Category: Statistics

Health Aff (Millwood). 2026 May;45(5):535-544. doi: 10.1377/hlthaff.2025.01659.

ABSTRACT

Outdoor workers face growing exposure to poor air quality, wildfire smoke, and extreme heat, yet protections remain uneven across states and incomplete federally, and little is known about outdoor workers. We combined data from national labor-force surveys with occupation-based exposure data and county-level environmental indicators on air quality, wildfire, and heat waves to describe and compare outdoor and indoor workers. Outdoor workers accounted for 21.9 percent of the workforce in 2023. About 16.9 percent of outdoor workers lived in counties with the highest frequency of unhealthy air quality days, and nearly one-third lived in counties with the highest wildfire (32.4 percent) and heat wave (31.4 percent) risks. Compared with indoor workers, outdoor workers had higher rates of uninsurance, more self-employment, lower access to paid sick leave, and higher rates of work injuries. Results identified outdoor workforces with elevated climate-related risks and differences in coverage and job arrangements, informing federal, state, and local prevention, standards, and enforcement.

PMID:42081754 | DOI:10.1377/hlthaff.2025.01659

JMIR Form Res. 2026 May 4;10:e80255. doi: 10.2196/80255.

ABSTRACT

BACKGROUND: The increasing reliance on patient portals for electronic health records has widened the digital health care access gap, particularly among low-income and Medicaid-insured populations. However, resources exist to assist low-income patients with portal enrollment; in obtaining a free smartphone; and, in New York, in obtaining low-cost internet. Automated bidirectional SMS text messaging offers a scalable and cost-effective strategy for identifying low-income patients’ digital health needs and eligibility for resources by using screening questions and providing tailored information on how to access available resources.

OBJECTIVE: This study aimed to increase portal access among low-income patients using automated bidirectional SMS text messaging and assess its feasibility and acceptability.

METHODS: This quality improvement initiative involved sending automated, bidirectional SMS text messages in English to 12,381 Medicaid-insured and/or low-income patients from a primary care practice. Messages assessed patients’ digital health needs and provided adaptive, personalized resources and assistance for enrolling in the patient portal and for accessing digital technology. We assessed response rates and follow-up portal enrollment rates. We surveyed participants regarding the acceptability, appropriateness, and usability of the SMS text messaging intervention, as well as their subsequent use of the patient portal. We performed descriptive statistics and a binomial probability test.

RESULTS: In total, 9.2% (1140/12,381) of patients responded to the SMS text messages, with 3.9% (481/12,381) opting out and 5.3% (659/12,381) actively engaging. Among respondents, 71.1% (469/659) completed the follow-up survey. Respondents were predominantly female (336/469, 71.6%), with ages ranging from 18 to 65 years or older. Most respondents rated the message’s clarity (420/469, 89.6%), its usefulness (400/469, 85.2%), and the demonstration of care by their health team (350/469, 74.6%) favorably. Concerns regarding privacy (61/469, 13%) and trustworthiness (71/469, 15%) were noted. Notably, 71% of initially unenrolled patients activated their patient portals after the intervention (P=.007), exceeding the hypothesized expectations.

CONCLUSIONS: Automated bidirectional SMS text messaging had mixed effects on promoting patient portal use among low-income patients. Response rates to SMS text messages were low when delivered from an unknown phone number. Among responders, most reported that these messages were useful and that they would recommend them to others. Research is needed to determine optimal strategies for introducing the program and vendor phone numbers to patients to improve engagement.

PMID:42081747 | DOI:10.2196/80255

JMIR Serious Games. 2026 May 4;14:e85673. doi: 10.2196/85673.

ABSTRACT

BACKGROUND: Asthma is a prevalent chronic respiratory condition among children worldwide. Inhalation therapy is the primary treatment method, but children often make errors in its use and exhibit poor adherence, which impacts treatment effectiveness. Therefore, interventions to improve inhalation techniques and enhance adherence are urgently needed.

OBJECTIVE: This study aimed to develop and evaluate BreatheBuddy, developed by Haoyu Zhang, a training system incorporating gamified feedback designed to enhance inhalation skills and treatment adherence in children with asthma.

METHODS: This study used a single-factor repeated-measures design and recruited 20 children aged 6 to 8 years (10 boys and 10 girls), all of whom had prior experience with inhalers. The experimental group used the BreatheBuddy system, which combines a physical inhaler with an interactive game-based software. The system provides real-time animated feedback based on data from inhalation, breath-holding, and exhalation to guide the rhythm and depth of inhalation. The control group used a conventional inhaler method without a gamified system. Inhalation accuracy, adherence, and satisfaction were assessed using the respiration sensor, the Player Experience of Need Satisfaction scale, the Game User Experience Satisfaction Scale (GUESS), and the System Usability Scale (SUS) scales. Statistical comparisons between the groups were conducted using paired t tests and Mann-Whitney U tests to analyze differences.

RESULTS: The experimental group demonstrated significant improvements in inhalation accuracy, with longer breath-holding times and more stable breathing patterns compared to the control group (P<.001). The experimental group also exhibited significantly higher engagement and motivation, with Player Experience of Need Satisfaction (standardized score=93.83) and GUESS (median 87.92, IQR 86.54-88.46) scores markedly higher than those of the control group. Usability scores for the experimental group were also superior, with an SUS score of 88.96 (P<.001). Additionally, children in the experimental group showed reduced anxiety and improved focus during training.

CONCLUSIONS: BreatheBuddy effectively optimized children’s inhalation skills, boosted treatment adherence, and relieved inhalation-related anxiety. Different from conventional non-gamified training or simple game-based distraction, this study integrated breathing behaviors into core game interaction. With dynamic respiratory rhythm feedback, the system unifies skill training, motivation promotion, and emotional regulation. Combined with standard inhaler operation and immersive gamified interaction, it presents a novel behavior-oriented design paradigm. This work provides empirical evidence for gamified intervention in pediatric respiratory treatment and offers a practical auxiliary tool for clinical daily training to strengthen children’s self-management. Further research will focus on personalized adjustment and wider clinical application of the system.

PMID:42081746 | DOI:10.2196/85673

JMIR Mhealth Uhealth. 2026 May 4;14:e85353. doi: 10.2196/85353.

ABSTRACT

BACKGROUND: Problematic smartphone use among adolescents is a growing public health concern closely associated with psychological distress and loneliness. Effective, culturally grounded, school-based interventions are needed.

OBJECTIVE: The aim of this study was to assess the effects of a 12-week program combining traditional social sports games and mental exercises on smartphone addiction, nomophobia, psychological distress, and loneliness in adolescents.

METHODS: In this randomized controlled trial, 69 school-recruited Tunisian adolescents (aged 14-16 years) with clinically elevated smartphone addiction scores were assigned to an experimental group (n=36, 52.2%) or a control group (n=33, 47.8%). The experimental group received a 12-week intervention comprising 4 weekly sessions integrating traditional social sports games with mental exercises, whereas the control group continued standard physical education. Outcomes (smartphone addiction, nomophobia, psychological distress, and loneliness) were assessed at baseline and after the intervention using scales validated in Arabic.

RESULTS: Linear mixed-effects models adjusted for age, sex, and BMI revealed significant group × time interactions of moderate magnitude across all outcomes (P<.05 in all cases) favoring the experimental group. Adjusted postintervention comparisons confirmed significantly lower scores in the experimental group for smartphone addiction, nomophobia, psychological distress, and loneliness (P<.05 in all cases; partial ηp2=0.08-0.12). Mediation analysis indicated that reductions in loneliness accounted for 34.4% of the intervention’s effect on smartphone addiction, consistent with partial mediation.

CONCLUSIONS: A culturally adapted, school-based intervention combining traditional social sports games and mental exercises significantly reduced problematic smartphone use and improved psychological well-being. The partial mediation through reduced loneliness highlights the critical role of social connectedness in adolescent digital health interventions.

PMID:42081744 | DOI:10.2196/85353

J Med Internet Res. 2026 May 4;28:e81070. doi: 10.2196/81070.

ABSTRACT

BACKGROUND: Obesity is a major global health concern, and scalable digital solutions are urgently needed. While digital lifestyle interventions (DLSIs) have shown promise, prior meta-analyses often included hybrid formats with human support, limiting insights into the effectiveness of fully digital interventions.

OBJECTIVE: This study aimed to evaluate the independent effects of standalone DLSIs-defined as interventions delivered exclusively via digital platforms without in-person or adjunctive support-on anthropometric and dietary outcomes in adults with overweight or obesity.

METHODS: We searched MEDLINE, Embase, PsycINFO, Web of Science, and the Cochrane Library from inception through March 4, 2026. Eligible studies were randomized controlled trials (RCTs) evaluating stand-alone DLSIs in adults with overweight or obesity. Interventions were included if they targeted diet or physical activity exclusively through digital platforms. We included fully automated, asynchronous, or one-to-many synchronous systems without individualized support. Studies involving hybrid interventions, including one-to-one synchronous human interaction, nonadult populations, or non-RCT designs, were excluded. Two independent reviewers performed study selection and data extraction. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool (Cochrane Bias Methods Group). Meta-analysis used a random-effects model with the Hartung-Knapp-Sidik-Jonkman method, and heterogeneity was assessed using I2 statistics. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS: A total of 19 RCTs involving 3556 participants were included. Stand-alone DLSIs significantly improved anthropometric outcomes compared to controls (standardized mean difference 0.26, 95% CI 0.14-0.38; 95% prediction interval [PI] -0.16 to 0.68; P<.001; 19 studies; n=3556; I2=56.1%), corresponding to an additional weight loss ranging from 2.62 kg to 6.55 kg, depending on the baseline body weight. Significant improvements were also found in dietary outcomes (standardized mean difference 0.26, 95% CI 0.04-0.48; 95% PI -0.29 to 0.81; P=.008; 8 studies; n=1365; I2=57.5%). Subgroup analyses for anthropometric outcomes revealed significant differences only by control group type (P<.001), with waitlist controls showing the largest effect. For dietary outcomes, no significant subgroup differences were found (P>.05). While most studies showed a low risk of bias, substantial statistical heterogeneity was observed in some outcomes. Consequently, the certainty of evidence for both outcomes was rated as moderate.

CONCLUSIONS: This review is innovative as it is the first to isolate the pure efficacy of stand-alone DLSIs by excluding synchronous human support. Our findings provide moderate-certainty evidence that these tools are effective for weight management and dietary improvement without human intervention. While stand-alone DLSIs offer a highly scalable, cost-effective first-step intervention, the PIs included zero, and substantial heterogeneity was observed, suggesting that benefits may vary across settings. Future research should identify user characteristics that maximize engagement with unguided digital tools.

PMID:42081742 | DOI:10.2196/81070

J Med Internet Res. 2026 May 4;28:e75675. doi: 10.2196/75675.

ABSTRACT

BACKGROUND: Medical residency is a demanding training stage characterized by high levels of stress and burnout. As digital natives, current medical trainees (ie, residents) are frequent users of social media; however, little is known about how their personal (nonprofessional) use relates to burnout and social media addiction (SMA).

OBJECTIVE: This study aims to characterize the prevalence of SMA among Chinese medical trainees and explore its complex relationships with social media use patterns, occupational burnout, and related risk and protective factors.

METHODS: A nationwide cross-sectional survey was deployed through Wenjuanxing and disseminated via WeChat between August 29 and September 10, 2024. Data included demographics, physical and psychiatric health history, work variables (eg, training year and night shifts), personality traits, and social media use. SMA was assessed using the Bergen Social Media Addiction Scale. Logistic regression was performed to identify predictors of addiction, and mediation and moderation analyses were conducted to clarify the role of occupational burnout.

RESULTS: Of 3621 medical trainees, 211 (5.8%) met the criteria for SMA (Bergen Social Media Addiction Scale ≥24, indicating addiction). Second-year medical trainees reported the highest addiction prevalence (92/1159, 7.9%). Logistic regression analysis revealed that higher burnout (odds ratio [OR] 1.41, 95% CI 1.23-1.62; P<.001), longer daily use (OR 1.39, 95% CI 1.23-1.56; P<.001), physical health problems (OR 1.56, 95% CI 1.13-2.16; P=.006), and psychiatric history (OR 2.00, 95% CI 1.41-2.84; P<.001) significantly increased the odds of addiction, whereas conscientiousness was protective (OR 0.92, 95% CI 0.86-0.99; P=.02). Social media use showed significant U-shaped associations with burnout, physical health problems, psychiatric history, personality characteristics, and mental health outcomes. For example, medical trainees using social media 1 hour or less (104/404, 25.7% with psychiatric history) and more than 4 hours daily (97/419, 23.2% with psychiatric history) both had higher risk profiles than moderate users. Mediation analysis showed that occupational burnout explained 28.1% of the effect of psychiatric history and 29.6% of the effect of physical health problems on addiction risk.

CONCLUSIONS: This large-scale survey provides the first systematic characterization of SMA among Chinese medical trainees and elucidates its associated risks and protective factors. Burnout consistently emerged as a key and pervasive predictor of SMA, functioning both as an independent risk factor and as a mediator amplifying the impact of health-related vulnerabilities. Moreover, the findings highlight that both minimal and excessive daily social media use may signal distinct behavioral manifestations of distress, potentially reflecting different clinical phenotypes: digital disengagement under acute stress versus compulsive engagement driven by chronic burnout. Notably, while mental health symptoms exhibited U-shaped associations with usage, SMA risk increased progressively with daily duration. These results underscore the need for interventions that extend beyond simply monitoring usage duration, emphasizing strategies to reduce burnout and enhance the overall well-being of medical trainees.

PMID:42081741 | DOI:10.2196/75675

J Med Internet Res. 2026 May 4;28:e85550. doi: 10.2196/85550.

ABSTRACT

BACKGROUND: Menstruation has long been framed primarily as a hygiene issue, with mainstream products and public messaging emphasizing concealment and disposal of menstrual blood (MB). This has contributed to a culture of silence in which conversations about menstrual health have been marginalized in public and clinical settings. Recent international guidance, including the World Health Organization’s call to reframe menstruation as a health issue, underscores the need for more open discourse. Simultaneously, social media has become a prominent space where menstruating individuals share experiences, seek advice, and challenge stigma. The resurgence of reusable menstrual products has increased users’ direct observation of MB, prompting questions about variations in color, texture, and smell. These developments highlight growing curiosity about MB yet reveal persistent information gaps regarding how MB is understood outside the clinical setting.

OBJECTIVE: This study aimed to examine how MB is represented in social media discourse and to explore individuals’ perceptions of MB’s potential use as a diagnostic tool.

METHODS: We conducted a cross-sectional, convergent mixed methods social listening study combining qualitative content analysis, social network analysis, sentiment analysis, and descriptive statistical analysis. Data were collected from TikTok (ByteDance), Facebook (Meta), Instagram (Meta), and Reddit using Mention and Apify. Between February 1 and 28, 2025, 6263 posts and videos were extracted using 3 strategies-group searches, hashtag searches, and social listening alerts. All data were anonymized, and demographic information was unavailable. After removing duplicates, non-English content, images, and posts without reference to blood, 349 posts were included. Coding followed a multistep deductive process in Atlas.ti. All posts were assigned with quotations, which were designated with one or more codes. Network analysis examined associations between appearance descriptors and reported health conditions. Sentiment analysis assessed perceptions of MB-based diagnostics.

RESULTS: Among the included posts (n=349), most originated from Reddit and Facebook. Seeking help (154/349, 44.1%) was the most common type of post. Appearance descriptions (n=243 posts) focused on color, particularly brown, bright red, pink, and black; consistency, particularly coagulation; and smell, mainly unpleasant. Network analysis linked specific colors and textures to perceived conditions, including miscarriage, endometriosis, hormonal changes, polycystic ovary syndrome (PCOS), and infections. Discussion of MB as a diagnostic tool (n=80 posts) was less frequent but included predominantly positive quotations (110/115, 95.7%), emphasizing accessibility, noninvasiveness, and home-based sampling. Concerns (19/115, 16.5%) focused on inclusivity, stigma, and bodily autonomy.

CONCLUSIONS: This study demonstrates that social media serves as an important source for discussion on MB-related topics and highlights a gap between public information needs and the available scientific evidence. The findings also indicate a strong interest in MB characteristics and support further research into its diagnostic potential. To our knowledge, this is the first study to analyze social media discussions on MB characteristics and its diagnostic potential.

PMID:42081739 | DOI:10.2196/85550

J Med Internet Res. 2026 May 4;28:e93164. doi: 10.2196/93164.

ABSTRACT

BACKGROUND: Low physical activity (PA) is a well-established risk factor for major depressive disorder (MDD). However, the temporal dynamics of PA preceding an incident clinical diagnosis of MDD remain poorly characterized, particularly using long-term, objective measures collected in real-world settings.

OBJECTIVE: This study aimed to characterize trajectories of wearable-measured PA during the year preceding incident MDD diagnosis and identify the timing of within-person changes.

METHODS: We conducted a retrospective nested case-control study using linked electronic health record and wearable (Fitbit) data from the All of Us Research Program. Adults with at least 6 months of valid Fitbit PA data in the 12 months preceding diagnosis were included. Incident MDD cases were identified based on a first electronic health record-recorded diagnosis and matched to MDD-free controls on age, sex, BMI, and calendar time of diagnosis, with up to 4 controls per case. Daily steps and moderate to vigorous PA (MVPA) were aggregated into monthly averages. Linear mixed-effects models were used to compare prediagnostic PA trajectories between cases and controls over a retrospective time scale from -12 to 0 months. Among cases, within-person contrasts were used to identify when PA levels first showed statistically significant deviations relative to levels observed 12 months before diagnosis. Exploratory analyses assessed heterogeneity by demographic factors.

RESULTS: The analytic cohort included 4104 participants (n=829, 20.2% incident MDD cases and n=3275, 79.8% matched controls; n=3355, 81.7% women; median age 48.4, IQR 36.3-61.3 years). Compared with controls, individuals who developed MDD exhibited consistently lower overall PA and significant downward trajectories in both daily steps and MVPA during the year preceding diagnosis (global trajectory tests; P<.001 for both outcomes). Differences widened progressively over time, indicating accelerating declines as diagnosis approached. Among cases, statistically significant changes in daily step counts emerged approximately 4 months before diagnosis (-145, 95% CI -253 to -37 steps vs month -12; P=.02) and reached -428 (95% CI -531 to -326) steps at diagnosis (P<.001). Declines in MVPA emerged approximately 5 months before diagnosis (-2.48, 95% CI -4.32 to -0.64 minutes; P=.02) and reached -5.61 (95% CI -7.35 to -3.86) minutes at diagnosis (P<.001). Furthermore, exploratory analyses suggested heterogeneity in prediagnostic trajectories across demographic subgroups, including steeper declines among men, more pronounced reductions in activity intensity at older ages, and persistently lower activity levels with flatter trajectories among individuals with obesity.

CONCLUSIONS: Unlike prior studies lacking objective PA assessment before MDD diagnosis, this study linked wearable and clinical data to characterize long-term prediagnostic trajectories in real-world settings. We observed sustained within-person declines emerging 4 to 5 months before diagnosis, providing insights into temporal dynamics preceding clinical recognition. These findings suggest that wearable-based monitoring may offer scalable early signals for risk stratification, prevention, and intervention for MDD.

PMID:42081737 | DOI:10.2196/93164

Diabet Med. 2026 May 4:e70344. doi: 10.1111/dme.70344. Online ahead of print.

ABSTRACT

AIM: To characterise CGM-derived glycaemic trajectories over 12months in people receiving maintenance haemodialysis, with a particular focus on hypoglycaemia burden and composite glycaemic risk.

METHODS: We conducted a longitudinal observational study. CGM data were collected at baseline, 6 and 12 months. Descriptive statistics summarised characteristics. Outcomes included time in range (TIR), time below range (TBR), time above range (TAR), glycaemic variability (GV), hypoglycaemia burden and glycaemic risk index (GRI). Metrics were summarised using means or medians, and changes between timepoints were assessed using paired t-tests or Wilcoxon signed-rank tests.

RESULTS: In 125 participants (mean age 63.7 years; 54.5% men), TIR increased from 51.6% at baseline to 56.6% at 6 months (mean difference 5.09%, 95% CI 1.06 to 9.12; p = 0.014) but was not sustained at 12 months (50.5%; p = 0.568), with a decline between 6 and 12 months (-6.11%, 95% CI -9.03 to -3.19; p < 0.001). TBR remained low, with a small increase between 6 and 12 months (1.61%, 95% CI 0.59-2.64; p = 0.002). TAR and GV were unchanged across timepoints. Hypoglycaemia burden increased over follow-up (p < 0.001), while GRI showed no change. HbA1c showed moderate concordance with CGM-derived glucose at baseline (ρ = 0.39; p = 0.0001) and 12 months (ρ = 0.59; p < 0.0001).

CONCLUSIONS: CGM revealed evolving glycaemic patterns. Early improvements in TIR were not sustained, hypoglycaemia increased modestly and the overall GRI remained unchanged. These findings support CGM-informed, individualised diabetes management, prioritising safety and stability.

PMID:42081714 | DOI:10.1111/dme.70344

JMIR Mhealth Uhealth. 2026 May 4;14:e82368. doi: 10.2196/82368.

ABSTRACT

BACKGROUND: Healthy aging has emerged as a global priority. However, older adults’ participation in health promotion programs remains low, and traditional health promotion models have achieved limited success in fostering sustained engagement among this population. Mobile health (mHealth)-based gamification interventions offer a promising way to address these challenges. However, no published reviews support or oppose the use of mHealth-based gamification interventions as health promotion strategies in older adults.

OBJECTIVE: The study aimed to identify mHealth interventions using gamification to promote health among older adults.

METHODS: Our scoping review was conducted following the Joanna Briggs Institute recommendations for scoping reviews and Arksey and O’Malley’s framework. The process followed PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines and PRISMA-S (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Literature Search Extension) checklist. A comprehensive literature search was conducted across 8 databases: PubMed, Scopus, Web of Science, Embase, Cochrane Library, CINAHL, PsycARTICLES, and IEEE Xplore Digital Library, from their inception to December 10, 2025. Two reviewers independently screened titles, abstracts, and full texts via Rayyan, with disagreements resolved by a third reviewer.

RESULTS: This scoping review identified 11 studies. Only 1 article was published before 2022. The interventions were found to improve enjoyment and motivation (n=5), cognitive function (n=3), physical activity (n=2), and digital literacy (n=2). Individual studies also reported improvements in mental health (n=1) and adherence (n=1), a reduction in suicidal ideation (n=1), improvements in physical function (n=1), the promotion of social engagement (n=1), and the identification of mild cognitive impairment (n=1). Game elements used were ranked by frequency as progress, challenges, goals, levels, reward, sensation, storytelling or narration, leaderboard, surprise, and avatar. No research was found to use the game element of “social sharing.” mHealth types included augmented and virtual reality-based training systems, wearable devices, mobile phones, tablets, and Windows platforms and devices. Notably, only 4 studies applied theoretical frameworks, and 3 omitted the concrete approach to gamification.

CONCLUSIONS: As the first scoping review to identify and map mHealth-based gamification interventions for older adults, this study highlights their potential as an innovative approach to health promotion. By systematically synthesizing evidence regarding intervention designs, gamification strategies, and preliminary health outcomes, it establishes a foundation for future inquiry. However, this review is limited by the small number of included studies, precluding broad generalizations. Future research should assess long-term impacts, integrate theoretical frameworks, establish reporting guidelines, design personalized social-interactive interventions, and expand to broader health domains. Ultimately, these insights provide targeted guidance for developing age-appropriate digital health solutions, contributing to the realization of active aging.

PMID:42081713 | DOI:10.2196/82368