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Telemedicine can be useful for diabetes patients living remotely, especially during pandemic times. We aimed to identify current knowledge of the use of telemedicine for diabetes in Norway by conducting a review of the literature. Telemedicine is mostly beneficial, and it seems that it can be adopted into the usual diabetes care in Norway as a low-cost alternative.

Digital interventions for increasing physical activity behavior have shown great potential, especially those with social media. Chatbots, also known as conversational agents, have emerged in healthcare in relation to digital interventions and have proven effective in promoting physical activity among adults. The study’s objective is to explore users’ experiences with a social media chatbot. The concept and the prototype development of the social media chatbot MYA were realized in three steps: requirement analysis, concept development, and implementation. MYA’s design includes behavior change techniques effective in increasing physical activity through digital interventions. Participants in a usability study answered a survey with the Chatbot Usability Questionnaire (CUQ), which is comparable to the Systems Usability Scale. The mean CUQ score was below 68, the benchmark for average usability. The highest mean CUQ score was 64.5 for participants who thought MYA could help increase their physical activity behavior. The lowest mean CUQ score was 40.6 for participants aged between 50 and 69 years. Generally, MYA was considered to be welcoming, very easy to use, realistic, engaging, and informative. However, some technical issues were identified. A good and diversified user experience promotes prolonged chatbot use. Addressing identified issues will enhance users’ interaction with MYA.

Introduction: We examined if we could identify predictors for smoking cessation at six months post cessation, among smokers enrolled in a large Norwegian populationbased intervention study. Methods: We followed 4333 (72.1% women) smokers who enrolled in an internetbased smoking cessation intervention during 2010–2012. The baseline questionnaire collected information on sociodemographic and lifestyle factors, including current snus use. The cessation outcome was self-reported no smoking past seven days, at six months. We used logistic regression to estimate odds ratios (ORs) with 95% confidence intervals, to identify predictors of smoking cessation, adjusting for potential confounders. Results: Women (OR=1.30; 95% CI: 1.01–1.69) compared with men, and those with medium (OR=1.31; 95% CI: 1.02–1.68) and longer (OR=1.42; 95% CI: 1.06–1.90) education compared with those with shorter education, were more likely to be successful quitters. Overall, being a student (OR=0.56; 95% CI: 0.37–0.85) compared with having fulltime work, and a moderate to high Fagerström test for nicotine dependence (FTND) score (OR=0.69; 95% CI: 0.55–0.87) compared with a low score, were predictors for unsuccessful cessation. Current snus use was a predictor for unsuccessful cessation compared to no snus use for both men (OR=0.49; 95% CI: 0.28–0.88) and women (OR=0.49; 95% CI: 0.32–0.75). Conclusions: Our study identifies female sex and longer education as predictors for successful smoking cessation, while a medium or high FTND score, being a student, and current snus use, were predictors for unsuccessful smoking cessation. Only current snus use was a predictor for unsuccessful cessation for both sexes. Our results indicate that smokers should be warned that snus use may prevent successful smoking cessation.

Fully automated self-help interventions integrated with social media chatbots could serve as highly cost-effective physical activity promotion tools for a large population. We have developed MYA, a Telegram-based chatbot for increasing physical activity. The objective of this study was to assess the usability of MYA. To identify usability issues, we recruited volunteers and asked them to interact with MYA and to answer the Chatbot Usability Questionnaire. Thirty volunteers participated in the study, 83.3% agreed MYA was welcoming during initial setup and 63.3% agreed MYA was very easy to use. MYA was perceived as realistic and engaging, easy to navigate, and its responses were useful, appropriate, and informative (all 53.3%). However, 63.3% of respondents agreed MYA failed to recognize most of their inputs, and 43.3% claimed it would be easy to get confused when using MYA. Although the results are encouraging, it remains unclear if a social media chatbot can motivate people to increase their physical activity. MYA has the potential to do that, with improvements in functionalities like challenge personalization. The efficacy of these approaches should be studied in a clinical trial.

Fully automated self-help interventions integrated with social media chatbots could serve as highly cost-effective physical activity promotion tools for a large population. We have developed MYA, a Telegram-based chatbot for increasing physical activity. The objective of this study was to assess the usability of MYA. To identify usability issues, we recruited volunteers and asked them to interact with MYA and to answer the Chatbot Usability Questionnaire. Thirty volunteers participated in the study, 83.3% agreed MYA was welcoming during initial setup and 63.3% agreed MYA was very easy to use. MYA was perceived as realistic and engaging, easy to navigate, and its responses were useful, appropriate, and informative (all 53.3%). However, 63.3% of respondents agreed MYA failed to recognize most of their inputs, and 43.3% claimed it would be easy to get confused when using MYA. Although the results are encouraging, it remains unclear if a social media chatbot can motivate people to increase their physical activity. MYA has the potential to do that, with improvements in functionalities like challenge personalization. The efficacy of these approaches should be studied in a clinical trial.

Health-dedicated groups on social media provide different contents and social support to their peers. Our objective is to analyze users' engagement with health education and physical activity promotion posts according to the expressed social support and social media. All health education and physical activity promotion posts on Facebook, Twitter, and Instagram during 2017-2019 by a diabetes association were extracted. We identified the type of social support within these posts; and analysed the users' engagement with these posts according to the type of social support and social media channel. A total of 260 posts dealing with health education (n=200) and physical activity promotion (n=60) were published. Posts promoting physical activity received 54% more likes than posts on health education (p0.05), but they were 69% less likely to receive comments and be shared (both p0.01). Posts expressing tangible assistance received 6 times more likes (p0.001), and the ones indicating network support almost 11 times more shares (p0.05). Posts expressing two or more types of social support were the most engaging (3 times more likes, 2 times more comments, and over 6 times more shares, all p0.001). Health-dedicated social media groups can be effective channels for providing health education and for promoting physical activity among individuals with diabetes. Our findings suggest that engagement with health education and physical activity promotion posts can be increased by providing tangible assistance, network support, or expressing two or more types of social support; and by posting on Facebook and Instagram.

Diabetes self-management, an integral part of diabetes care, can be improved with the help of digital self-management tools such as apps, sensors, websites, and social media. The study objective was to reach a consensus on the criteria required to assess and recommend digital diabetes self-management tools targeting those with diabetes in Norway. Healthcare professionals working with diabetes care from all health regions in Norway were recruited to participate in a three-round Delphi study. In all rounds, the panellists rated criteria identified in a systematic review and interviews on a scale from 0-10, with the option to provide comments. On a scale of 0:not important to 10:extremely important, the highest rated criteria for assessing and recommending digital diabetes self-management tools were “Usability” and “Information quality”, respectively. For assessing apps, “Security and privacy” was one of the lowest rated criteria. Having access to a list of criteria for assessing and recommending digital self-management tools can help diabetes care stakeholders to make informed choices in recommending and choosing suitable apps, websites, and social media for self-management. Future work on quality assessment of digital health tools should place emphasis on security and privacy compliance, to enable diabetes care stakeholders focus on other relevant criteria to recommend or choose and use such tools.

Diabetes self-management, an integral part of diabetes care, can be improved with the help of digital self-management tools such as apps, sensors, websites, and social media. The study objective was to reach a consensus on the criteria required to assess and recommend digital diabetes self-management tools targeting those with diabetes in Norway. Healthcare professionals working with diabetes care from all health regions in Norway were recruited to participate in a three-round Delphi study. In all rounds, the panellists rated criteria identified in a systematic review and interviews on a scale from 0-10, with the option to provide comments. On a scale of 0:not important to 10:extremely important, the highest rated criteria for assessing and recommending digital diabetes self-management tools were "Usability" and "Information quality", respectively. For assessing apps, "Security and privacy" was one of the lowest rated criteria. Having access to a list of criteria for assessing and recommending digital self-management tools can help diabetes care stakeholders to make informed choices in recommending and choosing suitable apps, websites, and social media for self-management. Future work on quality assessment of digital health tools should place emphasis on security and privacy compliance, to enable diabetes care stakeholders focus on other relevant criteria to recommend or choose and use such tools.

Background There is growing evidence that apps and digital interventions have a positive impact on diabetes self-management. Standard self-management for patients with diabetes could therefore be supplemented by apps and digital interventions to increase patients’ skills. Several initiatives, models, and frameworks suggest how health apps and digital interventions could be evaluated, but there are few standards for this. And although there are many methods for evaluating apps and digital interventions, a more specific approach might be needed for assessing digital diabetes self-management interventions. Objective This review aims to identify which methods and criteria are used to evaluate apps and digital interventions for diabetes self-management, and to describe how patients were involved in these evaluations. Methods We searched CINAHL, EMBASE, MEDLINE, and Web of Science for articles published from 2015 that referred to the evaluation of apps and digital interventions for diabetes self-management and involved patients in the evaluation. We then conducted a narrative qualitative synthesis of the findings, structured around the included studies’ quality, methods of evaluation, and evaluation criteria. Results Of 1681 articles identified, 31 fulfilled the inclusion criteria. A total of 7 articles were considered of high confidence in the evidence. Apps were the most commonly used platform for diabetes self-management (18/31, 58%), and type 2 diabetes (T2D) was the targeted health condition most studies focused on (12/31, 38%). Questionnaires, interviews, and user-group meetings were the most common methods of evaluation. Furthermore, the most evaluated criteria for apps and digital diabetes self-management interventions were cognitive impact, clinical impact, and usability. Feasibility and security and privacy were not evaluated by studies considered of high confidence in the evidence. Conclusions There were few studies with high confidence in the evidence that involved patients in the evaluation of apps and digital interventions for diabetes self-management. Additional evaluation criteria, such as sustainability and interoperability, should be focused on more in future studies to provide a better understanding of the effects and potential of apps and digital interventions for diabetes self-management.

The number of publications on the use of chatbots for health is recently increasing, however to our knowledge, there are no publications summarizing what is known about using chatbots for public health yet. The objective of this work is to provide an overview of the existing scientific literature on the use of chatbots for public health, for which purpose have chatbots been used, and whether health-related outcomes have been reported.We carried out a literature review on this topic across 5 databases: Pubmed, EMBASE, PsychINFO, SCOPUS, and IEEE Xplore. Identified papers were classified according to their underlying technology, application area, and study design.A total of 15 relevant papers were identified: eight of these papers were developmental studies that tested the feasibility or usability of a chatbot, and seven were interventional studies. All the interventional studies reported positive health- related outcomes associated with the chatbot use.The first studies testing chatbots for public health seem very promising; however, there are various aspects that should be improved, including the chatbots' designs, studies' methods, and analysis and reporting of results. More high-quality studies and improved reporting of chatbots' use are needed.

BACKGROUND Diabetes patient associations and diabetes-specific patient groups around the world are present on social media. Although active participation and engagement in these diabetes social media groups has been mostly linked to positive effects, very little is known about the content that is shared on these channels or the post features that engage their users the most. OBJECTIVE The objective of this study was to analyze (1) the content and features of posts shared over a 3-year period on 3 diabetes social media channels (Facebook, Twitter, and Instagram) of a diabetes association, and (2) users’ engagement with these posts (likes, comments, and shares). METHODS All social media posts published from the Norwegian Diabetes Association between January 1, 2017, and December 31, 2019, were extracted. Two independent reviewers classified the posts into 7 categories based on their content. The interrater reliability was calculated using Cohen kappa. Regression analyses were carried out to analyze the effects of content topic, social media channel, and post features on users’ engagement (likes, comments, and shares). RESULTS A total of 1449 messages were posted. Posts of interviews and personal stories received 111% more likes, 106% more comments, and 112% more shares than miscellaneous posts (all P<.001). Messages posted about awareness days and other celebrations were 41% more likely to receive likes than miscellaneous posts (P<.001). Conversely, posts on research and innovation received 31% less likes (P<.001), 35% less comments (P=.02), and 25% less shares (P=.03) than miscellaneous posts. Health education posts received 38% less comments (P=.003) but were shared 39% more than miscellaneous posts (P=.007). With regard to social media channel, Facebook and Instagram posts were both 35 times more likely than Twitter posts to receive likes, and 60 times and almost 10 times more likely to receive comments, respectively (P<.001). Compared to text-only posts, those with videos had 3 times greater chance of receiving likes, almost 4 times greater chance of receiving comments, and 2.5 times greater chance of being shared (all P<.001). Including both videos and emoji in posts increased the chances of receiving likes by almost 7 times (P<.001). Adding an emoji to posts increased their chances of receiving likes and being shared by 71% and 144%, respectively (P<.001). CONCLUSIONS Diabetes social media users seem to be least engaged in posts with content topics that a priori could be linked to greater empowerment: research and innovation on diabetes, and health education. Diabetes social media groups, public health authorities, and other stakeholders interested in sharing research and innovation content and promoting health education on social media should consider including videos and emoji in their posts, and publish on popular and visual-based social media channels, such as Facebook and Instagram, to increase user engagement. INTERNATIONAL REGISTERED REPORT RR2-10.1186/s12913-018-3178-7

BACKGROUND There is growing evidence that apps and digital interventions have a positive impact on diabetes self-management. Standard self-management for patients with diabetes could therefore be supplemented by apps and digital interventions to increase patients’ skills. Several initiatives, models, and frameworks suggest how health apps and digital interventions could be evaluated, but there are few standards for this. And although there are many methods for evaluating apps and digital interventions, a more specific approach might be needed for assessing digital diabetes self-management interventions. OBJECTIVE This review aims to identify which methods and criteria are used to evaluate apps and digital interventions for diabetes self-management, and to describe how patients were involved in these evaluations. METHODS We searched CINAHL, EMBASE, MEDLINE, and Web of Science for articles published from 2015 that referred to the evaluation of apps and digital interventions for diabetes self-management and involved patients in the evaluation. We then conducted a narrative qualitative synthesis of the findings, structured around the included studies’ quality, methods of evaluation, and evaluation criteria. RESULTS Of 1681 articles identified, 31 fulfilled the inclusion criteria. A total of 7 articles were considered of high confidence in the evidence. Apps were the most commonly used platform for diabetes self-management (18/31, 58%), and type 2 diabetes (T2D) was the targeted health condition most studies focused on (12/31, 38%). Questionnaires, interviews, and user-group meetings were the most common methods of evaluation. Furthermore, the most evaluated criteria for apps and digital diabetes self-management interventions were cognitive impact, clinical impact, and usability. Feasibility and security and privacy were not evaluated by studies considered of high confidence in the evidence. CONCLUSIONS There were few studies with high confidence in the evidence that involved patients in the evaluation of apps and digital interventions for diabetes self-management. Additional evaluation criteria, such as sustainability and interoperability, should be focused on more in future studies to provide a better understanding of the effects and potential of apps and digital interventions for diabetes self-management.

Background Diabetes patient associations and diabetes-specific patient groups around the world are present on social media. Although active participation and engagement in these diabetes social media groups has been mostly linked to positive effects, very little is known about the content that is shared on these channels or the post features that engage their users the most. Objective The objective of this study was to analyze (1) the content and features of posts shared over a 3-year period on 3 diabetes social media channels (Facebook, Twitter, and Instagram) of a diabetes association, and (2) users’ engagement with these posts (likes, comments, and shares). Methods All social media posts published from the Norwegian Diabetes Association between January 1, 2017, and December 31, 2019, were extracted. Two independent reviewers classified the posts into 7 categories based on their content. The interrater reliability was calculated using Cohen kappa. Regression analyses were carried out to analyze the effects of content topic, social media channel, and post features on users’ engagement (likes, comments, and shares). Results A total of 1449 messages were posted. Posts of interviews and personal stories received 111% more likes, 106% more comments, and 112% more shares than miscellaneous posts (all P Conclusions Diabetes social media users seem to be least engaged in posts with content topics that a priori could be linked to greater empowerment: research and innovation on diabetes, and health education. Diabetes social media groups, public health authorities, and other stakeholders interested in sharing research and innovation content and promoting health education on social media should consider including videos and emoji in their posts, and publish on popular and visual-based social media channels, such as Facebook and Instagram, to increase user engagement. International Registered Report Identifier (IRRID) RR2-10.1186/s12913-018-3178-7

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

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. CLINICALTRIAL ClinicalTrials.gov NCT01103427; https://clinicaltrials.gov/ct2/show/NCT01103427

Purpose: The main aim of the study was to identify predictors for successful smoking cessation at 6 months after enrolment in an E-health cessation program. Context: In 2010, 30% Norwegian men and 28% of women were smokers (daily and occasionally). The website www.slutta.no was open to the Norwegian public. It was free, and a part of the national smoking cessation strategy of the Directorate of Health. As many as 94% of the population in Norway have access to Internet in their homes and 96% owns a mobile phone. Methods : We followed 4,335 Norwegian men and women who signed up to a multi component Norwegian internet based smoking cessation program, www.slutta.no. The enrolment was from May 2010 until October 2012. The inclusion criteria were smokers above 16 years of age, who wanted to quit, who reported to have regular access to the internet, had their own mobile cell phone, had writing skills in Norwegian and who gave an informed consent. The outcome was self-reported, no smoking past 7 days, six months subsequent to the personal quit date. We used Cox proportional hazards (PH) regression model to test for predictors of successful quitting at 6 months compared with those who continued to smoke, while adjusting for relevant confounders. Results and discussion: At six months, those who reported to have more than 9 years of education were more than twice as likely to successfully having quit smoking [10-12 (HR=2.16; 95% CI=1.16-4.02), 13-16 (HR=2.68; 95% CI=1.45-4.96) and 17 + (HR=2.63; 95% CI=1.40-4.95)] compared with those who reported to have fewer than 9 years of education. Compared with participants who reported to have a weak motivation at baseline, those who reported to have a very strong motivation had a 93% statistically significantly higher success of quitting (HR-1.93; 95% CI=1.32-2.83). Those who reported to use snus daily were less likely to achieve successful quitting compared with non-snus users at baseline(HR=0.49; 95% CI=0.27-0.87). Those who reported that they had never tried to quit smoking before, were more likely to succeed compared with those who reported that they had tried to quit smoking earlier. Snus use has been advocated as a help tool for quitting smoking. Our results showing that snus users were less likely to successfully quit smoking is in contradiction to this belief. Our results suggest that the current E-Health program for quitting smoking may be revised and improved so it to a greater extend also help those with less education and less motivation to quit smoking.