Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Prevalent co-occurring poor diet and physical inactivity convey chronic disease risk to the population. Large magnitude behavior change could improve behaviors to recommended levels, but multiple behavior change interventions produce small, poorly maintained effects. Objective: The Make Better Choices 2 (MBC2) trial tested whether a multicomponent intervention integrating mHealth, modest incentives, and remote coaching could sustainably improve diet and activity. Methods: The 9-month RCT enrolled 212 Chicago area adults between 2012-2014 with low fruit and vegetable and high saturated fat intakes, low moderate vigorous physical activity (MVPA) and high sedentary leisure screen time. Participants were randomly assigned to either of two active interventions targeting MVPA Simultaneously with or Sequentially after other diet and activity targets or a stress and sleep contact control intervention. They used an app and accelerometer to track targeted behaviors and receive personalized remote coaching. Perfect behavioral adherence was incentivized $5/week for 12 weeks. Diet and activity behaviors were measured at baseline, 3, 6, and 9 months; primary outcome was 9-month diet and activity composite improvement. Results: Both Simultaneous and Sequential interventions produced large, sustained improvements exceeding Control (p<.001), and bringing all diet and activity behaviors to guideline levels. At 9 months, interventions increased fruit/vegetables by 6.5 servings/day, 95% CI [6.1, 6.8], increased MVPA by 24.7 min/day, 95% CI [20.0, 29.5], decreased sedentary leisure -170.5 min/day, 95% CI [-183.5,-157.5] and decreased saturated fat intake -3.6%, 95% CI [-4.1,-3.1]). Conclusions: Multicomponent mHealth diet and activity intervention involving connected coaching and modest initial performance incentives holds potential to scalably reduce chronic disease risk. Clinical Trial: URL: http://www.clinicaltrials.gov. Unique Identifier: NCT01249989

Background: Cancer survivors face an increased risk of cardiovascular events compared with the general population. Adopting a healthy lifestyle may reduce these risks, and guidelines encourage health‐promotion counseling for cancer survivors, but the extent of physician adherence is unclear.Methods: This mixed‐method study surveyed 91 physicians, including 30 primary care physicians (PCPs), 30 oncologists, and 31 specialists (urologists, dermatologists, and gynecologists). Interviews also were conducted with 12 oncologists.Results: Most PCPs (90%) reported recommending health promotion (eg, weight loss, smoking cessation) to at least some cancer survivors, whereas few oncologists (26.7%) and specialists (9.7%) said they ever did so (P < .001). Although most physicians believed that at least 50% of cancer survivors would be adherent to medication regimens to prevent cancer recurrence, they also believed that, if patients were trying to lose weight, they would not remain medication‐adherent. In interviews, oncologists expressed fear that providing health‐promotion advice would distress or overwhelm patients. Additional health‐promotion barriers identified by thematic analysis included: identifying cancer as oncologists' focal concern, time pressure, insufficient behavior change training, and care coordination challenges. Facilitators included perceiving a patient benefit and having health‐promotion resources integrated into the cancer care system.Conclusions: Physicians often do not have the time, expertise, or resources to address health promotion with cancer survivors. Research is needed to evaluate whether health‐promotion efforts compromise medical regimen adherence, as physicians' responses suggest.

Melanoma survivors often do not engage in adequate sun protection, leading to sunburn and increasing their risk of future melanomas. Melanoma survivors do not accurately recall the extent of sun exposure they have received, thus, they may be unaware of their personal UV exposure, and this lack of awareness may contribute towards failure to change behavior. As a means of determining behavioral accuracy of recall of sun exposure, this study compared subjective self-reports of time outdoors to an objective wearable sensor. Analysis of the meaningful discrepancies between the self-report and sensor measures of time outdoors was made possible by using a network flow algorithm to align sun exposure events recorded by both measures. Aligning the two measures provides the opportunity to more accurately evaluate false positive and false negative self-reports of behavior and understand participant tendencies to over- and under-report behavior. 39 melanoma survivors wore an ultraviolet light (UV) sensor on their chest while outdoors for 10 consecutive summer days and provided an end-of-day subjective self-report of their behavior while outdoors. A Network Flow Alignment framework was used to align self-report and objective UV sensor data to correct misalignment. The frequency and time of day of under- and over-reporting were identified. For the 269 days assessed, the proposed framework showed a significant increase in the Jaccard coefficient (i.e. a measure of similarity between self-report and UV sensor data) by 63.64% (p < .001), and significant reduction in false negative minutes by 34.43% (p < .001). Following alignment of the measures, under-reporting of sun exposure time occurred on 51% of the days analyzed and more participants tended to under-report than to over-report sun exposure time. Rates of under-reporting of sun exposure were highest for events that began from 12-1pm, and second-highest from 5-6pm. These discrepancies may reflect lack of accurate recall of sun exposure during times of peak sun intensity (10am–2pm) that could ultimately increase the risk of developing melanoma. This research provides technical contributions to the field of wearable computing, activity recognition, and identifies actionable times to improve participants’ perception of their sun exposure.

Ultraviolet radiation (UVR) exposure is the primary modifiable risk factor for melanoma. Wearable UVR sensors provide a means of quantifying UVR exposure objectively and with a lower burden than self-report measures used in most research. The purpose of this study was to evaluate the relationship between detected UVR exposure and reported sunburn occurrence. In this study, a UVR monitoring device was worn by 97 parent–child dyads during waking hours for 14 days to measure instantaneous and accumulated UVR exposure. The results showed that the participants’ total UVR exposure was associated with reported sunburn after adjusting for Fitzpatrick skin type and geographic location. It was observed that one standard erythemal dose (SED) increase in the participants’ daily total UVR exposure was associated with reported sunburn (an odds ratio (OR) of 1.26 with a 95% CI of 1.13 and 1.41, and p < 0.001 for parents and an OR of 1.28 with a 95% CI of 1.12 and 1.47, and p < 0.001 for children). A one-SED increase in the participants’ UVR exposure from 10 am to 4 pm was also associated with reported sunburn (an OR of 1.31 with a 95% CI of 1.15 and 1.49, and p < 0.001 for parents and an OR of 1.33 with a 95% CI of 1.12 and 1.59, and p = 0.001 for children). We found that elevated UVR exposure recordings measured by the UVR sensor were associated with reported sunburn occurrence. Future directions for wearable UVR sensors may include their use as an intervention tool to support in-the-moment sunburn prevention.

One in five US adults will be diagnosed with skin cancer. As most skin cancers are attributable to sun exposure, this risk factor is an important target for research and intervention. Most sun exposure measures assess frequency of specific sun-protection behaviors, which does not account for the use of multiple, potentially overlapping sun-protection methods. In contrast, the Daily Minutes of Unprotected Sun Exposure (MUSE) Inventory assesses sun-protection behavior during self-reported activities, providing several useful metrics, including duration of unprotected sun exposure on 17 body sites, combined to yield an overall MUSE score weighted by percent of body exposed. The present study was conducted July-September 2017, in Chicago, IL USA. For 10 days, participants (39 melanoma survivors; M_age = 58.59, 64.5% female) wore an ultraviolet radiation (UVR) sensor and completed the Daily MUSE Inventory each evening. The Sun Habits Survey was completed at the end of the study. Outdoor time reported in the MUSE Inventory significantly predicted outdoor time recorded by UVR sensors, B = 0.53, p < .001. For all sun-protection behaviors except shade, reports from the Daily MUSE Inventory (i.e., percentage of outdoor time a particular strategy was used) correlated with frequency ratings of the same strategy from the Sun Habits Survey (rs = 0.66-0.75, p < .05). In sum, the Daily MUSE Inventory corresponds with sensor and survey data, and provides a novel metric of unprotected sun exposure that will be useful for evaluating overall extent of sun exposure, including exposure on several smaller body sites that are at high risk for skin cancer.