Social and behavioral determinants of health in the era of artificial intelligence with electronic health records: A scoping review

Background: There is growing evidence that social and behavioral determinants of health (SBDH) play a substantial effect in a wide range of health outcomes. Electronic health records (EHRs) have been widely employed to conduct observational studies in the age of artificial intelligence (AI). However, there has been little research into how to make the most of SBDH information from EHRs. Methods: A systematic search was conducted in six databases to find relevant peer-reviewed publications that had recently been published. Relevance was determined by screening and evaluating the articles. Based on selected relevant studies, a methodological analysis of AI algorithms leveraging SBDH information in EHR data was provided. Results: Our synthesis was driven by an analysis of SBDH categories, the relationship between SBDH and healthcare-related statuses, and several NLP approaches for extracting SDOH from clinical literature. Discussion: The associations between SBDH and health outcomes are complicated and diverse; several pathways may be involved. Using Natural Language Processing (NLP) technology to support the extraction of SBDH and other clinical ideas simplifies the identification and extraction of essential concepts from clinical data, efficiently unlocks unstructured data, and aids in the resolution of unstructured data-related issues. Conclusion: Despite known associations between SBDH and disease, SBDH factors are rarely investigated as interventions to improve patient outcomes. Gaining knowledge about SBDH and how SBDH data can be collected from EHRs using NLP approaches and predictive models improves the chances of influencing health policy change for patient wellness, and ultimately promoting health and health equity. Keywords: Social and Behavioral Determinants of Health, Artificial Intelligence, Electronic Health Records, Natural Language Processing, Predictive ModelComment: 32 pages, 5 figure

Influences on the Uptake of and Engagement With Health and Well-Being Smartphone Apps: Systematic Review

Background: The public health impact of health and well-being digital interventions is dependent upon sufficient real-world uptake and engagement. Uptake is currently largely dependent on popularity indicators (eg, ranking and user ratings on app stores), which may not correspond with effectiveness, and rapid disengagement is common. Therefore, there is an urgent need to identify factors that influence uptake and engagement with health and well-being apps to inform new approaches that promote the effective use of such tools. Objective: This review aimed to understand what is known about influences on the uptake of and engagement with health and well-being smartphone apps among adults. Methods: We conducted a systematic review of quantitative, qualitative, and mixed methods studies. Studies conducted on adults were included if they focused on health and well-being smartphone apps reporting on uptake and engagement behavior. Studies identified through a systematic search in Medical Literature Analysis and Retrieval System Online, or MEDLARS Online (MEDLINE), EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsychINFO, Scopus, Cochrane library databases, DataBase systems and Logic Programming (DBLP), and Association for Computing Machinery (ACM) Digital library were screened, with a proportion screened independently by 2 authors. Data synthesis and interpretation were undertaken using a deductive iterative process. External validity checking was undertaken by an independent researcher. A narrative synthesis of the findings was structured around the components of the capability, opportunity, motivation, behavior change model and the theoretical domains framework (TDF). Results: Of the 7640 identified studies, 41 were included in the review. Factors related to uptake (U), engagement (E), or both (B) were identified. Under capability, the main factors identified were app literacy skills (B), app awareness (U), available user guidance (B), health information (E), statistical information on progress (E), well-designed reminders (E), features to reduce cognitive load (E), and self-monitoring features (E). Availability at low cost (U), positive tone, and personalization (E) were identified as physical opportunity factors, whereas recommendations for health and well-being apps (U), embedded health professional support (E), and social networking (E) possibilities were social opportunity factors. Finally, the motivation factors included positive feedback (E), available rewards (E), goal setting (E), and the perceived utility of the app (E). Conclusions: Across a wide range of populations and behaviors, 26 factors relating to capability, opportunity, and motivation appear to influence the uptake of and engagement with health and well-being smartphone apps. Our recommendations may help app developers, health app portal developers, and policy makers in the optimization of health and well-being apps

Planning, developing, and pilot testing a mobile health promotion program to prevent type 2 diabetes after gestational diabetes mellitus

Background: Gestational diabetes mellitus (GDM) is associated with an increased risk for type 2 diabetes (T2D) and related cardiometabolic disturbances. A healthy lifestyle with sufficient physical activity, a balanced nutrition, and psychosocial wellbeing decreases the risk of developing these conditions in the years following delivery. Current prevention programs for women after GDM insufficiently address the needs of a flexible, accessible, and practical tool for daily life in this target group. The aim of this dissertation project was to create a theory- and evidence-based scalable mobile health (mHealth) application that fulfils both academic and industrial standards, supports behavior change, and addresses the specific needs of women post-GDM. Methods: The Intervention Mapping approach was implemented to structure the development process. In the scope of this thesis, Intervention Mapping Steps 1 to 4 were applied as blueprint and analytical tool for planning, developing, and pilot testing the smartphone-based TRANGLE program to prevent T2D and related cardiometabolic disturbances in women post-GDM. In the Steps 1 to 3, we designed a theory- and evidence-based intervention model. In Step 4, we cooperated with industry to secure a high technological standard when translating the model into a practical intervention based on a smartphone app. For the associated user study and the clinical pilot trial, we used a mixed methods design based on validated questionnaires on user acceptance and lifestyle behavior, user logs, think alouds with semi-structured interviews, nutrition protocols, and clinical assessments. Results: The resulting TRIANGLE program is among the first mHealth apps for personalized stepwise habit change in the areas of physical activity, nutrition, and psychosocial wellbeing. The interactive app allows for self-pacing, addresses 11 behavioral determinants, and offers 39 behavior change methods to support individual lifestyle change. An associated online platform for healthcare practitioners allows for human coaching while a unique challenge system fosters habit change and education. Once a beta-version of the app and the coaching platform was available, the iterative development process comprised a user study with women post-GDM, followed by adaptations before the full program production. Lastly, a German multicenter randomized controlled pilot trial of the TRIANGLE program indicated first clinical effects for behavior change after six months of intervention. Women post-GDM showed a high acceptance and a high perceived impact of the program on their behavior. Conclusions: Using the Intervention Mapping approach, we developed an innovative mHealth solution for women post-GDM. The novel TRIANGLE program has the potential to prevent cardiometabolic disease as an easy to deliver technological support for behavior change. The program needs to be further refined and tested at a large scale. Intervention Mapping Steps 5 and 6 may support this implementation and evaluation process

Theory and evidence-based development and feasibility testing of a weight loss intervention (Health4LIFE) for overweight and obese primary school educators employed at public schools in low-income settings, Western Cape Province, South Africa

Background: Bearing in mind the prevalence of overweight/obesity found among educators (teachers) and their role modelling function, it is imperative that appropriate weight loss interventions are developed and implemented to control obesity in this target population, while ensuring that they model a healthy body size and lifestyle behaviours in their teaching environment. The United Kingdom (UK) Medical Research Council (MRC) state that best intervention development practice involves a systematic approach where best published research evidence and most suitable theories are combined, referred to as the ‘theory and evidence-based approach'. Intervention development should inherently consider behaviour change theories to assist researchers in deciding which theoretical constructs to target to achieve behaviour change. The MRC guidance recommends that following the development of an intervention, the next step should focus on feasibility testing to advise full-scale evaluation and implementation in real world settings. A feasibility study allows an intervention to be refined by either making incremental or simultaneous adaptations throughout the feasibility study, as well as during all phases of the development of the intervention. Aim: The aims of this research were to 1) conduct a theory and evidenced-based process to develop a weight loss intervention for overweight and obese primary school educators employed at public schools in low-income settings in the Western Cape Province, South Africa and 2) to test the feasibility of the developed intervention in a mixed methods study design. Intervention development Methods: This research firstly involved identification of an appropriate intervention development framework and then behaviour change theories for integration in the framework. The Behaviour Change Wheel (BCW) integrated with the Theory of Planned Behaviour (TPB) to gain insight in educator beliefs regarding dietary and physical activity behaviours and the Health Belief Model (HBM) to address the concept of health awareness (first step to behaviour change) were selected. The Step approach to Message Design and Testing (SatMDT) tool was chosen to underpin intervention message development. The systematic process approach applied in the development of the weight loss intervention in this research included five overarching stages, namely 1) identifying the target behaviours for weight loss, 2) understanding the behaviour, 3) identifying the intervention options, 4) identifying the content and implementation options, and 5) testing and refinement of the intervention materials. Key considerations that emerged in various steps that determined decisions regarding delivery format, are as follows: target population specific factors, setting, affordability, access to electronic devices and internet, limited or no professional contact and preference regarding weight loss intervention delivery mode. Outcome: Step by step application of the BCW framework combined with the TPB, the HBM and the SatMDT resulted in the development of the self-help Health4LIFE weight loss intervention consisting of three elements: 1) a wellness day, 2) a hard copy self-help manual and 3) 80 text messages sent over a 16-week period. The discussion of this section of the thesis focuses on critiquing the use of a theorybased approach (BCW combined with the TPB, HBM and SatMDT) in intervention development. Feasibility testing/assessment Methods: Feasibility outcomes that were identified for the purposes of this research included reach, applicability, acceptability, implementation integrity (primary outcomes), and signals of effect in terms of belief patterns (diet and physical activity beliefs), stage of change for dietary and physical activity behaviours, lifestyle behaviours (diet and physical activity) and weight (secondary outcomes). A cluster sampling method was used to randomly select public schools within the Metro North District in the Western Cape Province. These schools were contacted and educators were invited to participate in the wellness day and the subsequent intervention. Random sampling of schools was repeated until the target of 20 schools was achieved. Ten of these schools were then randomly assigned to the control and 10 to the intervention group. Three sub-studies were conducted to assess the feasibility outcomes. Sub-study 1 involved testing the intervention in a pilot randomised controlled trial. The intervention group received the Health4LIFE weight loss intervention, and the control group received a hard copy of the Department of Health's ‘Choose a Healthy Lifestyle' booklet. Analysis to assess within group change and differences between groups for within group change over the 16- week period were done by protocol, thus using data for completers only. Sub-study 2 investigated the perceptions of educators who participated in the intervention arm and sub-study 3 the perceptions of principals of participating schools regarding reach, acceptability, applicability and implementation integrity. Results: Recruitment (n= 137) and drop-out (n=52) statistics indicated that reach was acceptable, with the exception of male educators who were underrepresented, and black African educators and educators who had attempted weight loss before who were more likely to drop-out. Barriers that may compromise school participation include interruption of teaching time, prior commitments by schools/educators, an already full school program and need to obtain permission from the Department of Basic Education (DoBE) for deviations from the normal school day. Qualitative inputs from principals and educators supported acceptability and applicability of the intervention They were positive about the wellness day, approved of implementation in the school setting, found the hard copy manual useful, enjoyable and easy to understand, and considered the text messages to be helpful and motivational for the day. It was evident that aspects that may need refinement include self monitoring activities, low frequency of contact with interventionists and arrangement of visits to the school. The planned implementation procedure (wellness day, engagement with most sections in the manual and sending of text messages) went as intended, reflecting good implementation integrity, with the exception of the drop-out of three entire schools due to scheduling challenges. Clear signals of effect were evident. The Health4LIFE intervention resulted in favourable shifts in belief patterns regarding dietary intake and physical activity; favourable shifts in stage of change for “increase fruit intake” and “decrease sugar intake”, significant changes in some lifestyle behaviours (increased intake of low fat food items, increased intake of vegetables, decreased intake of sugary food items, decreased frequency of adding fat and sugar to food, increase in physical activity and decreased time spent being sedentary) and a trend towards weight loss in the intervention group. The only significant changes in the control group related to dietary intake (increased intake of vegetables and increased intake of low-fat foods). Overarching conclusions and recommendations: Although the time and effort required to follow a systematic process using the BCW cannot be denied, at the end of this process a very clear understanding of the determinants of a specific behaviour and the mechanisms of action required to affect behaviour change is achieved. These insights are imperative for identification of the most appropriate intervention delivery mode and development of the intervention content. This research provides a comprehensive and systematic guide to using the BCW in a theory and evidence-based process for the development of a self-help weight loss intervention. Results reflecting reach, acceptability, applicability, implementation integrity and potential effectiveness of the Health4LIFE intervention support feasibility of the intervention. Material signals of effect in terms of shifts in belief patterns and stage of change, as well as improvements in lifestyle behaviours were evident. It is plausible that these shifts and changes could collectively result in weight loss, as a trend towards weight loss were found. These signals of effect warrant further evaluation of the intervention in a full-scale study and/or consideration for implementation by the DoBE. Based on the feasibility outcomes it is recommended that the following minor refinements of the Health4LIFE intervention receive attention before next steps are taken: recruitment of male educators, drop-out of black African educators and those who have attempted weight loss before, lack of DoBE policies to address educator health and wellbeing, educator suggestions to improve the intervention manual and poor completion of self-monitoring activities. Major intervention refinements that emerged from the feasibility testing for consideration include more frequent in-person contact between educators and interventionists, extending intervention duration, and making use of eHealth options for contact sessions and self-monitoring. However, the feasibility of major refinements would require additional investigation, further extending the already lengthy intervention development process. Bearing this in mind, implementation of the Health4Life intervention in public schools in low-income settings in its current format, but with minor changes to the hard copy manual as recommended by educators, should be considered

An analysis of inter-professional collaboration in osteoporosis screening at a primary care level using the D'Amour model

Objectives This study describes the perspective of patients, nurses, pharmacists, doctors and policy makers to identify the level of collaboration and the areas for improvement to achieve inter-professional collaboration between doctors, nurses, pharmacists and policy makers in a primary care clinic. Methods Patients (n = 20), Nurses (n = 10), pharmacists (n = 11), doctors (n = 10) and policy makers (n = 5) from a primary care were individually interviewed using a semi-structured topic guide. Purposive sampling was used. Interviews were transcribed verbatim and analysed using thematic analysis informed by constant comparison. Results Patients, doctors, nurses, pharmacists and policy makers were eager for pharmacists to be more proactive in creating health awareness and conducting osteoporosis screening at the primary care clinic via inter-professional collaboration. These findings were further examined using the D'Amour's structural model of collaboration which encompasses four main themes: shared goals and visions, internalization, formalization and governance. This model supports our data which highlights a lack of understanding of the pharmacists' role among the doctors, nurses, policy makers and pharmacists themselves. There is also a lack of governance and formalization, that fosters consensus, leadership, protocol and information exchange. Nonetheless, the stakeholders trust that pharmacists have sufficient knowledge to contribute to the screening of osteoporosis. Our primary care clinic can be described as developing towards an inter-professional collaboration in managing osteoporosis but is still in its early stages. Conclusions Inter-professional collaboration in osteoporosis management at the primary care level is beginning to be practised. Efforts extending to awareness and acceptance towards the pharmacists' role will be crucial for a successful change

Development of a behaviour change intervention to encourage timely cancer symptom presentation among people living in deprived communities using the Behaviour Change Wheel

We are grateful to the National Awareness and Early Diagnosis Initiative (NAEDI) for funding this work. The NAEDI funding consortium, under the auspices of the National Cancer Research Institute (NCRI), consists of Cancer Research UK; Department of Health (England); Economic and Social Research Council; Health and Social Care R&D Division, Public Health Agency (Northern Ireland); National Institute for Social Care and Health Research (Wales); and the Scottish Government. We would like to thank ABACus project management team members Tim Banks and Maura Matthews from Tenovus Cancer Care for their ongoing support and involvement in the project. The authors would also like to acknowledge the support of the ABACus steering group (Danny Antebi, Tracey Deacon, Karen Gully, Jane Hanson, Sharon Hillier, Alex Murray, Richard Neal, Gill Richardson, Mark Rogers, and Sara Thomas). Compliance with Ethical StandardsPeer reviewedPublisher PD

Linguistics Landscape: a Cross Culture Perspective

This paper was to aim in discussing the linguistic landscape. It was the visibility and salience of languages on public and commercial signs in a given territory or region (Landry and Bourhis 1997). The linguistic landscape has been described as being somewhere at the junction of sociolinguistics, sociology, social psychology, geography, and media studies. It is a concept used in sociolinguistics as scholars study how languages are visually used in multilingual societies, from large metropolitan centers to Amazonia. For example, some public signs in Jerusalem are in Hebrew, English, and Arabic (Spolsky and Cooper 1991, Ben-Rafael et al., 2006). Studies of the linguistic landscape have been published from research done around the world. The field of study is relatively recent; the linguistic landscape paradigm has evolved rapidly and while it has some key names associated with it, it currently has no clear orthodoxy or theoretical core