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

BackgroundDrinking of alcohol among university students is a global phenomenon; heavy episodic drinking is accepted despite several potential negative consequences. There is emerging evidence that short message service (SMS) text messaging interventions are effective to promote behavior change among students. However, it is still unclear how effectiveness can be optimized through intervention design or how user interest and adherence can be maximized.ObjectiveThe objective of this study was to develop an SMS text message-based intervention targeting alcohol drinking among university students using formative research.MethodsA formative research design was used including an iterative revision process based on input from end users and experts. Data were collected via seven focus groups with students and a panel evaluation involving students (n=15) and experts (n=5). Student participants were recruited from five universities in Sweden. A semistructured interview guide was used in the focus groups and included questions on alcohol culture, message content, and intervention format. The panel evaluation asked participants to rate to what degree preliminary messages were understandable, usable, and had a good tone on a scale from 1 (very low degree) to 4 (very high degree). Participants could also write their own comments for each message. Qualitative data were analyzed using qualitative descriptive analysis. Quantitative data were analyzed using descriptive statistics. The SMS text messages and the intervention format were revised continuously in parallel with data collection. A behavior change technique (BCT) analysis was conducted on the final version of the program.ResultsOverall, students were positive toward the SMS text message intervention. Messages that were neutral, motivated, clear, and tangible engaged students. Students expressed that they preferred short, concise messages and confirmed that a 6-week intervention was an appropriate duration. However, there was limited consensus regarding SMS text message frequency, personalization of messages, and timing. Overall, messages scored high on understanding (mean 3.86, SD 0.43), usability (mean 3.70, SD 0.61), and tone (mean 3.78, SD 0.53). Participants added comments to 67 of 70 messages, including suggestions for change in wording, order of messages, and feedback on why a message was unclear or needed major revision. Comments also included positive feedback that confirmed the value of the messages. Twenty-three BCTs aimed at addressing self-regulatory skills, for example, were identified in the final program.ConclusionsThe formative research design was valuable and resulted in significant changes to the intervention. All the original SMS text messages were changed and new messages were added. Overall, the findings showed that students were positive toward receiving support through SMS text message and that neutral, motivated, clear, and tangible messages promoted engagement. However, limited consensus was found on the timing, frequency, and tailoring of messages.

BackgroundExcessive drinking among university students is a global challenge, leading to significant health risks. However, heavy drinking among students is widely accepted and socially normalized. Mobile phone interventions have attempted to reach students who engage in excessive drinking. A growing number of studies suggest that text message–based interventions could potentially reach many students and, if effective, such an intervention might help reduce heavy drinking in the student community.ObjectiveThe objective of this study was to test the effectiveness of a behavior change theory–based 6-week text message intervention among university students.MethodsThis study was a two-arm, randomized controlled trial with an intervention group receiving a 6-week text message intervention and a control group that was referred to treatment as usual at the local student health care center. Outcome measures were collected at baseline and at 3 months after the initial invitation to participate in the intervention. The primary outcome was total weekly alcohol consumption. Secondary outcomes were frequency of heavy episodic drinking, highest estimated blood alcohol concentration, and number of negative consequences attributable to excessive drinking.ResultsA total of 896 students were randomized to either the intervention or control group. The primary outcome analysis included 92.0% of the participants in the intervention group and 90.1% of the control group. At follow-up, total weekly alcohol consumption decreased in both groups, but no significant between-group difference was seen. Data on the secondary outcomes included 49.1% of the participants in the intervention group and 41.3% of the control group. No significant between-group difference was seen for any of the secondary outcomes.ConclusionsThe present study was under-powered, which could partly explain the lack of significance. However, the intervention, although theory-based, needs to be re-assessed and refined to better support the target group. Apart from establishing which content forms an effective intervention, the optimal length of an alcohol intervention targeting students also needs to be addressed in future studies.Trial RegistrationInternational Standard Randomised Controlled Trial Number ISRCTN95054707; http://www.isrctn.com/ISRCTN95054707 (Archived by WebCite at http://www.webcitation.org/70Ax4vXhd)

BackgroundEvidence-based practice for healthy lifestyle promotion in primary health care is supported internationally by national policies and guidelines but implementation in routine primary health care has been slow. Referral to digital interventions could lead to a larger proportion of patients accessing structured interventions for healthy lifestyle promotion, but such referral might have unknown implications for clinicians with patients accessing such interventions. This qualitative study aimed to explore the perceptions of clinicians in primary care on healthy lifestyle promotion with or without digital screening and intervention.MethodsFocus group interviews were conducted at 10 primary care clinics in Sweden with clinicians from different health professions. Transcribed interviews were analyzed using content analysis, with inspiration from a phenomenological-hermeneutic method involving naïve understanding, structural analysis and comprehensive understanding.ResultsTwo major themes captured clinicians’ perceptions on healthy lifestyle promotion: 1) the need for structured professional practice and 2) deficient professional practice as a hinder for implementation. Sub-themes in theme 1 were striving towards professionalism, which for participants meant working in a standardized fashion, with replicable routines regardless of clinic, as well as being able to monitor statistics on individual patient and group levels; and embracing the future with critical optimism, meaning expecting to develop professionally but also being concerned about the consequences of integrating digital tools into primary care, particularly regarding the importance of personal interaction between patient and provider. For theme 2, sub-themes were being in an unmanageable situation, meaning not being able to do what is perceived as best for the patient due to lack of time and resources; and following one’s perception, meaning working from a gut feeling, which for our participants also meant deviating from clinical routines.ConclusionsIn efforts to increase evidence-based practice and lighten the burden of clinicians in primary care, decision- and policy-makers planning the introduction of digital tools for healthy lifestyle promotion will need to explicitly define their role as complements to face-to-face encounters. Our overriding hope is that this study will contribute to maintaining meaningfulness in the patient-clinician encounter, when digital tools are added to facilitate patient behavior change of unhealthy lifestyle behaviors.Electronic supplementary materialThe online version of this article (10.1186/s12875-018-0829-z) contains supplementary material, which is available to authorized users.

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 user’s perspective. The findings may lead to the development of similar interventions targeting the high school population.

BackgroundDespite significant health risks, heavy drinking of alcohol among university students is a widespread problem; excessive drinking is part of the social norm. A growing number of studies indicate that short message service (SMS)-based interventions are cost-effective, accessible, require limited effort by users, and can enable continuous, real-time, brief support in real-world settings. Although there is emerging evidence for the effect of SMS-based interventions in reducing alcohol consumption, more research is needed. This study aims to test the effectiveness of a newly developed SMS-based intervention targeting excessive alcohol consumption among university and college students in Sweden.MethodsThe study is a two-arm randomized controlled trial with an intervention (SMS programme) and a control (treatment as usual) group. Outcome measures will be investigated at baseline and at 3-month follow up. The primary outcome is total weekly alcohol consumption. Secondary outcomes are frequency of heavy episodic drinking, highest estimated blood alcohol concentration and number of negative consequences due to excessive drinking.DiscussionThis study contributes knowledge on the effect of automatized SMS support to reduce excessive drinking among students compared with existing support such as Student Health Centres.Trial registrationISRCTN.com, ISRCTN95054707. Registered on 31 August 2016.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-017-1898-3) contains supplementary material, which is available to authorized users.

BackgroundScreening and brief interventions (SBI) in primary healthcare are cost-effective in risky drinkers, yet they are not offered to all eligible patients. This qualitative study aimed to provide more insight into the factors and mechanisms of why, how, for whom and under what circumstances implementation strategies work or do not work in increasing SBI.MethodsSemi-structured interviews were conducted between February and July 2014 with 40 GPs and 28 nurses in Catalonia, the Netherlands, Poland, and Sweden. Participants were purposefully selected from the European Optimising Delivery of Healthcare Interventions (ODHIN) trial. This randomised controlled trial evaluated the influence of training and support, financial reimbursement and an internet-based method of delivering advice on SBI. Amongst them were 38 providers with a high screening performance and 30 with a low screening performance from different allocation groups. Realist evaluation was combined with the Tailored Implementation for Chronic Diseases framework for identification of implementation determinants to guide the interviews and analysis. Transcripts were analysed thematically with the diagram affinity method.ResultsTraining and support motivated SBI by improved knowledge, skills and prioritisation. Continuous provision, sufficient time to learn intervention techniques and to tailor to individual experienced barriers, seemed important T&S conditions. Catalan and Polish professionals perceived financial reimbursement to be an additional stimulating factor as well, as effects on SBI were smoothened by personnel levels and salary levels. Structural payment for preventive services rather than a temporary project based payment, might have increased the effects of financial reimbursement. Implementing e-BI seem to require more guidance than was delivered in ODHIN. Despite the allocation, important preconditions for SBI routine seemed frequent exposure of this topic in media and guidelines, SBI facilitating information systems, and having SBI in protocol-led care. Hence, the second order analysis revealed that the applied implementation strategies have high potential on the micro professional level and meso-organisational level, however due to influences from the macro- level such as societal and political culture the effects risks to get nullified.ConclusionsEssential determinants perceived for the implementation of SBI routines were identified, in particular for training and support and financial reimbursement. However, focusing only on the primary healthcare setting seems insufficient and a more integrated SBI culture, together with meso- and macro-focused implementation process is requested.Trial registrationClinicalTrials.gov. Trial identifier: NCT01501552.

BackgroundHeavy consumption of alcohol among university students is a global problem, with excessive drinking being the social norm. Students can be a difficult target group to reach, and only a minority seek alcohol-related support. It is important to develop interventions that can reach university students in a way that does not further stretch the resources of the health services. Text messaging (short message service, SMS)–based interventions can enable continuous, real-time, cost-effective, brief support in a real-world setting, but there is a limited amount of evidence for effective interventions on alcohol consumption among young people based on text messaging. To address this, a text messaging–based alcohol consumption intervention, the Amadeus 3 intervention, was developed.ObjectiveThis study explored self-reported changes in drinking habits in an intervention group and a control group. Additionally, user satisfaction among the intervention group and the experience of being allocated to a control group were explored.MethodsStudents allocated to the intervention group (n=460) were asked about their drinking habits and offered the opportunity to give their opinion on the structure and content of the intervention. Students in the control group (n=436) were asked about their drinking habits and their experience in being allocated to the control group. Participants received an email containing an electronic link to a short questionnaire. Descriptive analyses of the distribution of the responses to the 12 questions for the intervention group and 5 questions for the control group were performed.ResultsThe response rate for the user feedback questionnaire of the intervention group was 38% (176/460) and of the control group was 30% (129/436). The variation in the content of the text messages from facts to motivational and practical advice was appreciated by 77% (135/176) participants, and 55% (97/176) found the number of messages per week to be adequate. Overall, 81% (142/176) participants stated that they had read all or nearly all the messages, and 52% (91/176) participants stated that they were drinking less, and increased awareness regarding negative consequences was expressed as the main reason for reduced alcohol consumption. Among the participants in the control group, 40% (52/129) stated that it did not matter that they had to wait for access to the intervention. Regarding actions taken while waiting for access, 48% (62/129) participants claimed that they continued to drink as before, whereas 35% (45/129) tried to reduce their consumption without any support.ConclusionsAlthough the main randomized controlled trial was not able to detect a statistically significant effect of the intervention, most participants in this qualitative follow-up study stated that participation in the study helped them reflect upon their consumption, leading to altered drinking habits and reduced alcohol consumption.Trial RegistrationInternational Standard Randomized Controlled Trial Number ISRCTN95054707; http://www.isrctn.com/I...