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Background: A decade ago paper questionnaires were more common in epidemiology than those administered online, but increasing Internet access may have changed this. Researchers planning to use a self-administered questionnaire should know whether response rates to questionnaires administered electronically differ to those of questionnaires administered by post. We analysed trials included in a recently updated Cochrane Review to answer this question., Methods: We exported data of randomised controlled trials included in three comparisons in the Cochrane Review that had evaluated hypotheses relevant to our research objective and imported them into Stata for a series of meta-analyses not conducted in the Cochrane review. We pooled odds ratios for response using random effects meta-analyses. We explored causes of heterogeneity among study results using subgroups. We assessed evidence for reporting bias using Harbord's modified test for small-study effects., Results: Twenty-seven trials (66,118 participants) evaluated the effect on response of an electronic questionnaire compared with postal. Results were heterogeneous (I-squared = 98%). There was evidence for biased (greater) effect estimates in studies at high risk of bias; A synthesis of studies at low risk of bias indicates that response was increased (OR = 1.43; 95% CI 1.08-1.89) using postal questionnaires. Ten trials (39,523 participants) evaluated the effect of providing a choice of mode (postal or electronic) compared to an electronic questionnaire only. Response was increased with a choice of mode (OR = 1.63; 95% CI 1.18-2.26). Eight trials (20,909 participants) evaluated the effect of a choice of mode (electronic or postal) compared to a postal questionnaire only. There was no evidence for an effect on response of a choice of mode compared with postal only (OR = 0.94; 95% CI 0.86-1.02)., Conclusions: Postal questionnaires should be used in preference to, or offered in addition to, electronic modes., (© 2024. The Author(s).)

Introduction: Online e-cigarette retailers use e-mail communications to promote products directly to consumers, which may facilitate e-cigarette use. Little is known about the content of these e-mails. As such, this study collected e-mails from online e-cigarette retailers in California to conduct a content analysis., Aims and Methods: This study included 13 online e-cigarette retailers in California using Yelp. To be included in the study, e-cigarette retailers needed a live website, physical retail location (ie, vape shop), and e-cigarettes available for purchase online. The research team entered each website and signed up (if possible) for an e-mail newsletter. Data were collected from the Gmail Application Programming Interface over a 1-year study period (November 1, 2021-November 1, 2022). Members of the research team coded e-mails for the presence of e-cigarettes, other products, flavors, marketing categories, and promotional activities, among other variables., Results: Seven hundred and forty-nine promotional e-mails (2.1 avg/day) were received over the 1-year study period. Second-generation e-cigarettes (n = 581, 77.6%) were the most observed product in e-mails followed by disposable e-cigarettes (n = 391, 52.2%). The most common flavor profile was fruit or sweet or liquor (n = 424, 56.6%). E-mails included links to social media pages (n = 366, 48.9%). Online coupons were found in 53.1% (n = 398) of the e-mails. Age warnings were displayed in 8.0% (n = 60) of the e-mails., Conclusions: E-cigarette retailers' e-mails promoted new products, flavors, and contained promotional discounts. Future research should examine the impact of exposure to such e-mails on e-cigarette-related attitudes and behaviors., Implications: Findings from this study may help inform prevention programs and interventions focused on increasing tobacco-related digital media literacy (ie, evaluate tobacco advertising messages on digital media) among gender and ethnic minorities. Future research should examine if exposure to e-mail marketing is causally linked with e-cigarette use among gender and ethnic minorities., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Participant recruitment in rural and hard-to-reach (HTR) populations can present unique challenges. These challenges are further exacerbated by the need for low-cost recruiting, which often leads to use of web-based recruitment methods (eg, email, social media). Despite these challenges, recruitment strategy statistics that support effective enrollment strategies for underserved and HTR populations are underreported. This study highlights how a recruitment strategy that uses email in combination with follow-up, mostly phone calls and email reminders, produced a higher-than-expected enrollment rate that includes a diversity of participants from rural, Appalachian populations in older age brackets and reports recruitment and demographic statistics within a subset of HTR populations., Objective: This study aims to provide evidence that a recruitment strategy that uses a combination of email, telephonic, and follow-up recruitment strategies increases recruitment rates in various HTR populations, specifically in rural, older, and Appalachian populations., Methods: We evaluated the overall enrollment rate of 1 recruitment arm of a larger study that aims to understand the relationship between genetics and substance use disorders. We evaluated the enrolled population's characteristics to determine recruitment success of a combined email and follow-up recruitment strategy, and the enrollment rate of HTR populations. These characteristics included (1) enrollment rate before versus after follow-up; (2) zip code and county of enrollee to determine rural or urban and Appalachian status; (3) age to verify recruitment in all eligible age brackets; and (4) sex distribution among age brackets and rural or urban status., Results: The email and follow-up arm of the study had a 17.4% enrollment rate. Of the enrolled participants, 76.3% (4602/6030) lived in rural counties and 23.7% (1428/6030) lived in urban counties in Pennsylvania. In addition, of patients enrolled, 98.7% (5956/6030) were from Appalachian counties and 1.3% (76/6030) were from non-Appalachian counties. Patients from rural Appalachia made up 76.2% (4603/6030) of the total rural population. Enrolled patients represented all eligible age brackets from ages 20 to 75 years, with the 60-70 years age bracket having the most enrollees. Females made up 72.5% (4371/6030) of the enrolled population and males made up 27.5% (1659/6030) of the population., Conclusions: Results indicate that a web-based recruitment method with participant follow-up, such as a phone call and email follow-up, increases enrollment numbers more than web-based methods alone for rural, Appalachian, and older populations. Adding a humanizing component, such as a live person phone call, may be a key element needed to establish trust and encourage patients from underserved and rural areas to enroll in studies via web-based recruitment methods. Supporting statistics on this recruitment strategy should help researchers identify whether this strategy may be useful in future studies and HTR populations., (©Tabitha Milliken, Donielle Beiler, Samantha Hoffman, Ashlee Olenginski, Vanessa Troiani. Originally published in JMIR Formative Research (https://formative.jmir.org), 22.08.2024.)

Introduction: Multiple modalities and frequencies of contact are needed to maximize recruitment in many public health surveys. The purpose of this analysis is to characterize respondents to a statewide SARS-CoV-2 testing study whose participation followed either postcard, phone outreach or electronic means of invitation. In addition, we examine how participant characteristics differ based upon the number of contacts needed to elicit participation., Methods: This is a cross-sectional analysis of survey data collected from participants who were randomly selected to represent Indiana residents and were invited to be tested for Covid-19 in April 2020. Participants received invitations via postcard, text/emails, and/or robocalls/texts based upon available contact information. The modality, and frequency of contacts, that prompted participation was determined by when the notification was sent and when the participant responded and subsequently registered to participate in the study. Chi square analyses were used to determine differences between groups and significant findings were analyzed using multinomial logistic regression., Results: Respondents included 3,658 individuals and were stratified by postcards (7.9%), text/emails (26.5%), and robocalls/text (65.7%) with 19.7% registering after 1 contact, 47.9% after 2 contacts, and 32.4% after 3 contacts encouraging participation. Females made up 54.6% of the sample and responded at a higher rate for postcards (8.2% vs. 7.5%) and text/emails (28.1 vs. 24.6%) as compared to males (χ 2  = 7.43, p = 0.025). Compared to males, females responded at a higher percentage after 1 contact (21.4 vs. 17.9%, χ 2  = 7.6, p = 0.023). Those over 60 years responded most often after 2 contacts (χ 2  = 27.5, p < 0.001) when compared to others at younger age groups. In regression analysis, participant sex (p = 0.036) age (p = 0.005), educational attainment (p = < 0.0001), and being motivated by "free testing" (p = 0.036) were correlated with participation in the prevalence study., Discussion: Researchers should be aware that the modality of contact as well as the number of prompts used could influence differential participation in public health studies. Our findings can inform researchers developing studies that rely on selective participation by study subjects. We explore how to increase participation within targeted demographic groups using specific modalities and examining frequency of contact., (© 2024. The Author(s).)

Objective: To report the impact of the COVID-19 pandemic on the activity of nurses working on an inflammatory bowel disease (IBD) unit and to identify reasons for telehealth care and its relationship to certain characteristics., Background: The COVID-19 pandemic had led to an increase in demand for remote care in patients with inflammatory bowel disease who require monitoring and frequent access to health services., Design - Methods: A retrospective study of all activity (in person and by phone call or email) done on the unit during the acute phase of the pandemic at a reference hospital in Spain. Numbers of activities done by nurses, reasons for telehealth care and sociodemographic and clinical data were collected. Statistical analysis was performed using frequency, chi-squared and analysis of variance tests., Results: A total of 1095 activities for 561 patients who received care were reported. Among them, 1042 (95.2%) were telemedicine activities, amounting to a 47.3% increase over the prior year. COVID-19-related activities numbered 588 (59.5%). Consultations due to disease flare-up numbered 134 (13.7%), representing a 145% increase compared to 2019. Significant differences were found between reasons for using telemedicine and diagnosis, occupational status, contact week and treatment., Conclusion: The acute phase of the pandemic has changed the activity managed by the nursing staff on the unit. Identifying and analysing these changes has yielded valuable information to achieve more efficient management and better care quality for patients in special situations., (Copyright © 2021 The Author(s). Publicado por Elsevier España, S.L.U. All rights reserved.)

Big data require new techniques to handle the information they come with. Here we consider four datasets (email communication, Twitter posts, Wikipedia articles and Gutenberg books) and propose a novel statistical framework to predict global statistics from random samples. More precisely, we infer the number of senders, hashtags and words of the whole dataset and how their abundances (i.e. the popularity of a hashtag) change through scales from a small sample of sent emails per sender, posts per hashtag and word occurrences. Our approach is grounded on statistical ecology as we map inference of human activities into the unseen species problem in biodiversity. Our findings may have applications to resource management in emails, collective attention monitoring in Twitter and language learning process in word databases., Competing Interests: The authors have declared that no competing interests exist.

Objective: To compare two strategies for requesting additional information for systematic reviews (SR) from study authors., Study Design and Setting: Randomised study within a SR of hospital volume-outcome relationships in total knee arthroplasty. We sent personalized email requests for additional information to study authors as either email text ("Email" group) or attachment with self-developed, personalised data request forms ("Attachment" group). The primary outcome was the response rate, the secondary outcomes were the data completeness rate and the reviewer time invested in author contact., Results: Of 57 study authors, 29 were randomised to the Email group and 28 to the Attachment group. The response rate was 93% for Email and 75% for Attachment (odds ratio 4.5, 95% confidence interval [0.9-24.0]). Complete data were provided by 55% (Email) vs. 36% (Attachment) of authors (odds ratio 2.2 [0.8-6.4]). The mean reviewer time was shorter in the Email (mean ± standard deviation of 20.2±14.4 minutes/author) than the Attachment group (31.8±14.4 minutes/author) with a mean difference of 11.6 [4.1-19.1] minutes/author., Conclusion: Personalised email requests elicited high response but only moderate data completeness rates regardless of the method (email text or attachment). Email requests as text took less reviewer time than creating attachments., (Copyright © 2021. Published by Elsevier Inc.)

Adult siblings maintain contact and remain close to one another. The current study used participants recruited via Amazon Mechanical Turk ( n = 491) to conduct regression analyses examining five methods of contact (in person, telephone, email, texting, and social media) predicting sibling closeness and conflict. Further, two- and three-way interactions assessed the role of sibling dyad composition (e.g., women with a sister and women with a brother). Results suggested that as contact in person, through social media, the telephone, or email increased, sibling closeness increased, while increased contact through email indicated less conflict. Assessing sibling dyad composition suggested as telephone contact increased, sibling closeness increased for all sibling dyads, especially for women with a sister compared to men with a brother. In-person and texting contacts were beneficial for women with a brother. Even in mid- to later-life, siblings connect through synchronous and asynchronous mediums, and this contact appears beneficial for sisters.

Meeting recruitment targets for clinical trials and health research studies is a notable challenge. Unsuccessful efforts to recruit participants from traditionally underserved populations can limit who benefits from scientific discovery, thus perpetuating inequities in health outcomes and access to care. In this study, we evaluated direct mail and email outreach campaigns designed to recruit women who gave birth in North Carolina for a statewide research study offering expanded newborn screening for a panel of rare health conditions. Of the 54,887 women who gave birth in North Carolina from September 28, 2018, through March 19, 2019, and were eligible to be included on the study's contact lists, we had access to a mailing address for 97.9% and an email address for 6.3%. Rural women were less likely to have sufficient contact information available, but this amounted to less than a one percentage point difference by urbanicity. Native American women were less likely to have an email address on record; however, we did not find a similar disparity when recruitment using direct-mail letters and postcards was concerned. Although we sent letters and emails in roughly equal proportion by urbanicity and race/ethnicity, we found significant differences in enrollment across demographic subgroups. Controlling for race/ethnicity and urbanicity, we found that direct-mail letters and emails were effective recruitment methods. The enrollment rate among women who were sent a recruitment letter was 4.1%, and this rate increased to 5.0% among women who were also sent an email invitation. Study Highlights WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC? Under-representation by traditionally underserved populations in clinical trials and health research is a challenge that may in part reflect inequitable opportunities to participate. WHAT QUESTION DID THIS STUDY ADDRESS? Are direct-mail and email outreach strategies effective for reaching and recruiting women from traditionally underserved and rural populations to participate in large-scale, population-based research? WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE? Despite sending recruitment letters and email invitations in roughly equal proportion by urbanicity and race/ethnicity, women living in rural areas were less likely to enroll (2.8%) than women from urban areas (4.2%). Additionally, enrollment rates decreased as the probability that women were members of a racial or ethnic minority group increased. HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE? Results from this study might encourage researchers to take a holistic and participant-centered view of barriers to study enrollment that may disproportionately affect underserved communities, including differences in willingness to participate, trust, and access to resources needed for uptake., (© 2020 The Authors. Clinical and Translational Science published by Wiley Periodicals LLC on behalf of the American Society for Clinical Pharmacology and Therapeutics.)

While many employees read and respond to work-related e-mails in the evenings after work, the mechanisms through which after-hours e-mailing influences well-being remain poorly understood. In particular, there has been limited consideration of whether different characteristics of after-hours e-mails (frequency, duration, perceived tone) may trigger work-related rumination that influences employee well-being at bedtime (i.e., the end of the post-work period). To address this gap in the literature, data were collected from 59 employees during a 5-day daily survey period. We expected after-hours e-mail frequency, duration, and perceived tone to indirectly relate to employee vigour and fatigue at bedtime (two common well-being criteria) via affective rumination and problem-solving pondering (two major forms of work-related rumination). Our results indicated that a more negatively perceived after-hours e-mail tone influenced both vigour and fatigue via affective rumination. Further, our findings suggested diverging implications of after-hours e-mailing frequency and duration for problem-solving pondering, with longer duration and more frequent after-hours e-mailing co-varying with higher and lower levels of this form of rumination, respectively. These findings demonstrate the importance of considering various characteristics of after-hours e-mailing and corresponding implications of work-related rumination when studying employee well-being., (© 2020 John Wiley & Sons Ltd.)

Background: It is well known that recruitment is a challenging aspect of any study involving human subjects. This challenge is exacerbated when the population sought is reticent to participate in research as is the case with pregnant women and individuals with depression. This paper compares recruitment methods used for the Food, Feelings, and Family Study, an observational, longitudinal pilot study concerning how diet and bisphenol A exposure affect maternal mood and cognitive function during and after pregnancy., Methods: Pregnant women were recruited to this study over a period of 15 months using traditional methods, social media including paid and unpaid posts, and emails broadcast to the university community. Contingency analysis using the Pearson's Chi-square test was used to determine if recruitment method was associated with likelihood of participation. T-tests were used to analyze Facebook advertisement success. ANOVAs and Fisher exact tests were used to determine if recruitment method was related to continuous and categorical demographics, respectively., Results: Social media resulted in the largest number of recruits, followed by traditional methods and broadcast email. Women recruited through social media were less likely to participate. In contrast, use of broadcast email resulted in a smaller pool of recruits but these recruits were more likely to be eligible for and complete the study. Most women recruited via social media were the result of unpaid posts to the study's Facebook page. Paid posts lasting at least 4 days were the most successful. Recruitment method was not associated with participant demographics., Conclusions: Social media has the potential to recruit a large pool of potential subjects; however, when studies require a large time investment such as the case here, women recruited through social media are less likely to participate and complete the study than women recruited through other means., Trial Registration: N/A. This study does not describe a health care intervention.

Patients consented to biobanking studies typically do not specify research conducted on their samples and data. Our objective was to gauge cancer biobanking participant preferences on research topics. Patient-participants of a biobanking study at a comprehensive cancer center who had an appointment within the last 5 years, had a valid email address, and with a last known vital status of alive, were emailed a newsletter containing a link to a survey about preferences and priorities for research. The survey assessed demographics and research interest in three domains: cancer site, cancer-related topics, and issues faced by cancer patients. 37,384 participants were contacted through email to participate in the survey. 16,158 participants (43.2%) opened the email, 1,626 (4.3% overall, 10% of those who opened the email) completed the survey, and 1,291 (79.4% of those who completed the survey) selected at least one research priority. Among those who selected at least one research priorities for cancer-relevant topics, the most commonly selected were cancer treatment (66%), clinical trials (54%), and cancer prevention (53%). Similarly, the most selected priorities for cancer-related issues faced by patients were physical side effects of cancer (57%), talking to the oncologist (53%), and emotional challenges due to cancer (47%). Differences by gender were observed, with females reporting more interest in research generally. Cancer patients participating in a biobanking protocol prioritized research on treatments, prevention and side effects, which varied by gender., Competing Interests: The authors have declared that no competing interests exist.

We investigated the prevalence of vaping among college students in South-central Appalachia in the United States and explored factors which were associated with and could predict vaping among the college students. A sample of 498 enrolled students voluntarily completed a self-report REDCap health survey questionnaire in 2018. Outcome variable was use of electronic cigarettes categorized as yes/no. Independent variables included risky behaviors such as texting or emailing while driving, riding in a car with someone who had been drinking, history of protected and unprotected sexual intercourse, age at first intercourse, and type of contraceptive used. Covariates were age, gender, ethnicity/race and high school location. The first category was used as reference. Binary logistic regression was used to identify factors associated with and predicting vaping. Mean age of participants was 20.93(± 8.26), 62.9% were female, a majority (76.5%) were non-Hispanic White, and 43.2% reported vaping at some point in their lives. Initial univariate analysis showed gender (p < 0.0001), seat belt usage (p = 0.002), texting or emailing while driving (p = 0.002), riding in a car with someone who had been drinking (p = 0.001), history of sexual intercourse (p < 0.001), coitarche (p = 0.026), use of birth control pills and withdrawal method were associated with vaping. Adjusting for co-variates, gender (p < 0.002), county of high school (p < 0.009) and texting and e-mailing while driving (0.05), seat belt usage (0.04) remained significant. Vaping was highly prevalent (43.2%) among our participants. Gender, location of high school, texting/emailing while driving and seat belt usage are predictors of vaping among these students.

Objectives: To identify the changes in rheumatology service delivery across the five regions of Africa from the impact of the COVID-19 pandemic., Methods: The COVID-19 African Rheumatology Study Group created an online survey consisting of 40 questions relating to the current practices and experiences of rheumatologists across Africa. The CHERRIES checklist for reporting results of internet e-surveys was adhered to., Results: A total of 554 completed responses were received from 20 countries, which include six in Northern Africa, six in West Africa, four in Southern Africa, three in East Africa and one in Central Africa. Consultant grade rheumatologists constituted 436 (78.7%) of respondents with a mean of 14.5 ± 10.3 years of experience. A total of 77 (13.9%) rheumatologists avoided starting a new biologic. Face-to-face clinics with the use of some personal protective equipment continued to be held in only 293 (52.9%) rheumatologists' practices. Teleconsultation modalities found usage as follows: telephone in 335 (60.5%), WhatsApp in 241 (43.5%), emails in 90 (16.3%) and video calls in 53 (9.6%). Physical examinations were mostly reduced in 295 (53.3%) or done with personal protective equipment in 128 (23.1%) practices. Only 316 (57.0%) reported that the national rheumatology society in their country had produced any recommendation around COVID-19 while only 73 (13.2%) confirmed the availability of a national rheumatology COVID-19 registry in their country., Conclusion: COVID-19 has shifted daily rheumatology practices across Africa to more virtual consultations and regional disparities are more apparent in the availability of local protocols and registries., (© The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Importance: Primary care physicians (PCPs) report multitasking during workdays while processing electronic inbox messages, but scant systematic information exists on attention switching and its correlates in the health care setting., Objectives: To describe PCPs' frequency of attention switching associated with electronic inbox work, identify potentially modifiable factors associated with attention switching and inbox work duration, and compare the relative association of attention switching and other factors with inbox work duration., Design, Setting, and Participants: This cross-sectional study of the work of 1275 PCPs in an integrated group serving 4.5 million patients used electronic health record (EHR) access logs from March 1 to 31, 2018, to evaluate PCPs' frequency of attention switching. Statistical analysis was performed from October 15, 2018, to August 28, 2020., Main Outcomes and Measures: Attention switching was defined as switching between the electronic inbox, other EHR work, and non-EHR periods. Inbox work duration included minutes spent on electronic inbox message views and related EHR tasks. Multivariable models controlled for the exposures., Results: The 1275 PCPs studied (721 women [56.5%]; mean [SD] age, 45.9 [8.5] years) had a mean (SD) of 9.0 (7.6) years of experience with the medical group and received a mean (SD) of 332.6 (148.3) (interquartile range, 252-418) new inbox messages weekly. On workdays, PCPs made a mean (SD) of 79.4 (21.8) attention switches associated with inbox work and did a mean (SD) 64.2 (18.7) minutes of inbox work over the course of 24 hours on workdays. In the model for attention switching, each additional patient secure message beyond the reference value was associated with 0.289 (95% CI, 0.217-0.362) additional switches, each additional results message was associated with 0.203 (95% CI, 0.127-0.278) additional switches, each additional request message was associated with 0.190 (95% CI, 0.124-0.257) additional switches, and each additional administrative message was associated with 0.262 (95% CI, 0.166-0.358) additional switches. Having a panel (a list of patients assigned to a primary care team) with more elderly patients (0.144 switches per percentage increase [95% CI, 0.009-0.278]) and higher inbox work duration (0.468 switches per additional minute of inbox work [95% CI, 0.411-0.524]) were also associated with higher attention switching involving the inbox. In the model for inbox work duration, each additional patient secure message beyond the reference value was associated with 0.151 (95% CI, 0.085-0.217) additional minutes, each additional results message was associated with 0.338 (95% CI, 0.272-0.404) additional minutes, each additional request message was associated with 0.101 (95% CI, 0.041-0.161) additional minutes, and each additional administrative message was associated with 0.179 (95% CI, 0.093-0.265) additional minutes. A higher percentage of the panel's patients initiating messages (0.386 minutes per percentage increase [95% CI, 0.026-0.745]) and attention switches (0.373 minutes per switch [95% CI, 0.328-0.419]) were also associated with higher inbox work duration. In addition, working at a medical center where all PCPs had high inbox work duration was independently associated with high or low inbox work duration., Conclusions and Relevance: This study suggests that PCPs make frequent attention switches during workdays while processing electronic inbox messages. Message quantity was associated with both attention switching and inbox work duration. Physician and patient panel characteristics had less association with attention switching and inbox work duration. Assisting PCPs with message quantity might help modulate both attention switching and inbox work duration.

There is currently limited direct evidence of how sponsorship of scientific conferences fits within the food industry's strategy to shape public policy and opinion in its favour. This paper provides an analysis of emails between a vice-president of The Coca-Cola Company (Coke) and prominent public health figures in relation to the 2012 and 2014 International Congresses of Physical Activity and Public Health (ICPAPH). Contrary to Coke's prepared public statements, the findings show that Coke deliberated with its sponsored researchers on topics to present at ICPAPH in an effort to shift blame for the rising incidence of obesity and diet-related diseases away from its products onto physical activity and individual choice. The emails also show how Coke used ICPAPH to promote its front groups and sponsored research networks and foster relationships with public health leaders in order to use their authority to deliver Coke's message. The study questions whether current protocols about food industry sponsorship of scientific conferences are adequate to safeguard public health interests from corporate influence. A safer approach could be to apply the same provisions that are stipulated in the Framework Convention on Tobacco Control on eliminating all tobacco industry sponsorship to the food industry.

Importance: Systematically capturing cancer stage is essential for any serious effort by health systems to monitor outcomes and quality of care in oncology. However, oncologists do not routinely record cancer stage in machine-readable structured fields in electronic health records (EHRs)., Objective: To evaluate whether a peer comparison email intervention that communicates an oncologist's performance on documenting cancer stage relative to that of peer physicians was associated with increased likelihood that stage was documented in the EHR., Design, Setting, and Participants: This 12-month, randomized quality improvement pilot study aimed to increase oncologist staging documentation in the EHR. The pilot study was performed at Massachusetts General Hospital Cancer Center from October 1, 2018, to September 30, 2019. Participants included 56 oncologists across 3 practice sites who treated patients in the ambulatory setting and focused on diseases that use standardized staging systems. Data were analyzed from July 2, 2019, to March 5, 2020., Interventions: Peer comparison intervention with as many as 3 emails to oncologists during 6 months that displayed the oncologist's staging documentation rate relative to all oncologists in the study sample., Main Outcomes and Measures: The primary outcome was patient-level documentation of cancer stage, defined as the likelihood that a patient's stage of disease was documented in the EHR after the patient's first (eg, index) ambulatory visit during the pilot period., Results: Among the 56 oncologists participating (32 men [57%]), receipt of emails with peer comparison data was associated with increased likelihood of documentation of cancer stage using the structured field in the EHR (23.2% vs 13.0% of patient index visits). In adjusted analyses, this difference represented an increase of 9.0 (95% CI, 4.4-13.5) percentage points (P = .002) in the probability that a patient's cancer stage was documented, a relative increase of 69% compared with oncologists who did not receive peer comparison emails. The association increased with each email that was sent, ranging from a nonsignificant 4.0 (95% CI, -0.8 to 8.8) percentage points (P = .09) after the first email to a statistically significant 11.2 (95% CI, 4.9-17.4) percentage points (P = .003) after the third email . The association was concentrated among an oncologist's new patients (increase of 11.8 [95% CI, 6.2-17.4] percentage points; P = .001) compared with established patients (increase of 1.6 [95% CI, -2.9 to 6.1] percentage points; P = .44) and persisted for 7 months after the email communications stopped., Conclusions and Relevance: In a quality improvement pilot trial, peer comparison emails were associated with a substantial increase in oncologist use of the structured field in the EHR to document stage of disease.

Background: Patient-powered research networks (PPRNs) have been employing and exploring different methods to engage patients in research activities specific to their conditions. One way to intensify patient engagement is to partner with payer stakeholders. The objective of this study was to evaluate the effectiveness of two common payer-initiated outreach methods (postal mail versus email) for inviting prospective candidates to participate in their initiatives., Methods: This descriptive study linked members of a nationally-representative private insurance network to four disease-specific PPRN registries. Eligible members meeting diagnostic criteria who were not registered in any of the four PPRNs by 02/28/2018 were identified, and randomly assigned to either the mail or email group. They were contacted in two outreach efforts: first on 04/23/2018, and one follow-up on 05/23/2018. New registration rates by outreach method as of 8/31/2018 were determined by relinking. We compared registrants and non-registrants using bivariate analysis., Results: A total of 14,571 patients were assigned to the mail group, and 14,574 to the email group. Invitations were successfully delivered to 13,834 (94.9%) mail group and 10,205 (70.0%) email group members. A small but significantly larger proportion of mail group members, (n = 78; 0.54, 95% Confidence Interval [CI] {0.42-0.67%}) registered in PPRNs relative to the email group (n = 24; 0.16, 95% CI {0.11-0.25%}), p < 0.001. Members who registered had more comorbidities, were more likely to be female, and had marginally greater medical utilization, especially emergency room visits, relative to non-registrants (52.0% vs. 42.5%, p = 0.05)., Conclusion: A health plan outreach to invite members to participate in PPRNs was modestly effective. Regular mail outperformed less costly email. Providing more value-add to participants may be a possible way to increase recruitment success.

Purpose: To examine the association between patients' use of online health portal-based secure messaging and the likelihood of traditional encounters (office visits and telephone calls) and to identify patient characteristics associated with use of the messaging feature of health portals., Methods: This retrospective cohort study used EHR data from 80,801 patients aged 18 and older to determine traditional encounter rates among portal users who sent at least 1 message compared to those who sent none. Association between the number of messages sent and number of traditional encounters, while accounting for other covariates (including number of traditional encounters the year before account activation and other patient characteristics) was examined using a hurdle negative-binomial (NB) model., Results: In the year after their portal account activation, 22,789 (28%) patients sent at least 1 message (median = 3, mean = 5.38). Patients who sent messages were more likely to be female (63.9% vs 58.0%, P <0.001), white (92.2% vs 90.0%, P <0.001), and have depression (27.0% vs 24.2%, P <0.001) than those who sent none. We observed a positive association between sending messages and number of traditional encounters. Patients who sent messages were more likely to have a traditional encounter and have more traditional encounters in the year after account activation than those who sent none (mean 17.6 vs 11.4, P <0.001); they also had more in-person office visits (7.6 vs 5.0, P <0.001) and telephone calls (9.9 vs 6.4, P <0.001)) when examined separately., Conclusions: Our study adds to the growing literature that EHR messaging is associated with increased traditional resource utilization. This has the potential to add to workload while diminishing productivity and increasing the risk of staff and physician burnout. Health systems should prepare for the increased visits and calls expected as more patients use secure messaging., (Copyright© Board of Regents of the University of Wisconsin System and The Medical College of Wisconsin, Inc.)

Background and Objectives: Our study aimed to identify patients' perception of an eReferral process and e-mail notification system., Methods: Patients within the Waterloo Wellington Local Health Integration Network who registered their e-mail address with physicians who adopted the eReferral system, and therefore received e-mail notifications of their booked appointment, were invited to complete an online satisfaction survey. This patient experience survey is an ongoing online link embedded within the confirmation e-mail of the booked appointment. The survey is hosted on the eReferral solution platform and has been operational since November 2017. The survey consists of 8 questions with 3 main categories to assess patients' opinion of their experience of the referral process and notification system using a 5-point Likert scale and open-ended questions., Results: A total of 545 patients have completed the patient satisfaction survey within this reporting period with a response rate of 15%. In general, 94% of patients agreed that receiving a confirmation e-mail of their booked appointment had improved their experience with the referral process. The majority (94%) agreed that the eReferral process was easy to follow, and 83% agreed that they were able to get the care they needed within a reasonable time. Compared with their past referral experiences, 80% of patients felt more informed throughout this electronic referral process. Using binominal logistic regression, participants whose preferences were considered had 8.06 times higher odds to exhibit satisfaction with the referral process than those who did not. Patients' qualitative responses identified the eReferral process as being quick, efficient, and resulting in a sense of being in control of their own health care. There are some limitations to the system felt by some of the patients who responded to the open-ended questions of the survey. Patients identified the need to add a complementary structure to the notification design consisting of multiple dates and times with a chance to pick the appointment that suits patients best instead of being restricted to only 1 appointment date. A few patients thought that the heading of the e-mail notification system should be more distinguishable for easier tracking. Furthermore, some patients felt the need to add some notes to the initial e-mail advising patients of the next steps throughout their referral process., Conclusion: eReferral has improved patients' experience with the referral process. Our findings in this study would support the solution vendor in its efforts to refine and enhance active communication channels with patients for sustainable health care that meets patients' expectations and needs.

Importance: The increasing use of electronic communications has enhanced access to physicians for patients and clinical staff. Primary care physicians (PCPs) have anecdotally identified electronic inbox management as a new source of work-related stress., Objectives: To describe PCPs' experiences managing their electronic inboxes and to characterize the array of management strategies developed by individual physicians and practice groups., Design, Setting, and Participants: This qualitative study was conducted in 8 medical centers of a large group practice with more than 4 million patients in diverse settings and a mature electronic health record. The group encourages patients to use portal secure messaging to enhance access to their physicians and the care experience. Semistructured interviews were conducted with 24 internists and family medicine physicians identified via snowball sampling. Interviews were conducted July through November 2018. Data analysis was conducted between November 2018 and April 2019., Main Outcomes and Measures: Audio recorded interviews were transcribed and analyzed using thematic analysis to identify major themes and subthemes., Results: The 24 participants (12 women [50.0%]; mean [SD] age, 45.5 [6.5] years), including 9 department chiefs and 15 PCPs, had a mean (SD) of 16.8 (7.8) years since medical school graduation. Participants described substantial changes in medical practice due to electronic communication, including perceived patient expectations to receive rapid responses to portal secure messages. They described portal secure messaging as useful for building relationships with patients, but also reported that electronic message management has created new stressors, including erosion of work-life boundaries and anxiety associated with unlimited inbox volume. Individual PCPs used a diverse array of strategies, including multitasking during and outside work and delegating to medical assistants. Chiefs described group-level strategies, including reserving clinic time for inbox management, coverage systems for vacation and sick days, physician-to-physician training, and interdisciplinary teams to share messaging work., Conclusions and Relevance: Individual physicians and local practice groups have developed a wide array of strategies for electronic inbox management. The volume of electronic messages and PCPs' perceptions that patients expect rapid responses have created new stressors in primary care practice. Medical groups and health systems can support PCPs by facilitating knowledge transfer among physicians about inbox management strategies and further developing team structures for inbox coverage.

Background: The development of technology, novel communication, and social networking can positively or negatively affect the therapeutic alliance between patients and psychiatrists. We conducted this study to identify Internet use patterns of psychiatrists and psychiatry residents in South Korea and to provide basic data for developing e-professionalism., Methods: In this questionnaire survey included a total of 250 participants, of which 195 (78%) completed the questionnaire. Questions included demographics, use of email, web searches, personal and professional use of websites and social networking, and negative and positive experiences of electronic communication and social networking. We confirmed the correlation between experience and use patterns of psychiatrists' electronic communication and social networking., Results: A total of 129 participants (66.2%) reported that they posted their personal or professional content online, 112 (57.9%) had received patients' requests through electronic communication or social networking, and 120 (61.4%) had communicated with patients via electronic communication or social networking. In total, 170 participants (87.2%) reported that they were worried about the negative consequences of using electronic communication and social networking, and 180 (92.3%) indicated they were not educated about electronic communication or social networking., Conclusion: In order to reduce the negative effects of electronic communication and social networking, we need guidelines that are appropriate for the situation in South Korea. Furthermore, future research will need to identify and suggest solutions for negative experiences of electronic communication and social networking that may affect the relationship between patients and physicians.

Background: Little is known about patients who have caregiver proxies communicate with healthcare providers via portal secure messaging (SM). Since proxy portal use is often informal (e.g., sharing patient accounts), novel methods are needed to estimate the prevalence of proxy-authored SMs., Objective: (1) Develop an algorithm to identify proxy-authored SMs, (2) apply this algorithm to estimate predicted proxy SM (PPSM) prevalence among patients with diabetes, and (3) explore patient characteristics associated with having PPSMs., Design: Retrospective cohort study., Participants: We examined 9856 patients from Diabetes Study of Northern California (DISTANCE) who sent ≥ 1 English-language SM to their primary care physician between July 1, 2006, and Dec. 31, 2015., Main Measures: Using computational linguistics, we developed ProxyID, an algorithm that identifies phrases frequently found in registered proxy SMs. ProxyID was validated against blinded expert categorization of proxy status among an SM sample, then applied to identify PPSM prevalence across patients. We examined patients' sociodemographic and clinical characteristics according to PPSM penetrance, "none" (0%), "low" (≥ 0-50%), and "high" (≥ 50-100%)., Key Results: Only 2.3% of patients had ≥ 1 registered proxy-authored SM. ProxyID demonstrated moderate agreement with expert classification (Κ = 0.58); 45.7% of patients had PPSMs (40.2% low and 5.5% high). Patients with high percent PPSMs were older than those with low percent and no PPSMs (66.5 vs 57.4 vs 56.2 years, p < 0.001) had higher rates of limited English proficiency (16.1% vs 3.2% vs 3.5%, p < 0.05), lower self-reported health literacy (3.83 vs 4.43 vs 4.44, p < 0.001), and more comorbidities (Charlson index 3.78 vs 2.35 vs 2.18, p < 0.001)., Conclusions: Among patients with diabetes, informal proxy SM use is more common than registered use and prevalent among socially and medically vulnerable patients. Future research should explore whether proxy portal use improves patient and/or caregiver outcomes and consider policies that integrate caregivers in portal communication.

Information on occupational health and safety practices in Brazilian aquaculture is limited. This paper reports preliminary results from an online survey based on research questions to identify occupational hazards, risk assessment practices, and prevention measures adopted in Brazilian aquaculture. Data were collected through an online questionnaire, comprising 25 questions, on a voluntary and anonymous basis. Aquaculture stakeholders were invited to participate in the study through email and social media channels. The demographic data demonstrated that the majority of respondents were men (72%) and having a higher education (95%). Most respondents employed administrative controls and personal protective equipment (PPE) rather than substitution and other risk elimination measures to reduce exposure. The most commonly adopted measures were PPE use (87%), adequate handling of chemicals (86%), and imparting knowledge of risks (90%). However, only 12% of participants reported the presence of safety protocols at their workplace, and 17% had some form of immunization of workers. In this study, it was possible to identify a lack of hazard signage in the workplace and lack of occupational health and safety training. The results further indicate that risk management in aquaculture continues to be a challenge in low-income countries. Aquaculture farmers should be encouraged and supported in adopting measures and appropriate technologies to eliminate risks in Brazilian aquaculture.

Background: There is a need to deliver smoking cessation support at a population level, both in developed and developing countries. Studies on internet-based and mobile phone-based smoking cessation interventions have shown that these methods can be as effective as other methods of support, and they can have a wider reach at a lower cost., Objective: This randomized controlled trial (RCT) aimed to compare, on a population level, the efficacy of an identical, tailored smoking cessation intervention delivered by mobile text messaging versus email., Methods: We conducted a nationwide 2-arm, double-blinded, fully automated RCT, close to a real-world setting, in Norway. We did not offer incentives to increase participation and adherence or to decrease loss to follow-up. We recruited users of the website, slutta.no, an open, free, multi-component Norwegian internet-based smoking cessation program, from May 2010 until October 2012. Enrolled smokers were considered as having completed a time point regardless of their response status if it was 1, 3, 6, or 12 months post cessation. We assessed 7315 participants using the following inclusion criteria: knowledge of the Norwegian language, age 16 years or older, ownership of a Norwegian cell phone, having an email account, current cigarette smoker, willingness to set a cessation date within 14 days (mandatory), and completion of a baseline questionnaire for tailoring algorithms. Altogether, 6137 participants were eligible for the study and 4378 participants (71.33%) provided informed consent to participate in the smoking cessation trial. We calculated the response rates for participants at the completed 1, 3, 6, and 12 months post cessation. For each arm, we conducted an intention-to-treat (ITT) analysis for each completed time point. The main outcome was 7-day self-reported point prevalence abstinence (PPA) at the completed 6 months post cessation. We calculated effect size of the 7-day self-reported PPA in the text message arm compared with the email arm as odds ratios (ORs) with 95% CIs for the 4 time points post cessation., Results: At 6 months follow-up, 21.06% (384/1823) of participants in the text message arm and 18.62% (333/1788) in the email arm responded (P=.07) to the surveys. In the ITT analysis, 11.46% (209/1823) of participants in the text message arm compared with 10.96% (196/1788) in the email arm (OR 1.05, 95% CI 0.86-1.30) reported to have achieved 7 days PPA., Conclusions: This nationwide, double-blinded, large, fully automated RCT found that 1 in 9 enrolled smokers reported 7-day PPA in both arms, 6 months post cessation. Our study found that identical smoking cessation interventions delivered by mobile text messaging and email may be equally successful at a population level., Trial Registration: ClinicalTrials.gov NCT01103427; https://clinicaltrials.gov/ct2/show/NCT01103427., (©Inger Torhild Gram, Dillys Larbi, Silje Camilla Wangberg. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 27.09.2019.)

Objectives: To identify characteristics of office-based provider used as a usual source of care (USC) associated with secure electronic messaging (SM) use., Data Source: 2015 Medical Expenditure Panel Survey Household Component and the supplemental Medical Organizations Survey., Study Design: Cross-sectional analysis., Extraction Methods: Patients are linked to characteristics of their usual source of care provider., Main Findings: We found that 89 percent of patients whose USC had electronic health records were able to exchange secure messages with their provider. Patients whose USC reported being patient-centered medical homes (PCMHs) or that used other health information technology (HIT) were also more likely to have been able to exchange SM with their provider. Patients of independent group or solo practices were less likely to have been able to exchange SM relative to patients whose USC practice was hospital owned., Conclusions: Patients were more likely to have visited a USC that exchanged SMs if that practice also used other electronic health records functionalities. Study findings suggest that while patients' USC practices were likely to exchange secure messages, there is a disparity in SM use between physician-owned practices, and hospital-owned practices., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Despite concerns about physicians' workload associated with electronic health records (EHRs), little attention has been paid to the relationship between physicians' well-being and the in-basket messages physicians receive-specifically, their volume and sources. Analyses of EHR work performed by physicians in a multispecialty practice found that in-basket messages generated by the EHR system accounted for almost half (114) of the 243 weekly in-basket messages received per physician, on average-far exceeding the numbers received from their colleagues (53) and patients (30). In a survey, 36 percent of the physicians reported burnout symptoms, and 29 percent intended to reduce their clinical work time in the upcoming year. Receiving more than the average number of system-generated in-basket messages was associated with 40 percent higher probability of burnout and 38 percent higher probability of intending to reduce clinical work time. Physicians' perceptions of a positive work environment were associated with lower odds of burnout and intention to reduce clinical work time and with greater satisfaction with life. Female physicians had a higher risk of burnout and lower satisfaction with life, compared to males. Meaningful redesign of EHR in-basket workflow and a wellness-enhancing work environment are necessary to effectively improve physicians' well-being.

Background: The number of web-based E-epidemiologic studies using online recruitment methods is increasing. However, the optimal online recruitment method in terms of maximizing recruitment rates is still unknown. Our aim was to compare the recruitment rates of three online recruitment methods and to describe how these rates differ according to individual's socioeconomic and demographic factors., Methods: A total of 2394 members of the 1993 Pelotas birth cohort that provided an e-mail address, a Facebook name, and a WhatsApp number during a face-to-face follow-up were randomly allocated to be recruited by e-mail, Facebook or WhatsApp (798 individuals per method). This was a parallel randomised trial applying a block randomisation (block size = 3). Between January and February 2018, we sent messages inviting them to register into the web-based coortesnaweb platform. Recruitment rates were calculated for each method, and stratified according to the individual's socioeconomic and demographic characteristics. We also analysed absolute and relative inequalities on recruitment according to schooling and socioeconomic position., Results: Out of the 2394 individuals analysed, 642 registered into the platform. The overall recruitment rate was 26.8%. Recruitment rates for women were almost 10 percentage points higher compared to men. Facebook was the most effective recruitment method, as 30.6% of those invited through the social network were recruited. Recruitment rates of e-mail and WhatsApp were similar (recruitment rate = 24.9%). E-mail and Facebook were the most effective recruitment methods to invite highly educated and wealthier individuals. However, sending e-mails to recruit individuals also reflected in the highest inequalities according to schooling and socioeconomic position. In contrast, the lowest inequalities according to socioeconomic position were observed using Facebook., Conclusions: Facebook was the most effective online recruitment method, also achieving the most equitable sample in terms of schooling and socioeconomic position. The effectiveness of online recruitment methods depends on the characteristics of the sample. It is important to know the profile of the target sample in order to decide which online recruitment method to use., Trial Registration: Brazilian Registry of Clinical Trials, identifier: RBR-3dv7gc , retrospectively registered in 10 April 2018.

Introduction: In order to address health disparities, it is important to understand how vulnerable individuals seek information. This study used an adapted version of the Health Information National Trends Survey (HINTS) administered in English, Spanish, and Chinese to describe the behaviors and preferences of a diverse group of vulnerable urban residents., Methods: We administered a modified HINTS survey in English, Spanish, and Chinese and used purposive sampling to ensure 50% were non-English speakers evenly divided between Spanish and Chinese speakers, and 50% of English-speakers identified as Black. We used multivariable logistic regression to determine characteristics associated with sources used for health information and preferences for delivery of health information., Results: Among 1027survey respondents (514 English, 256 Spanish, 260 Chinese), 55% had adequate health literacy, and 50% reported household income <$20,000, but 77% reported owning a smartphone. A plurality sought health information on the Internet (39%) or from a health care provider (36%). In multivariable analyses, smartphone ownership predicted higher odds of seeking health information on the Internet [odds ratio, (OR) 2.98; 95% confidence interval (CI), 1.81-4.91]. Participants most preferred email (41%) and brochures (40%) for delivery of health information, but non-English survey respondents were less likely to prefer email: Spanish (OR, 0.30; 95% CI, 0.11-0.83) and Chinese (OR, 0.25; 95% CI, 0.09-0.71). Smartphone ownership predicted an email preference (OR, 2.19; 95% CI, 1.43-3.36)., Conclusions: Among vulnerable populations, smartphone ownership and language preferences impact preferences for seeking and receiving health information. These preferences need to be considered in designing health messages.

Objective: To investigate the scope of academic spam emails (ASEs) among career development grant awardees and the factors associated with the amount of time spent addressing them., Design: A cross-sectional survey of career development grant investigators via an anonymous online survey was conducted. In addition to demographic and professional information, we asked investigators to report the number of ASEs received each day, how they determined whether these emails were spam and time they spent per day addressing them. We used bivariate analysis to assess factors associated with the amount of time spent on ASEs., Setting: An online survey sent via email on three separate occasions between November and December 2016., Participants: All National Institutes of Health career development awardees funded in the 2015 fiscal year., Main Outcome Measures: Factors associated with the amount of time spent addressing ASEs., Results: A total of 3492 surveys were emailed, of which 206 (5.9%) were returned as undeliverable and 96 (2.7%) reported an out-of-office message; our overall response rate was 22.3% (n=733). All respondents reported receiving ASEs, with the majority (54.4%) receiving between 1 and 10 per day and spending between 1 and 10 min each day evaluating them. The amount of time respondents reported spending on ASEs was associated with the number of peer-reviewed journal articles authored (p<0.001), a history of publishing in open access format (p<0.01), the total number of ASEs received (p<0.001) and a feeling of having missed opportunities due to ignoring these emails (p=0.04)., Conclusions: ASEs are a common distraction for career development grantees that may impact faculty productivity. There is an urgent need to mitigate this growing problem., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Primary care (PC) professionals' knowledge about alcohol use has been identified as one of the barriers PC providers face in their clinic. Both PC professionals' level of training and attitude are crucial in the clinical practice regarding alcohol use., Objective: To evaluate the knowledge, attitude, and preventive practices of Spanish PC physicians and nurses towards alcohol use., Design: An observational, descriptive, cross-sectional, multi-center study., Methodology: Location: PC centers of the Spanish National Health System (NHS). Participants: PC physicians and nurses selected randomly from health care centers, and by sending an e-mail to semFYC and SEMERGEN members. Healthcare providers completed an online survey on knowledge, attitude, and follow-up recommendations for reducing alcohol intake. A descriptive, bivariate, and multivariate statistical analysis was conducted (p<0.05)., Results: Participants: 1,760 healthcare providers completed the survey (75.6% [95% CI 73.5-77.6] family physicians; 11.4% [95% CI 9.9-12.9] medical residents; and 12.5% [95% CI 10.9-14.1] nurses), with a mean age of 44.7 (SD 11.24, range: 26-64, 95% CI: 47.2-48.2). Knowledge was higher in family physicians (p<0.001), older professionals (Spearman's r = 0.11, p<0.001), and resident trainers (p<0.001). The PC professional most likely to provide advice for reducing alcohol use was: a nurse (p <0.001), female (p = 0.010), between 46 and 55 years old (p <0.001)., Conclusions: PC providers' knowledge and preventive practices regarding alcohol use are scarce, hence specific training strategies to increase their knowledge and improve their attitude and skills with regard to this health problem should be considered a healthcare policy priority., Competing Interests: The authors have declared that no competing interests exist.

Background: Reliable data from health surveys are essential to describe the status and trends in health indicators by means of information not available from official registers. In Denmark, nationally representative health surveys (the Danish Health and Morbidity Surveys) have been carried out among adults during the past three decades by the Danish National Institute of Public Health, University of Southern Denmark. The aim of the present study is to describe the study design of the three most recent surveys in 2010, 2013, and 2017, including the survey mode and response rates., Methods: In 2010, 2013, and 2017, the samples (n = 25,000 each) were based on random sampling of individuals aged 16 years or older with a permanent residence in Denmark. A subsample of previously invited respondents was also re-invited in subsequent survey waves. Data were collected through self-administered questionnaires, yet with a concurrent mixed-mode approach, allowing for the invited individuals to complete either a web questionnaire or an identical paper questionnaire. In 2010 and 2013, survey invitations were sent by regular postal mail, whereas a secure electronical mail service, Digital Post, was used to invite the majority (90.1%) of the sample in 2017., Results: The overall response rate decreased from 60.7% in 2010 to 57.1% in 2013 and 56.1% in 2017. Between 2010 and 2017 the response mode distribution for the web questionnaire increased markedly from 31.7 to 73.8%. The largest increase in the proportion which completed the web questionnaire was found in the oldest age group., Conclusions: Data from the Danish Health and Morbidity Surveys reveal an increasing proportion of the respondents to complete web questionnaires instead of paper questionnaires. Even though the response rate remained relatively stable in 2017, declining response rates is a major concern in health surveys. As the generalizability to the Danish population may be compromised by a low response rate, efforts to increase the response rate or keep it stable are crucial in future surveys. Thus, efforts should be made to ensure convenience and feasibility in relation to access to and the completion of survey (web) questionnaires.

Objective: To analyse the evolution and adequacy of referrals from Primary Care to Urology, after the implementation of referral protocols on the most frequent urological diseases and the establishment of a continuing education program., Material and Methods: A Primary Care-Urology work group was created in 2011. Initially, performance and clinical practice protocols in prostatic pathology (BPH and PSA) were established. These were supported by training sessions for primary care physicians. After analysing the effect of the mentioned joint work, 3more (scrotal pathology, urinary tract infections and urinary incontinence) were included. We analysed and compared the referrals and their adequacy before and after the establishment of the protocols., Results: The most common referral causes were symptoms of the lower urinary tract due to BPH, which initially represented 22.8% of the total, and decreased to 16.9%. After the introduction of the new algorithms, we observed a decrease in referrals for scrotal pathology (13-14% to 7.8%), an increase in urinary incontinence referrals (3% al 10.3%) and those related to urinary tract infections remained stable. The adequacy to the protocols improved progressively: LUTS from 46% to 65.3%; PSA from 55% to 84.4% and urinary incontinence from 66.2% to 73.1%. Adequacy in scrotal pathology decreased (de 67.1% a 63.3%), while in UTI it stayed much the same (around 76%)., Conclusions: The joint work between Urology and Primary Care achieves an improvement in referrals adequacy regarding the most frequent urological pathologies., (Copyright © 2019 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: There is evidence that the physician response rate is declining. In response to this, methods for increasing the physician response rate are currently being explored. This paper examines the response rate and extent of non-response bias in a mixed-mode study of Minnesota physicians., Methods: This mode experiment was embedded in a survey study on the factors that influence physicians' willingness to disclose medical errors and adverse events to patients and their families. Physicians were randomly selected from a list of licensed physicians obtained from the Minnesota Board of Medical Practice. Afterwards, they were randomly assigned to either a single-mode (mail-only or web-only) or mixed-mode (web-mail or mail-web) design. Differences in response rate and nonresponse bias were assessed using Fischer's Exact Test., Results: The overall response rate was 18.60%. There were no statistically significant differences in the response rate across modes (p - value = 0.410). The non-response analysis indicates that responders and non-responders did not differ with respect to speciality or practice location., Conclusions: The mode of administration did not affect the physician response rate.

Purpose: American Pediatric Surgical Association (APSA) committees send monthly email blasts to members with links to peer-reviewed publications. This study assesses the utilization of this service., Methods: Email-opening and click-through rates were analyzed from 5/2012 to 4/2017 and compared to APSA and industry standards. Access was analyzed based on subject, disease type, journal, impact factor, and committee. CME questions were added in 10/2014 and emails consolidated in 1/2016. Effects of these changes were analyzed., Results: Over 60 months, 281 articles were distributed from 58 journals. Access increased significantly with impact factor (P = 0.0039). Overall email opening rate (53% ± 3%) and click-through rate (37% ± 10%) were significantly higher than all APSA emails (43%,18%, P < 0.0001) and 2017 industry standard (26%,12%,P < 0.0001). Access rates differed significantly between the twenty-five topics covered (P < 0.0001), with the highest access for appendicitis (240 ± 79, P < 0.0001). Common condition articles (157 ± 93) were accessed more than rare (55 ± 60, P < 0.0001). With email consolidation, opening rates increased (53 ± 3 to 55 ± 2, P = 0.003) and click-through rates decreased (40 ± 9 to 30 ± 8, P = 0.0002). By adding CME questions, opening rates increased nonsignificantly (52 ± 3 to 54 ± 2, P = 0.066) and click-through rate decreased significantly(41 ± 10 to 33 ± 9, P = 0.001)., Conclusions: APSA email blasts are valued by members based on high access rates. Click-through rates have declined, potentially indicating user fatigue. APSA members prefer common conditions and high impact factor journals. These data will help refine this service., Level-Of-Evidence: Level III., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Studies find that identifying additional study data is possible by contacting study authors or experts. What is less certain is the time taken, costs involved and value found by using this supplementary search method. The purpose of this study is to determine the effectiveness, efficiency, cost and value of contacting study authors by e-mail, updating the evidence available for this search method., Methods: Eighty-eight study authors, whose studies met title/abstract inclusion in a. systematic review, were contacted by e-mail. * effectiveness was assessed by comparing the number of study authors contacted. compared to the number of replies received; * efficiency was assessed by recording the time taken to contact study authors; * cost was assessed by comparing the efficiency of contacting authors with the. effectiveness; and * value was assessed by reading and comparing the published studies with the replies received to see if any unique data was identified., Results: Contacting study authors took 6 h, 54 min and 25 s across 7 weeks. 38 answers (46%) were received from 83 possible contacts. Contacting study authors cost £80.33 or £2.11 per reply. We identified unique data from author replies when compared with data reported in published studies, determining this method as 'valuable'., Conclusions: Whilst our effectiveness findings differ from other studies, we believe that this study demonstrates the effectiveness of contacting study authors. By linking effectiveness to value and cost, we offer a new way to interpret the 'effectiveness' of this supplementary search method.

Purpose: This study evaluated how breast cancer diagnoses were shared with patients., Methods: Current members of the Dr. Susan Love Research Foundation's Army of Women cohort were sent one email with a link to a survey assessing how their breast cancer diagnosis was communicated, a description of their support system during treatment, basic demographic information, and breast cancer diagnosis details., Results: Participants (n = 2896) were more likely to be given their diagnosis over the telephone in more recent years (OR 1.07, 95% CI 1.06-1.08). Up until about 10 years ago (1967-2006), breast cancer diagnoses were communicated in person more often than by telephone. Since 2006, more than half of participants learned about their diagnosis over the telephone. From 2015 to 2017, almost 60% of participants learned about their diagnosis over the telephone. Among those who heard the news in person, a steady 40% were alone. Characteristics of those who received the news over the telephone included having identified support members, heterosexual identity, and a diagnosis of in situ breast cancer., Conclusions: Receiving a telephone call about breast cancer diagnosis may be the norm rather than the exception in health care today. Trends in practice, as well as current best practices based primarily on expert opinion, may not provide optimal care for women diagnosed with breast cancer. Patient outcome research to guide future practice, such as the impact of modes of delivery of bad news, is urgently needed to determine appropriate patient-centered approaches for notification of breast cancer diagnoses.

Background: e-Mental health services have the capacity to overcome barriers to care and reduce the unmet need for psychological services, particularly in developing countries. However, it is unknown how acceptable e-mental health interventions may be to these populations., Aims: The purpose of the current study was to examine consumer attitudes and perceived barriers to e-mental health usage across four countries: Australia, Iran, the Philippines and South Africa., Methods: An online survey was completed by 524 adults living in these countries, assessing previous contact with e-mental health services, willingness to use e-mental health services, and perceived barriers and needs for accessing e-mental health services., Results: Although previous contact with e-mental health services was low, the majority of respondents in each sample reported a willingness to try e-mental health services if offered. Barriers toward e-mental health usage were higher among the developing countries than Australia. The most commonly endorsed barriers concerned needing information and assurances regarding the programmes., Conclusions: Across countries, participants indicated a willingness to use e-mental health programmes if offered. With appropriate research and careful implementation, e-mental health has the potential to be a valuable part of mental healthcare in developing countries.

Introduction: Social media interactions via email and instant messaging (E/IM) are common in children and adolescents and may lead to insufficient sleep. This study investigated associations between high-frequency E/IM use to interact with peers, perceived insufficient sleep, and reduced time in bed (TIB) in female children and adolescents., Methods: The Children's Report of Sleep Patterns was completed by 189 female primary and secondary school students (8-16 years old). Responses were categorized as binary variables (high-frequency use vs not high-frequency use; right amount of sleep vs too little sleep), and TIB was calculated from bed and wake times for the previous 24 hours., Results: High-frequency social media interactions using E/IM during the hour before bed were significantly associated with perceived insufficient sleep (odds ratio [confidence interval]: 2.68 [1.39-5.17]) but not with reduced TIB (-19.07 [-40.02 to 1.89])., Conclusions: High-frequency social media interactions using E/IM in the hour before bed are a potentially modifiable risk factor for insufficient sleep in female students. Strategies to reduce nighttime usage may improve sleep in children and adolescents., (Copyright © 2018 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

OBJECTIVEThere remains uncertainty regarding the appropriate level of care and need for repeating neuroimaging among children with mild traumatic brain injury (mTBI) complicated by intracranial injury (ICI). This study's objective was to investigate physician practice patterns and decision-making processes for these patients in order to identify knowledge gaps and highlight avenues for future investigation.METHODSThe authors surveyed residents, fellows, and attending physicians from the following pediatric specialties: emergency medicine; general surgery; neurosurgery; and critical care. Participants came from 10 institutions in the United States and an email list maintained by the Canadian Neurosurgical Society. The survey asked respondents to indicate management preferences for and experiences with children with mTBI complicated by ICI, focusing on an exemplar clinical vignette of a 7-year-old girl with a Glasgow Coma Scale score of 15 and a 5-mm subdural hematoma without midline shift after a fall down stairs.RESULTSThe response rate was 52% (n = 536). Overall, 326 (61%) respondents indicated they would recommend ICU admission for the child in the vignette. However, only 62 (12%) agreed/strongly agreed that this child was at high risk of neurological decline. Half of respondents (45%; n = 243) indicated they would order a planned follow-up CT (29%; n = 155) or MRI scan (19%; n = 102), though only 64 (12%) agreed/strongly agreed that repeat neuroimaging would influence their management. Common factors that increased the likelihood of ICU admission included presence of a focal neurological deficit (95%; n = 508 endorsed), midline shift (90%; n = 480) or an epidural hematoma (88%; n = 471). However, 42% (n = 225) indicated they would admit all children with mTBI and ICI to the ICU. Notably, 27% (n = 143) of respondents indicated they had seen one or more children with mTBI and intracranial hemorrhage demonstrate a rapid neurological decline when admitted to a general ward in the last year, and 13% (n = 71) had witnessed this outcome at least twice in the past year.CONCLUSIONSMany physicians endorse ICU admission and repeat neuroimaging for pediatric mTBI with ICI, despite uncertainty regarding the clinical utility of those decisions. These results, combined with evidence that existing practice may provide insufficient monitoring to some high-risk children, emphasize the need for validated decision tools to aid the management of these patients.

Objective: Systematic reviews often rely on the acquisition of unpublished analyses or data. We carried out a nested randomised trial comparing two different approaches for contacting authors to request additional data for a systematic review., Participants: Participants were authors of published reports of prevention or treatment trials in stroke in which there was central adjudication of events. A primary and secondary research active author were selected as contacts for each trial., Interventions: Authors were randomised to be sent either a short email with a protocol of the systematic review attached ('Short') or a longer email that contained detailed information and without the protocol attached ('Long'). A maximum of two emails were sent to each author to obtain a response. The unit of analysis was trial, accounting for clustering by author., Primary and Secondary Outcome Measures: The primary outcome was whether a response was received from authors. Secondary outcomes included time to response, number of reminders needed before a response was received and whether authors agreed to collaborate., Results: 88 trials with 76 primary authors were identified in the systematic review, and of these, 36 authors were randomised to Short (trials=45) and 40 to Long (trials=43). Responses were received for 69 trials. There was no evidence of a difference in response rate between trial arms (Short vs Long, OR 1.10, 95% CI 0.36 to 3.33). There was no evidence of a difference in time to response between trial arms (Short vs Long, HR 0.91, 95% CI 0.55 to 1.51). In total, 27% of authors responded within a day and 22% of authors never responded., Conclusions: There was no evidence to suggest that email format had an impact on the number of responses received when acquiring data for a systematic review involving stroke trials or the time taken to receive these responses., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: Locum tenens continues to be an increasingly utilized employment option among healthcare organizations to cope with short-term provider vacancies. There exist no studies that explore the job characteristics of such assignments. The purpose of this study was to characterize the clinical responsibilities and compensation of anesthesiology locum tenens positions through content analysis of recruitment emails. Through this data, anesthesiologists interested in locum tenens will be better equipped to evaluate the merit of potential opportunities., Methods: The study was conducted using a compiled database of unsolicited emails received by one of the authors. A total of 241 emails containing 794 assignments were included during the period of 1/09/17 to 1/26/18 (383 days in total). The information was extracted using a standardized template and was entered into a database. Additional validation of the content was done using a data mining tool., Results: Most of the job opportunities originated from five staffing agencies. A total of 37, 25, and 17% of the assignments were allocated to hospitals, ambulatory surgical centers, and trauma centers respectively. The mean caseload for the assignments was between 8.5 and 11.1 cases per day. The mean daily work shift was 9.1 hours, and the average duration of the assignment was one week. The most frequently requested cases included general (74%), orthopedics (54%), and OB/GYN (51%). However, information regarding training qualifications and licensing was not routinely provided. Only 13.1% of assignments specified a system of medical documentation with paper charting being the most common. The mean hourly rate for locum anesthesiologists in our sample was $186.19, significantly higher than the national average of $127.88. Around 28% of staffing agencies covered the licensing expenses of specialists while 23% covered the expense of travels and 20% covered accommodation costs., Conclusions: Descriptions for locum tenens positions follow common anesthesiology practices and feature superior compensation to national estimates. However, vital information is often omitted from recruitment emails, and practice settings are highly variable. Anesthesiologists are urged to fully investigate opportunities before accepting based on recruitment emails. Managers should require more details to be provided in job offers.

Objective: To understand the frequency and nature of postinterview communication as it relates to the rules and regulations of the American Urological Association Urology Residency Match, as well as the impact of such communication on the outcomes of the match., Methods: An anonymous, electronic survey questionnaire was sent to all applicants to a single urology residency training program during the 2017 American Urological Association match cycle. The survey was administered 1 month after the release of match results and queried applicants regarding their experiences with postinterview communication., Results: Of 231 surveys sent, 78 were returned completed for a 34% response rate. Among respondents, 47 (60%) reported receiving postinterview communication from at least one residency program, 20 (26%) were asked to reveal where they would be ranking a program on their rank list, and 15 (19%) reported that postinterview communication caused them to rank a program higher than initially planned, or to keep the program ranked at #1 if currently ranked there. Postinterview communication via telephone was associated with significantly increased odds of matching at the contacting program (odds ratio 20.0, 95% confidence interval 2.12-188.66, P = 0.003)., Conclusion: Postinterview communication between applicants and urology residency programs is prevalent, with numerous violations of the rules of the match. Prohibited communication may impact the rank lists of urology applicants., (Copyright © 2018. Published by Elsevier Inc.)

Purpose: Determine the prevalence and explore individual- and state-level factors associated with texting/emailing while driving (TWD) among adolescent drivers in the United States., Methods: Data from 35 states that administered the 2015 state Youth Risk Behavior Survey were analyzed. We used Poisson regression models with robust error variance to estimate prevalence ratios (PRs) for TWD., Results: Among the 101,397 high school students aged ≥ 14 years who had driven a vehicle during the past 30 days, 38% reported TWD at least once. TWD prevalence ranged from 26% in Maryland to 64% in South Dakota. TWD prevalence was higher in states with a lower minimum learner's permit age and in states where a larger percentage of students drove. Multivariable analyses revealed that the likelihood of TWD increased substantially with age, and white students were more likely to engage in TWD than students of all other races/ethnicities. Infrequent seatbelt users were 21% more likely to engage in TWD compared with frequent seatbelt users (adjusted PR = 1.21, 95% confidence interval: 1.16-1.26), and students who reported drinking and driving were almost twice as likely to TWD as compared to students who did not (adjusted PR = 1.91, 95% confidence interval: 1.79-2.04)., Conclusions: Prevalence of TWD among US high school students varied by more than two-fold across states. TWD prevalence was higher in states with lower minimum learner's permit ages and in states where a larger percentage of students drove. Older age, white race/ethnicity, and other risky driving behaviors were associated with TWD., (Copyright © 2018 Society for Adolescent Health and Medicine. All rights reserved.)

Introduction: HIV transmission presents an ongoing risk to Hispanic women, and prevention efforts remain a priority. The use of technology to prevent HIV transmission among Hispanic women and those of lower socioeconomic status underscore the need for effective implementation of technology. The purpose of this study is to describe technology preferences and predictors of the use of the internet for HIV prevention among low-income Hispanic women., Method: A secondary analysis was conducted using baseline data from an intervention to prevent HIV among 320 Hispanic women. The parent study was SEPA, Salud (health), Educación (education), Promoción (promotion), y [and] Autocuidado (self-care)., Results: Most participants reported using personal technology, such as smartphones (90.6%), the internet (78.1%), and personal email (67.5%), every day. Most (71.3%) participants were open to learning about HIV education via the internet. In the logistic regression analysis, education and time since the last visit to the health care provider were significant predictors of the use of the internet to learn about HIV prevention, after controlling for age, living with the partner, and years living in the United States., Conclusion: Hispanic women demonstrated high levels of comfort with different forms of technology. These results indicated the potential to expand future HIV intervention efforts by implementing electronic dissemination of bilingual and culturally appropriate information for Hispanic women of diverse ages.

Objectives: We describe online portal account adoption and feature access among subgroups of patients who traditionally have been disadvantaged or represent those with high healthcare needs., Study Design: Retrospective cohort study of insured primary care patients 18 years and older (N = 20,282) receiving care from an integrated health system., Methods: Using data from an electronic health record repository, portal adoption was defined by 1 or more online sessions. Feature access (ie, messaging, appointment management, visit/admission summaries, and medical record access and management) was defined by user-initiated "clicks." Multivariable regression methods were used to identify patient factors associated with portal adoption and feature access among adopters., Results: One-third of patients were portal adopters, with African Americans (odds ratio [OR], 0.50; 95% CI, 0.46-0.56), Hispanics (OR, 0.63; 95% CI, 0.47-0.84), those 70 years and older (OR, 0.48; 95% CI, 0.44-0.52), and those preferring a language other than English (OR, 0.43; 95% CI, 0.31-0.59) less likely to be adopters. On the other hand, the likelihood of portal adoption increased with a higher number of comorbidities (OR, 1.04; 95% CI, 1.02-1.07). Among adopters, record access and management features (95.9%) were accessed most commonly. The majority of adopters also accessed appointment management (76.6%) and messaging (59.1%) features. Similar race and age disparities were found in feature access among adopters., Conclusions: The diversity of portal features accessed may bode well for the ability of portals to engage some patients, but without purposeful intervention, reliance on portals alone for patient engagement may exacerbate known social disparities-even among those with an activated portal account.