Effectiveness of holistic mobile health interventions on diet, and physical, and mental health outcomes: a systematic review and meta-analysis.

Background: Good physical and mental health are essential for healthy ageing. Holistic mobile health (mHealth) interventions-including at least three components: physical activity, diet, and mental health-could support both physical and mental health and be scaled to the population level. This review aims to describe the characteristics of holistic mHealth interventions and their effects on related behavioural and health outcomes among adults from the general population. Methods: In this systematic review and meta-analysis, we searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, Scopus, China National Knowledge Infrastructure, and Google Scholar (first 200 records). The initial search covered January 1, 2011, to April 13, 2022, and an updated search extended from April 13, 2022 to August 30, 2023. Randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs) were included if they (i) were delivered via mHealth technologies, (ii) included content on physical activity, diet, and mental health, and (iii) targeted adults (≥18 years old) from the general population or those at risk of non-communicable diseases (NCDs) or mental disorders. Studies were excluded if they targeted pregnant women (due to distinct physiological responses), individuals with pre-existing NCDs or mental disorders (to emphasise prevention), or primarily utilised web, email, or structured phone support (to focus on mobile technologies without exclusive human support). Data (summary data from published reports) extraction and risk-of-bias assessment were completed by two reviewers using a standard template and Cochrane risk-of-bias tools, respectively. Narrative syntheses were conducted for all studies, and random-effects models were used in the meta-analyses to estimate the pooled effect of interventions for outcomes with comparable data in the RCTs. The study was registered in PROSPERO, CRD42022315166. Findings: After screening 5488 identified records, 34 studies (25 RCTs and 9 pre-post NRSIs) reported in 43 articles with 5691 participants (mean age 39 years, SD 12.5) were included. Most (91.2%, n = 31/34) were conducted in high-income countries. The median intervention duration was 3 months, and only 23.5% (n = 8/34) of studies reported follow-up data. Mobile applications, short-message services, and mobile device-compatible websites were the most common mHealth delivery modes; 47.1% (n = 16/34) studies used multiple mHealth delivery modes. Of 15 studies reporting on weight change, 9 showed significant reductions (6 targeted on individuals with overweight or obesity), and in 10 studies reporting perceived stress levels, 4 found significant reductions (all targeted on general adults). In the meta-analysis, holistic mHealth interventions were associated with significant weight loss (9 RCTs; mean difference -1.70 kg, 95% CI -2.45 to -0.95; I2 = 89.00%) and a significant reduction in perceived stress levels (6 RCTs; standardised mean difference [SMD] -0.32; 95% CI -0.52 to -0.12; I2 = 14.52%). There were no significant intervention effects on self-reported moderate-to-vigorous physical activity (5 RCTs; SMD 0.21; 95%CI -0.25 to 0.67; I2 = 74.28%) or diet quality scores (5 RCTs; SMD 0.21; 95%CI -0.47 to 0.65; I2 = 62.27%). All NRSIs were labelled as having a serious risk of bias overall; 56% (n = 14/25) of RCTs were classified as having some concerns, and the others as having a high risk of bias. Interpretation: Findings from identified studies suggest that holistic mHealth interventions may aid reductions in weight and in perceived stress levels, with small to medium effect sizes. The observed effects on diet quality scores and self-reported moderate-to-vigorous physical activity were less clear and require more research. High-quality RCTs with longer follow-up durations are needed to provide more robust evidence. To promote population health, future research should focus on vulnerable populations and those in middle- and low-income countries. Optimal combinations of delivery modes and components to improve efficacy and sustain long-term effects should also be explored. Funding: National Research Foundation, Prime Minister's Office, Singapore, under its Campus for Research Excellence and Technological Enterprise (CREATE) Programme and Physical Activity and Nutrition Determinants in Asia (PANDA) Research Programme.

Holistic mHealth interventions for the promotion of healthy ageing: protocol for a systematic review.

INTRODUCTION: Maintaining physical and mental health is essential for healthy ageing. It can be supported by modifying lifestyle factors such as physical activity and diet. Poor mental health, in turn, contributes to the opposing effect. The promotion of healthy ageing may therefore benefit from holistic interventions integrating physical activity, diet and mental health. These interventions can be scaled up to the population level by using mobile technologies. However, systematic evidence regarding the characteristics and effectiveness of such holistic mHealth interventions remains limited. This paper presents a protocol for a systematic review that aims to provide an overview of the current state of the evidence for holistic mHealth interventions, including their characteristics and effects on behavioural and health outcomes in general adult populations . METHODS AND ANALYSIS: We will conduct a comprehensive search for randomised controlled trials and non-randomised studies of interventions published between January 2011 and April 2022 in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, Scopus, China National Knowledge Infrastructure and Google Scholar (first 200 records). Eligible studies will be mHealth interventions targeting general adult populations with content on physical activity, diet and mental health. We will extract information on all relevant behavioural and health outcomes, as well as those related to intervention feasibility. Screening and data extraction processes will be carried out independently by two reviewers. Cochrane risk-of-bias tools will be used to assess risk of bias. We will provide a narrative overview of the findings from eligible studies. With sufficient data, a meta-analysis will be conducted. ETHICS AND DISSEMINATION: Ethical approval is not required because this study is a systematic review based on published data. We intend to publish our findings in a peer-reviewed journal and present the study at international conferences. PROSPERO REGISTRATION NUMBER: CRD42022315166.

Development of "LvL UP 1.0": a smartphone-based, conversational agent-delivered holistic lifestyle intervention for the prevention of non-communicable diseases and common mental disorders.

Background: Non-communicable diseases (NCDs) and common mental disorders (CMDs) are the leading causes of death and disability worldwide. Lifestyle interventions via mobile apps and conversational agents present themselves as low-cost, scalable solutions to prevent these conditions. This paper describes the rationale for, and development of, "LvL UP 1.0″, a smartphone-based lifestyle intervention aimed at preventing NCDs and CMDs. Materials and Methods: A multidisciplinary team led the intervention design process of LvL UP 1.0, involving four phases: (i) preliminary research (stakeholder consultations, systematic market reviews), (ii) selecting intervention components and developing the conceptual model, (iii) whiteboarding and prototype design, and (iv) testing and refinement. The Multiphase Optimization Strategy and the UK Medical Research Council framework for developing and evaluating complex interventions were used to guide the intervention development. Results: Preliminary research highlighted the importance of targeting holistic wellbeing (i.e., both physical and mental health). Accordingly, the first version of LvL UP features a scalable, smartphone-based, and conversational agent-delivered holistic lifestyle intervention built around three pillars: Move More (physical activity), Eat Well (nutrition and healthy eating), and Stress Less (emotional regulation and wellbeing). Intervention components include health literacy and psychoeducational coaching sessions, daily "Life Hacks" (healthy activity suggestions), breathing exercises, and journaling. In addition to the intervention components, formative research also stressed the need to introduce engagement-specific components to maximise uptake and long-term use. LvL UP includes a motivational interviewing and storytelling approach to deliver the coaching sessions, as well as progress feedback and gamification. Offline materials are also offered to allow users access to essential intervention content without needing a mobile device. Conclusions: The development process of LvL UP 1.0 led to an evidence-based and user-informed smartphone-based intervention aimed at preventing NCDs and CMDs. LvL UP is designed to be a scalable, engaging, prevention-oriented, holistic intervention for adults at risk of NCDs and CMDs. A feasibility study, and subsequent optimisation and randomised-controlled trials are planned to further refine the intervention and establish effectiveness. The development process described here may prove helpful to other intervention developers.

Decoupling and scenario analysis of economy-emissions pattern in China's 30 provinces.

The tension between reducing CO2 emissions and economic growth has become increasingly prominent in recent years, while China is vigorously promoting ecological civilization to achieve sustainable development. However, the factors influencing China's current economic emission nexus at the regional and provincial levels and the sustainability of the strong decoupling state remain unclear. We analyze the decoupling of emissions at the national and provincial levels of the Chinese economy from the perspective of historical patterns and current drivers from 1997 to 2019. Also, we developed three scenarios (i.e., pessimistic, median, and optimistic scenarios) to analyze the impact of decoupling relationship changes. We find that China's national decoupling relationship has eased since 1997, but it has not yet reached the ideal state, with provinces mainly exhibiting weak decoupling. The EKC hypothesis is tested for the whole country and 30 provinces and finds that 15 provinces have two turning points, 13 provinces have one turning point, and the others have no turning point. Based on the scenario analysis, the total emissions in the pessimistic scenario (S1) without any improvement of decoupling would increase by 73.97% compared to the level of 2019. However, the total emissions in the optimistic scenario (S3), in which all provinces obtained strong decoupling, are almost half of the level of 2019. This is mainly from the reduction of emissions in the western less developed regions (e.g., Shanxi, Inner Mongolia, and Xinjiang) and developed coastal regions (e.g., Jiangsu and Shandong). On the basis of the results of factor analysis, we put forward policy recommendations for expanding electrification, optimizing industrial structure, and promoting technological innovation.

Effects of Human Capital on Energy Consumption: The Role of Income Inequality.

High-quality human capital (HC) development has a strong influence on achieving a win-win target of economic growth and energy consumption mitigation based on the background of the contemporary "carbon neutrality" constraints in China. We here aim to empirically assess the effect of HC on energy consumption (EC) in 30 provinces of China from 2000 to 2019. Moreover, we broaden the literature by discussing the effect of HC in terms of impact mechanism and nonlinear relationship. Based on methods of the augmented mean group (AMG), the estimation of long-term impacts indicates that the improvement of HC significantly discourages the increase in EC. The intrinsic mechanism shows that the accumulation of HC significantly promotes the decline of EC through economic structure adjustment and technological innovation. Moreover, the threshold model indicates that income equality lifts the inhibitory impact of HC on EC. Accordingly, the development of HC should be involved in the policy preference of China's provincial and national development strategies considering its effectiveness in stimulating the reduction of energy consumption.

Persistent mitigation efforts and implications for China's emissions peak using statistical projections.

To keep global warming below 2 °C by 2100, as per the Paris Agreement, China has announced to peak its CO2 emissions before 2030. Several studies have explored the emissions trajectories in China, but it is as yet uncertain how persistent mitigation efforts of individual provinces and sectors will impact the achievement of ambitious emissions reduction goal. Here we develop a Markov Chain Monte Carlo (MCMC) Bayesian analysis with a modified Kaya identity to project the CO2 emissions in China before 2050. We find that, with persistent mitigation efforts, China can reach an emissions peak in 2032 at 13395 Mt. CO2, which is later than its announced time. Moreover, China's total emissions will reduce slowly after peaking time, with an average annual reduction rate of 0.47%. There are 15 provinces whose emissions will peak before 2030, while 11 provinces can peak during 2030-2050, and 4 provinces can hardly obtain the peak before 2050. Future emission decreases result from the interplay between a rapid reduction driven by decreasing emission intensities, especially in industry, against the increases from economic and population growth. In addition, we find an important mitigation impact from economic structure shift towards services. Such information will be necessary for China's future low-carbon development and will provide implications for policy making.

Remuneration systems of community health workers in India and promoted maternal health outcomes: a cross-sectional study.

BACKGROUND: This study assessed the association of remuneration systems of paid-for-performance Accredited Social Health Activists (ASHAs) and salaried Anganwadi workers (AWWs) on seven maternal health outcomes in four states in India: Andhra Pradesh (AP), Chhattisgarh, Odisha (Orissa), and Uttar Pradesh (UP). METHODS: The cross-sectional study surveyed mothers of children aged 6-23 months. A total of 3455 mothers were selected via multistage cluster sampling. The seven health outcomes related to the community health worker (CHW) visits were: institutional delivery, complete immunization, exclusive breastfeeding for six months, timely introduction of complementary feeding, continued breastfeeding during child's illness, handwashing, and awareness of Nutrition and Health Days (NHDs). RESULTS: The results varied by state. Mothers who received ASHA visits were significantly less likely to have an institutional delivery, timely introduction of complementary feeding, awareness of Nutrition and Health Days (NHDs), proper handwashing, and exclusive breastfeeding for the first six months in at least one of the four states. Conversely, AWW's home visits were positively predictive of the following health outcomes in certain states: complete immunization for index child, continued breastfeeding during the child's illness, handwashing, and awareness of NHDs. CONCLUSIONS: ASHAs' home visits were not more strongly associated with health outcomes for which they were paid than outcomes for which they were unpaid. AWWs' home visits were positively associated with awareness of NHDs, and associations varied for other recommended health behaviors. Further research could elucidate the causes for successes and failures of CHW programs in different states of India.

Perceptions of Physical Activity in African American Older Adults on Hemodialysis: Themes From Key Informant Interviews.

OBJECTIVE: To determine key themes underlying the perceptions of older (≥65y) adults on hemodialysis regarding physical activity using qualitative methodology. DESIGN: Semistructured key informant interviews. SETTING: Academic medical center. PARTICIPANTS: Convenience sample of older adults on hemodialysis (N=10). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Interview transcripts were coded and analyzed using the framework method to extract themes and subthemes. Participants also answered Likert statements regarding their perceptions of physical activity, and the responses were tallied. RESULTS: Ten older adults on hemodialysis participated (mean age 73±5y; 60% women); all were African American. All participants stated physical activity would make them feel better. The major themes that emerged were barriers and facilitators. Facilitators included internal motivators, family and friend support, and feasibility of incorporating physical activity into routine activities. Barriers were lack of motivation, health issues, and environmental restrictions. CONCLUSIONS: Physical activity potentially could prevent the physical decline commonly seen in older adults on hemodialysis. Yet information regarding the perceptions of this population toward physical activity is sparse. Although the study is limited by selection bias, our study presents qualitative evidence that black older adults on hemodialysis desire physical activity for their health. Future interventions to increase physical activity in this population should consider leveraging existing facilitators, such as the support of family and friends, and use strategies to address barriers like minimal motivation.

Sources and Variations in Social Support and Risk for Elder Mistreatment in a US Chinese Population.

OBJECTIVES: Research has examined the relationships between positive social support (PSS) and elder mistreatment (EM) but less is known regarding the negative aspect of social support (NSS), especially among minority groups in the United States. This study aimed to investigate the relationships between PSS/NSS from different sources and EM among US Chinese older adults. DESIGN: Population-based cross-sectional study. SETTING: Greater Chicago, IL, area. PARTICIPANTS: A representative sample of Chinese older adults aged 60 years or older (N = 3157) from the Population Study of ChINese Elderly in Chicago in 2011 to 2013. MEASUREMENTS: We applied a 10-item widely used instrument to assess EM. PSS and NSS from spouse/family members/friends were measured by a 12-item scale. Multivariate logistic regression analyses were conducted to examine the relationships. RESULTS: After adjusting for confounders, higher levels of overall PSS from all three sources, including spouse, family members, and friends (odds ratio [OR] = 0.88 [95% confidence interval {CI} = 0.85-0.91]), were associated with lower risk of EM. But participants with a higher level of overall NSS from all three sources (OR = 1.51 [95% CI = 1.41-1.61]) were more likely to experience EM. The results on the relationships between PSS from spouse (OR = 0.70 [95% CI = 0.64-0.76]), PSS from family members (OR = 0.73 [95% CI = 0.68-0.79]), and EM were similar to overall PSS. But PSS from friends had a nonsignificant association with EM. Greater levels of NSS from spouse (OR = 1.84 [95% CI = 1.64-2.07]), family members (OR = 2.36 [95% CI = 2.03-2.75]), and friends (OR = 1.69 [95% CI = 1.32-2.17]) were associated with increased risks of EM. CONCLUSION: Higher levels of SS were not always associated with lower risks of EM among US Chinese older adults. NSS might have counter effects. Future qualitative or longitudinal research needs to explore detailed cultural explanations and casual relationships between SS and EM. J Am Geriatr Soc 67:S499-S505, 2019.