased MVPA at 4 months (mean difference 60.1, CoI 3.6-116.5; POE 98.2%). Heavy episodic drinking was reduced at 2 months by screening and feedback (incidence rate ratio 0.87, CoI 0.74-1.02; POE 95.2%), and the effect was greater when combined with goal-setting and mindfulness. There was some evidence that the motivation component was harmful with respect to heavy episodic drinking and that self-authored SMS text messages were harmful with respect to sugary drink consumption.

Conclusions:We dismantled a complex digital multiple behavior intervention and examined it using a factorial design to provide novel insights into the effectiveness of the intervention’s different components. Both marginal and synergistic effects were observed across multiple behaviors, providing evidence regarding which components are most promising in complex interventions. These findings should be considered in light of the risk of bias introduced by attrition to follow-up, which was high in this effectiveness trial with low barriers to participation.

Trial Registration:International Standard Randomised Controlled Trial Number (ISRCTN) ISRCTN23310640; https://www.isrctn.com/ISRCTN23310640

Digital multiple health behaviour interventions could reduce the prevalence of behavioural risk factors for several non-communicable diseases, but their design could be improved through better understanding of how individuals navigate behavioural change. Using a mixed-methods approach, this study evaluated 2657 prompts that were written by individuals (N = 722) for their personal use while taking part in a digital multiple health behaviour intervention trial. This unique data reflects individuals’ thoughts and feelings whilst actively trying to change, rather than post-hoc descriptions or explanations thereof. Inductive qualitative analysis was used to evaluate the prompts and extract themes within the material; then correspondence analysis was used to test whether these themes manifested differently across four behavioural categories (alcohol consumption, tobacco use, healthy diet, physical activity). Six main themes, each with subthemes, were identified (Encouragement & Motivation, Implementing Change, Self-Focus, Mindset, Negotiation Style, and Specific Motives), which reflect nuances in the concept of self-regulation and align well with behavioural change theory. People favoured different approaches to change depending on the target behavioural category, which were broadly discriminated by dimensions of action vs inaction and external/impersonal vs internal/personal focus. This work reveals the various ways individuals approach and navigate changing their health behaviours. Inclusion of self-authoring modules in digital interventions may offer individuals an opportunity to develop skills and know-how gained through intervention engagement, and remind themselves of personal reasons to change.

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.

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.

This study investigated forensic patients perceptions of relevant factors for violence risk, to facilitate an understanding of potential reasons for violence and the effect of risk management interventions. Semi-structured interviews with 13 forensic patients were analyzed with qualitative content analysis using an inductive approach. The sample of participants could identify an array of potentially relevant factors for their use of violence related to themselves, the external context, social and relational aspects, as well as situational factors. Most also actively strived to manage such risk. Considering patients perceptions could potentially add relevant perspectives and improve clinical and structured risk assessments.

Background: The use of e-visits in health care is progressing rapidly worldwide. To date, studies on the advantages and disadvantages of e-consultations in the form of chat services for all inquiries in primary care have focused on the perspective of health care professionals (HCPs) rather than those of end users (patients). Objective: This study aims to explore patients experiences using a chat-based and automated medical history-taking service in regular, tax-based, not-for-profit primary care in Sweden. Methods: Overall, 25 individual interviews were conducted with patients in the catchment areas of 5 primary care centers (PCCs) in Sweden that tested a chat-based and automated medical history-taking service for all types of patient inquiries. The semistructured interviews were transcribed verbatim before content analysis using inductive and deductive strategies, the latter including an unconstrained matrix of human, organization, and technology perspectives. Results: The service provided an easily managed way for patients to make written contact with HCPs, which was considered beneficial for some patients and issues but less suitable for others (acute or more complex cases). The automated medical history-taking service was perceived as having potential but still derived from what HCPs need to know and how they address and communicate health and health care issues. Technical skills were not considered as necessary for a mobile phone chat as for handling a computer; however, patients still expressed concern for people with less digital literacy. The opportunity to take ones time and reflect on ones situation before answering questions from the HCPs was found to reduce stress and prevent errors, and patients speculated that it might be the same for the HCPs on the other end of the system. Patients appreciated the ability to have a conversation from almost anywhere, even from places not suitable for telephone calls. The asynchronicity of the chat service allowed the patients to take more control of the conversation and initiate a chat at any time at their own convenience; however, it could also lead to lengthy conversations where a single issue in the worst cases could take days to close. The opportunity to upload photographs made some visits to the PCC redundant, which would otherwise have been necessary if the ordinary telephone service had been used, saving patients both time and money. Conclusions: Patients generally had a positive attitude toward e-visits in primary care and were generally pleased with the prospects of the digital tool tested, somewhat more with the actual chat than with the automated history-taking system preceding the chat. Although patients expect their PCC to offer a range of different means of communication, the human, organization, and technology analysis revealed a need for more extensive (end) user experience design in the further development of the chat service.

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).

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.

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

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.