Expanding the research area of behavior change support systems

The First International Workshop on Behavior Change Support Systems attracted a great research interest. The selected papers focused on abstraction, implementation and evaluation of Behavior Change Support Systems. The workshop is an evidence of how researchers from around the globe have their own perspective of behavior change interventions. In this abstract, we have attempted to outline core issues that can enhance persuasiveness of such support systems. Finally, we highlight important research questions relating to the development of effective Behavior Change Support System

Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care

Background: Shared decision making is an important component of patient-centred care. It is a set of communication and evidence-based practice skills that elicits patients' expectations, clarifies any misperceptions and discusses the best available evidence for benefits and harms of treatment. Acute respiratory infections (ARIs) are one of the most common reasons for consulting in primary care and obtaining prescriptions for antibiotics. However, antibiotics offer few benefits for ARIs, and their excessive use contributes to antibiotic resistance - an evolving public health crisis. Greater explicit consideration of the benefit-harm trade-off within shared decision making may reduce antibiotic prescribing for ARIs in primary care. Objectives: To assess whether interventions that aim to facilitate shared decision making increase or reduce antibiotic prescribing for ARIs in primary care. Search methods: We searched CENTRAL (2014, Issue 11), MEDLINE (1946 to November week 3, 2014), EMBASE (2010 to December 2014) and Web of Science (1985 to December 2014). We searched for other published, unpublished or ongoing trials by searching bibliographies of published articles, personal communication with key trial authors and content experts, and by searching trial registries at the National Institutes of Health and the World Health Organization. Selection criteria: Randomised controlled trials (RCTs) (individual level or cluster-randomised), which evaluated the effectiveness of interventions that promote shared decision making (as the focus or a component of the intervention) about antibiotic prescribing for ARIs in primary care. Data collection and analysis: Two review authors independently extracted and collected data. Antibiotic prescribing was the primary outcome, and secondary outcomes included clinically important adverse endpoints (e.g. re-consultations, hospital admissions, mortality) and process measures (e.g. patient satisfaction). We assessed the risk of bias of all included trials and the quality of evidence. We contacted trial authors to obtain missing information where available. Main results: We identified 10 published reports of nine original RCTs (one report was a long-term follow-up of the original trial) in over 1100 primary care doctors and around 492,000 patients. The main risk of bias came from participants in most studies knowing whether they had received the intervention or not, and we downgraded the rating of the quality of evidence because of this. We meta-analysed data using a random-effects model on the primary and key secondary outcomes and formally assessed heterogeneity. Remaining outcomes are presented narratively. There is moderate quality evidence that interventions that aim to facilitate shared decision making reduce antibiotic use for ARIs in primary care (immediately after or within six weeks of the consultation), compared with usual care, from 47% to 29%: risk ratio (RR) 0.61, 95% confidence interval (CI) 0.55 to 0.68. Reduction in antibiotic prescribing occurred without an increase in patient-initiated re-consultations (RR 0.87, 95% CI 0.74 to 1.03, moderate quality evidence) or a decrease in patient satisfaction with the consultation (OR 0.86, 95% CI 0.57 to 1.30, low quality evidence). There were insufficient data to assess the effects of the intervention on sustained reduction in antibiotic prescribing, adverse clinical outcomes (such as hospital admission, incidence of pneumonia and mortality), or measures of patient and caregiver involvement in shared decision making (such as satisfaction with the consultation; regret or conflict with the decision made; or treatment compliance following the decision). No studies assessed antibiotic resistance in colonising or infective organisms. Authors' conclusions: Interventions that aim to facilitate shared decision making reduce antibiotic prescribing in primary care in the short term. Effects on longer-term rates of prescribing are uncertain and more evidence is needed to determine how any sustained reduction in antibiotic prescribing affects hospital admission, pneumonia and death

Privacy and Accountability in Black-Box Medicine

Black-box medicine—the use of big data and sophisticated machine learning techniques for health-care applications—could be the future of personalized medicine. Black-box medicine promises to make it easier to diagnose rare diseases and conditions, identify the most promising treatments, and allocate scarce resources among different patients. But to succeed, it must overcome two separate, but related, problems: patient privacy and algorithmic accountability. Privacy is a problem because researchers need access to huge amounts of patient health information to generate useful medical predictions. And accountability is a problem because black-box algorithms must be verified by outsiders to ensure they are accurate and unbiased, but this means giving outsiders access to this health information. This article examines the tension between the twin goals of privacy and accountability and develops a framework for balancing that tension. It proposes three pillars for an effective system of privacy-preserving accountability: substantive limitations on the collection, use, and disclosure of patient information; independent gatekeepers regulating information sharing between those developing and verifying black-box algorithms; and information-security requirements to prevent unintentional disclosures of patient information. The article examines and draws on a similar debate in the field of clinical trials, where disclosing information from past trials can lead to new treatments but also threatens patient privacy

The Unsung Virtues of Global Forum Shopping

Forum shopping gets a bad name. This is even more true in the context of transnational litigation. The term is associated with unprincipled gamesmanship and undeserved victories. Courts therefore often seek to thwart the practice. But in recent years, exaggerated perceptions of the “evils” of forum shopping among courts in different countries have led U.S. courts to impose high barriers to global forum shopping. These extreme measures prevent global forum shopping from serving three unappreciated functions: protecting access to justice, promoting private regulatory enforcement, and fostering legal reform. This Article challenges common perceptions about global forum shopping that have supported recent doctrinal developments. It traces the history of concerns about global forum shopping and distinguishes between domestic and global forum shopping to discern the core objections to the practice. It then identifies these unappreciated virtues of global forum shopping and suggests balanced ways for courts to protect them

Algorithmic Challenges to Autonomous Choice

We then explore how autonomous algorithmic assistants affect the legal framework. Some issues challenge the very use of algorithmic assistants: Should the law place an age limit on the use of such algorithms? Should legal limits be placed on their use in certain spheres? Other issues arise from the construction of preferences by algorithms. To wit, in a market in which demand is driven by algorithms, can we necessarily regard the choices made as expressions of user preferences that serve our socio-political goals? Even if the answer is positive—does this new mode of user choice fit current legal assumptions, such as those that apply to the notions of consent or intent? And are our regulatory tools, which seek to ensure that individual consumers can make informed decisions, outmoded? It is therefore essential to determine whether the existing legal framework is sufficiently potent to deal with this brave new world, or whether we need new regulatory tools. Despite their importance and timeliness, these questions have not been dealt with in depth. This article seeks to fill this void. It proceeds as follows. Part II explores the lure and modes of operation of algorithmic assistants, and how these characteristics may affect human choice. Part III then analyzes the rationales for such choice and explores how these rationales are affected by the employment of autonomous algorithmic assistants. As shown, while some rationales are not harmed—and might even be strengthened— by the use of autonomous algorithmic assistants, others challenge us to reconsider the meaning and the role that choice plays in our lives and to deal with the conflict between the efficient fulfillment of short-term preferences and the long-term ability to form such preferences. Part IV analyzes the implications of these new private orderings on regulation, with a special focus on laws based on assumptions of human autonomous decision-making. We summarize our findings in a short conclusion

Eating for Environmental and Personal Health: Green Eating, Health Behavior and Environmental Perceptions at the University of Maine

The purpose of this study was to determine if green eating (GE), defined as environmentally conscious eating, in college students had an impact on BMI, health behavior, fruit and vegetable intake, physical activity, and perceptions of the campus environment. This was a cross-sectional study of undergraduate and graduate students (n=190) at the University of Maine. The GE Survey was used to determine GE stage of change; participants were classified as either pre-action (precontemplation, contemplation, preparation) (n=113) or post-action (action, maintenance) (n=77). The GE Survey was also used to assess GE behavior, decisional balance, and self-efficacy. A de novo health behavior scale was used to measure frequency of healthful behavior (10 (never) to 50 (frequently)), including looking for healthy foods and participating in on-campus health programs. The National Cancer Institute (NCI) Screener was used to assess fruit and vegetable intake, the International Physical Activity Questionnaire (IPAQ) was used to assess physical activity in MET (Metabolic Equivalents of Task)-minutes, and a de novo environmental perceptions scale (0 (strongly disagree) to 100 (strongly agree)) was used to assess students’ perceptions of the campus environmental supports for healthful behavior, including availability of healthy foods on campus and presence of policies to promote healthy eating. Statistical analyses included chi-square and two-way ANOVA tests were used to compare pre- and post-action stages of change by gender. Significance was set at p Overall, the participants were mostly female (67.9%) and almost all were white (94.6%). The mean BMI was 24.2±4.9, with no difference between pre- and post-action. Participants in the post-action stage of change had higher scores than pre-action for GE behavior (p=0.0001), and were more confident in their ability to practice GE at school (p=0.0001) and at home (p=0.005). Post-action participants also placed greater importance on pros of GE (p=0.0001) and less importance on cons of GE (p=0.001). Post-action participants had higher health behavior scores than pre-action (30.9±5.0 vs. 33.5±4.8) (p=0.001). Based on the NCI Screener, post-action participants had higher daily intake of fruits and vegetables (5.0±4.4 cups) compared to pre-action (2.9±2.4 cups) (p=0.0001). Post-action participants also engaged in more weekly vigorous physical activity (1439.7±1475.7 MET-minutes) than pre-action (984.0±1367.2 MET-minutes) (p=0.003), and more total physical activity (2662.9±1781.5 MET-minutes) than pre-action (2237.11±2104.5 MET-minutes) (p=0.012). For perceptions of the campus environmental supports for healthful behavior, there was an interaction between GE stage of change and gender; males in the pre-action stage had more positive perceptions (65.2±12.5) and females in the pre-action stage had more negative perceptions (55.5±9.6), whereas males and females in the post-action stage had similar perceptions (males: 59.3±12.0; females: 60.4± 11.4) (p=0.047). College students who were green eaters engaged in more healthful behavior, consumed more cups of fruits and vegetables, and engaged in more physical activity than those who were not green eaters. Based on these results, increased awareness of GE may raise consciousness about the environmental impact of food choices and one’s own health behavior among college students. In the future, educating college students about GE may have an added benefit of promoting healthful behavior

Regulation, Deregulation, and Happiness

Happiness, in general, is in many respects the topic du jour. A great deal of theoretical and empirical work has been devoted to dissecting it. Studies of happiness have crossed over to law, and the result is an addition to the long list of the list of “law and” interdisciplinary areas. In fact, in 2010, Eric Posner and Matthew Alder presented an excellent book of readings the title of which is Law and Happiness. Peter Henry Huang has written the definitive survey of law and happiness literature. My own writing has reflected on the promise of happiness research and the difficulties of implementing its teachings. Most of the interdisciplinary work evaluates the potential impact of happiness on policy or programs. For example, in response to evidence that hosting large scale sports events like the Olympics or the Super Bowl may not be unqualified economic successes, work is now being conducted to assess the impact of those events on happiness. The teachings of happiness scholarship have yet to be applied to the traditional rationales for business regulation and the issue of how regulation could be altered, if at all, by considerations of happiness. This is the topic to which most of what follows is devoted

Older persons’ and their caregivers’ perspectives and experiences of research participation with impaired decision-making capacity: A scoping review

Background and Objectives: Human research ethics statements support equitable inclusion of diverse groups. Yet older people are under-represented in clinical research, especially those with impaired decision-making capacity. The aim of this study was to identify perspectives and experiences of older persons and their caregivers of research participation with impaired decision-making capacity. Research Design and Methods: Scoping review of literature and online sources in January-February 2019 (updated June 2020) according to Joanna Briggs Institute methodology and PRISMA Extension for Scoping Reviews. English-language peer-reviewed research articles and Australian online narratives were included. Data were tabulated and narratively synthesized. Results: From 4171 database records and 93 online resources, 22 articles (2000-2019, 82% United States, 16 first authors) and one YouTube webinar (2018) were initially included; updated searches yielded an additional article (2020) and YouTube webinar (2020). Studies were heterogeneous in terminology, methods and foci, with hypothetical scenarios, quantitative analyses and examination of proxy consent predominating. Participants (n=7331) were older persons (71%), caregivers of older persons with dementia/cognitive impairment (23%) and older persons with dementia/cognitive impairment (6%). Synthesis identified two themes: willingness to participate and decision-making approaches. Discussion and Implications: Research participation by older persons with dementia may be optimized through reducing risks and burdens and increasing benefits for participants, greater consumer input into study development, and shared and supported decision-making. Older persons’ and caregivers’ perspectives and experiences of research participation with impaired decision-making capacity require investigation in a greater range of countries and conditions other than dementia, and dissemination through more varied media

A Pilot Study of MY VOICE: Strengths-Based and Self-Directed Recovery Planning

An imbalance of power and autonomy exists between individuals with psychiatric disabilities and their treatment providers. Electronic decision support interventions (EDSI's) help individuals with psychiatric disabilities increase consumer self-determination and decision-making in care. The MY VOICE: Strengths-based and Self-Directed Recovery Planning is an EDSI designed to assist consumers in writing their own recovery plans. The purpose of this randomized waitlist controlled pilot study of the MY VOICE program was to test the hypothesis that participation in a self-directed EDSI program will lead to increases in consumer self-identified empowerment, self-determination and recovery. Findings indicate that participation in the MY VOICE program in comparison to the control group was a significant predictor of consumer self-identified recovery while participation in MY VOICE was not a significant predictor of self-identified empowerment or self-determination. The number of tasks a person completes and completion of the program itself were also not predictors of self-identified empowerment, self-determination, or recovery. Future research may need to control for the relationship with the peer-support worker facilitating the MY VOICE program, endeavor to the determine elements within the MY VOICE program that facilitate increases in self-identified recovery, and conduct qualitative analysis to better understand how participants are using their self-directed recovery plans and how they view the MY VOICE program and the peer support facilitator influencing them