N = 116), when using strengths profiling at the start and end of a 10-week, strengths-based intervention. Mixed-method data was obtained from the strengths profiles, questionnaires measuring resilience, self-worth, and well-being, and diary entries. Findings revealed a rich array of character strength terminology and individual meanings. Participants found strengths profiling to be highly engaging, particularly due to their active role in strength identification, which prompted interesting and meaningful reflections on character strengths that were pertinent to them. Participants felt their signature strengths were vital protective factors within their lives and strengths profiles were correlated with resilience, self-worth, and well-being. Character strengths and resilience were also significantly and meaningfully improved pre/post-intervention, providing support for the use of strengths profiling as a tool for monitoring change in character strength perceptions. Overall, this study demonstrates the utility and versatility of strengths profiling as a new method in the discipline of positive psychology and strengths-based research and applied practice.Individuals, particularly those considered “hard-to-reach,” often engage well with assessment tools that involve active dialogue and the co-construction of knowledge. Strengths profiling is one such tool that enables a person-centered and autonomy supportive approach to the identification of character strengths. Strength profiling is an adaptation of performance profiling used in sport psychology, which has not yet been utilized in broader psychological research or clinical practice. Supporting an individual by raising awareness of their personal character strengths is an effective and growing mechanism for promoting psychological well-being. Strengths profiling involves several stages of exploring, defining, and assessing character strengths, leading to the identification of signature strengths and goals for future development. Informed by personal construct theory, the present study explored the experiences of homeless young people living in sheltered accommodation ( A strengths-based approach involves identifying areas of life in which a person succeeds, and the positive characteristics they demonstrate in doing so . This foStrengths-based interventions may be of particular importance in homeless young people, who generally report having fewer character strengths and instead perceive themselves as “a list of problems” in need of “fixing” . In feelMost character strength interventions begin by administering a tool that helps individuals to identify their “signature” character strengths, before these signature strengths are applied and further developed in a variety of behavioral experiments . Common These standardized frameworks and instruments have many benefits as they enable researchers and practitioners to categorize an individual’s strengths into a universal framework. This categorization helps to make sense of a person’s positive attributes in a common language, administer tools to large groups, and easily compare between groups . In thisWhilst nomothetic instruments such as the VIA-IS contribute greatly to the positive psychology movement, there are certain situations where administering a nomothetic survey is problematic. These situations include “hard-to-reach” populations, such as homeless young people, who are typically more effectively engaged through active dialogue and co-construction of knowledge, rather than a more prescriptive and often solo “pen and paper” survey e.g., . Even whAn alternative, or supplement, to the more standardized, nomothetic survey instruments is the ideographic approach, which seeks to understand the unique way an individual interprets reality . IdeograAside from qualitative interviews, ideographic tools such as repertory grids and Q-sort rarely feature in published research in youth development and applied practice , their ideal level, and their current level . A discrepancy score is then calculated for each characteristic by subtracting the current level from the ideal, and multiplying by importance ; whether discrepancy scores calculated through strengths profiling are related to brief nomothetic measures of resilience, well-being, and self-worth; and whether strengths profiling detects change following a youth development intervention. These questions were addressed using an integrated mixed-method approach.M = 19.90 years; SD = 2.28), 56.9% were female, 41.4% male, and 1.7% transgender. The majority described their ethnicity as White (60.7%), followed by multiple ethnic groups (18.8%), Black (15.2%), and Asian (4.5%). The majority were born in the United Kingdom (87.6%) and spoke English as their first language (95.6%). Those born outside the United Kingdom had lived in the United Kingdom for an average of 10 years (SD = 6 months). Participants had either been homeless or at risk of homelessness, and as a result, had been living in supported accommodation for between a few days and 3.5 years intermittently . In response to their employment status, 39.6% described themselves as unemployed, 22.5% in full time education, 9.9% in paid employment, 8.1% on an apprenticeship scheme, and 16.2% as being unable to work. A number of participants (17.3%) also disclosed having a learning disability.Of the 118 young people who participated in the study, ages ranged from 16–24 years , especially if they were not engaged in education, employment, or training (NEET). MST4LifeTM is delivered in groups of between 6 and 12 young people and is facilitated by a multidisciplinary team, including academics , support workers and peer mentors at St Basils, and a consultant Clinical Psychologist.Participants of the present study were living in supported accommodation provided by the United Kingdom Midlands-based youth homeless charity, St BasilsTM involves 10 weekly sessions of community-based, experiential learning. During this time, the group meets weekly for between 2 and 4 h for activities designed to introduce and develop mental techniques, skills, and qualities . These activities, such as organizing a charity cake sale, are designed to provide opportunities for the self-discovery of strengths, which is prompted through guided reflections led by the mental skills facilitator  as a way of maximizing their ability to be heard within program evaluations.Phase 1 of MST4LifeTM and was completed in seven stages during a single 60–90 min group session. Step 1 involved a group discussion about the personal qualities and characteristics that are important in life. Following a strengths-based approach, the facilitator typically asked the group to think about their own experiences and the positive characteristics that help them to thrive or cope with life’s challenges. During this process, the facilitator would probe for additional meaning and sometimes challenge assumptions to encourage deeper and broader reflections. At times, additional meaning would also be generated through reflecting on the polar opposites of characteristics , which together is known as a “construct” in personal construct theory , what, realistically, would be a satisfactory level for them to reach in relation to this characteristic , and where they were currently . In step 6, a discrepancy score was calculated for each characteristic by subtracting the current level from the ideal level and multiplying by importance  Therapy SFBT;  and streResilience was measured using the 10-item Connor-Davidson Resilience Scale CD-RISC; . FollowiThe 13-item Self Description Questionnaire III  was usedThe EPOCH Measure of Adolescent Well-being  was usedN = 118) were a subsample recruited from 307 young people who had engaged with MST4LifeTM over a 2-year period between April 2015 and April 2017. As MST4LifeTM for the most part was an open group, not all young people attended every session. This subsample of 118 therefore comprised only those who attended the baseline strengths profiling session at the start of their program and had opted to complete a short baseline questionnaire the week before .The participants in the present study (n = 35) were invited, using purposive sampling, to complete a semi-structured diary room entry about their character strengths and how they felt about the strengths profiling activity. The video diary room approach introduced by Within this subsample of 118 participants, 30%  attended the session and were provided with their list of characteristics from their initial strengths profile and invited to re-score themselves. During this session, participants also completed a short post-program questionnaire again measuring their resilience, self-worth, and well-being.In Week 10, at the end of Phase 1 of MST4Lifen = 4; SC, MQ, MH, and BP) ran the sessions either on their own or as a group, which resulted in a total of 78 journal entries.In summary, 118 young people attended the relevant baseline questionnaire and strengths profiling sessions to be included as participants. Of this sample, 30% completed a diary entry after strengths profiling, and 39% completed a post-intervention strengths profile and questionnaire. Facilitator reflective diaries were also collected from each of the 32 separate strengths profiling sessions that were facilitated during the course of the study. Facilitators .Data was manually entered into SPSS (Version 22.0) before being cleaned, screened, and checked for outliers and normality . MissingDiary room entries were on average 450 words in length  and facilitator reflective notes were on average 230 words in length . Data from both sources were analyzed in one single thematic analysis, following an iterative process of data familiarization, coding of raw data, and the inductive sorting of codes into themes . ContinuTo explore whether the character strengths identified through strengths profiling could be transformed into the VIA framework , each cht-tests and Chi-Square tests revealed no significant or meaningful differences at baseline between those who attended only the baseline strengths profiling session (n = 69) and those who also attended the end-of-program session where strengths profiling was completed a second time (n = 49) .Independent samples Correlational analyses were used as an indicator of whether the component scores of strengths profiling  were reflective of distinct constructs. This analysis did indeed indicate distinct constructs with correlations between importance, ideal, and current levels ranging from non-significant to moderately sized positive correlations . ImportaParticipants discussed experiencing positive affect as well as instrumental benefits during strengths profiling, for example, “I like how we can all just have a bit of a laugh, but at the same time have a good think about how I’ve been with my feelings and that and trying to get them under control.” There were also reports of participants losing track of time and engaging in rich and passionate conversations about their character strengths. One facilitator explained, “there were a lot of good insights from the young people. I also noticed that they were all asking lots of questions throughout the session and they genuinely seemed really engaged with the activity.” This engagement was aided by finding a balance between the written work and group discussion, for example, “I thought it would just be like, sitting in a room all day and just filling out paper work and that, but it’s not… So that’s good” (young person).The degree of autonomy experienced by participants was another key factor in supporting their engagement in strengths profiling. Young people attended voluntarily, with various motivations for being there, from simply “passing the time because there was nothing else to do” to developing confidence for a job interview . The facilitators did not dictate the goals of strengths profiling and instead encouraged young people to set their own goals and direct the activity toward meaningful areas of their lives. For example, one facilitator talks of their experience with a group of young mothers, “When brainstorming the strengths, the young people came up with much more suggestions when we started thinking about what strengths are needed to look after their babies and young children.” Facilitators also gave “options for the strengths profiles  to give them choice in how they want to engage in the activity” (facilitator). The discussions around character strengths also came about organically, with another facilitator explaining how “often a discussion broke out about mental skills or sometimes on subjects completely unrelated, which we encouraged.” Young people were given the space to gauge their own involvement, where “some worked more quietly than others, which I don’t think was them not being engaged, just them taking a lot of time to think about it” (facilitator).Young people welcomed the opportunity to reflect on, set goals, and develop their vocabulary around their character strengths. Participants regularly voiced how the structured reflection surrounding their character strengths that was led by the facilitators was not something they typically engaged in prior to the program, for example, “You evaluate the skills you use, the skills you’re good at and the skills you’re not good at. And then you look at how you can work on these. So I think it’s good because it’s not something you necessarily always think about.” Several young people also voiced their satisfaction with the strengths-based approach to reflection, and how it helped them to look toward a brighter future, for example, “I’ve been knocked down and stuff and drawing a line under it and moving on and getting into things that I need to get myself into. So, I’m quite happy, it keeps me in my mind happy.” A facilitator later noted that a support worker had commented “that for some of them [young people] it was the first time that he had heard them talking about their aspirations.” In addition, young people left the session feeling inspired to incorporate new ways of reflecting, for example, “2 days later now, when I’m on my own, I’ll have a good think about what I’ve done today. It does make me feel a bit more happier in myself.”A theme discussed by almost every participant was how important and accurate they felt their strengths profiles were, usually surpassing their prior expectations. Young people felt their top character strengths  were indeed ones they used on a daily basis and were key to current and future success. For example, “getting my point across. I think that’s pretty good for different parts of life because like, you gotta get your point across, no matter what it is, in everyday conversation, in debates, with life, staff here, or anything.” Young people also felt those who knew them best would agree with their profiles; for example, “being courageous, I mean, ask anybody which knows me well enough. [I] basically get a little bit nitty gritty, do the things that other people might shy away from.”Often, it was only when hearing a young person describe their character strength that it became clear what that characteristic was referring to. Young people would often use broad terms in reference to very specific characteristics; for example, one young person included problem-solving as one of their top strengths, which to them referred specifically to their financial situation, “going to the shop working out your money or your income, your rents, your bus fares here there and everywhere, and like what you’re gonna be doing working.” At times, a characteristic meant very different things to different young people; for example, one young person defined confidence as being comfortable in “what you’re wearing,” whereas another used confidence in reference to speaking “to a lot of different people every day.”Participants discussed a number of ways that being in a group supported their process of strengths identification. Most commented on having enjoyed the interactions with their peers, and for others, attending the group felt challenging but was seen as a way of improving their social anxiety . Young people also reported it useful to “learn a little bit more about other peoples’ mental strengths and skills and how they cope with things” (young person), which supported them in identifying their own character strengths. A shared understanding between young people often meant they “chipped in with noting each other’s strengths, which was nice” (facilitator). At times, being aware of each other’s strengths also helped to build connections, particularly when a young person expressed a quality that others felt in need of; for example, “being caring. I apply that to my life by just being there for people, even if they’re not there for me, you know, I’m always door open, heart-warming.” Often, the young people attributed their comfort with the social environment and ease in which they were able to discuss their character strengths to the positive rapport they had built with the facilitators, who were described as able to “get through to the [young people] which not many people can do” (young person).The majority of young people did not have the support systems typical of those their age, and compounding this issue was the complex needs and mental health difficulties many were grappling with on a daily basis. It was apparent that, for most young people, it was their perceptions of signature character strengths that served as their main, and sometimes only, source of security. For example, one young person talked about how optimism was their signature strength, “If you don’t have optimism, if you don’t have hope for a better day each day, you’re just gonna feel depressed.” Other young people described how having perspective enabled them to keep going, “I use this when I’m recovering from daily stresses and I will tell myself that I’ve made it through worse.” or how their positive attitude enabled them to “bounce back from things, even when I’ve been through some difficult things I’m always smiling, trying to make the better situation out of what it is.”The quantitative data was in line with the qualitative themes in that young people scored their characteristics highly in importance and ideal level, which remained high post-course . In suppn = 41 to 47) and resulted in no significant correlations with pre- to post-program changes in resilience, self-worth, and well-being, although the correlation with the change in self-worth was of a small effect size . In addition, a significant, positive correlation was found between the change in discrepancy score and the duration of time the participant had been staying in the sheltered accommodation .From pre- to post-program, the only significant and meaningful changes in the strengths profile scores were those for current level and discrepancy score . This chSD = 3.23) within their strengths profile. Based on the meanings provided by participants, 217 different character strengths were identified across the sample, each with multiple terms used to describe it. The vast majority (98%) of the 217 character strengths identified were deductively categorized into the 24 VIA subcategories. Only four terms  could not be categorized due to ambiguous wording and inadequate description obtained to explain what the terms referred too. This process revealed an average of 7.03 VIA character strengths per profile (SD = 1.82), meaning that participants often included more than one term within their strengths profile to describe the same VIA group of character strengths .Each participant listed an average of 10.27 characteristics . This finding may be expected given that the characteristics were closely related to their day-to-day sense of safety and were self-selected from a large pool. In contrast to importance and ideal level, scores for current level showed greater variance between characteristics, participants, and time points, and therefore had a much stronger correlation with discrepancy scores. This may raise the question as to whether the scores for importance and ideal level were therefore redundant. Statistically, this argument is somewhat supported in the data; however, at an individual, qualitative level, scores for importance and ideal level provided valuable information for young people and the facilitators, such as to get to know each other better, build rapport, and tailor the intervention. For example, individuals often had multiple characteristics with the same current score, in which case, even slight differences in scores for importance and/or ideal level  resulted in different discrepancy scores and facilitated goal setting. Further to this, in other populations, where strengths profiling may be directed toward other areas of life , the variance in scores for importance and ideal level may be greater. It was for these reasons that a score for importance was first added to performance profiling used in sports settings .In line with prior research, a more positive perception of character strengths , was negatively related to feelings of resilience, self-worth, and well-being e.g., . In addiIn support of the VIA framework , the vaspost hoc), it is unlikely this connection would have been made by the participant. For example, one participant used the label “organic” to describe themselves as being authentic and having integrity, yet, although their description was matched very closely to the VIA character strength “honesty,” the young person rejected this alternative term during discussions. The term organic, in this case, had a unique meaning for the participant.As predicted by Kelly’s personal construct theory PCT; , particiTM to use and further develop these strengths. In future practice, it may be useful to incorporate the VIA framework into this guided reflection phase of strengths profiling to maximize on the characteristics considered.In addition to these unique labels and meanings, and in line with the individuality corollary of PCT , the preWith regards to the frequency each of the 24 VIA character strength groups featured in participants’ strengths profiles , the finTM), the study nevertheless provides support for this broader intervention. Significant and meaningful improvements were observed in character strength discrepancy scores and perceptions of resilience, self-worth, and well-being. Previous interventions have similarly demonstrated an ability to improve perceptions of character strengths in other populations  . Previoupost hoc and with a high degree of accuracy, into the nomothetic VIA framework. In doing so, this broadens the scope of strengths profiling by enabling standardized comparisons across individuals and groups, thus addressing the statistical generalizability limitations of ideographic approaches (post hoc research purposes should nomothetic questions be required, rather than as a way of trying to change an individual’s personal constructs during an intervention into the language of the VIA, as such an approach would go against the aforementioned benefits of an ideographic and person centered approach.Whilst ideographic approaches may prove more beneficial in understanding and developing personal constructs during character strength interventions, nomothetic approaches are often necessary in achieving statistically generalizable research . Indeed,proaches . StrengtAnother area for consideration in future research is the social environment in which character strengths are identified. In the present study, and in line with the sociality corollary of PCT , young pOverall, the present study demonstrates the utility of strengths profiling in a population of homeless young people. This person-centered approach enabled voices to be heard that may not have come forward in other more conventional research approaches . These hThis study was carried out in accordance with the recommendations of the British Psychology Society Code of Human Research Ethics with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the University of Birmingham Ethics Committee.SC and JC conceived the study idea and designed the research. SC, MQ, and BJ collected and processed the data. SC analyzed the quantitative and qualitative data, and wrote the first draft of the manuscript. JC, MH, MQ, and BJ contributed to the interpretation of the data. All authors contributed to the manuscript revision, and read and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Digital health has become an advancing phenomenon in the health care systems of modern societies. Over the past two decades, various digital health options, technologies, and innovations have been introduced; many of them are still being investigated and evaluated by researchers all around the globe. However, the actual trends and visibility of peer-reviewed publications using “digital health” as a keyword to reflect the topic, published by major relevant journals, still remain to be quantified.This study aimed to conduct a bibliographic-bibliometric analysis on articles published in JMIR Publications journals that used “digital health” as a keyword. We evaluated the trends, topics, and citations of these research publications to identify the important share and contribution of JMIR Publications journals in publishing articles on digital health.All JMIR Publications journals were searched to find articles in English, published between January 2000 and August 2019, in which the authors focused on, utilized, or discussed digital health in their study and used “digital health” as a keyword. In addition, a bibliographic-bibliometric analysis was conducted using the freely available Profiles Research Networking Software by the Harvard Clinical and Translational Science Center.Journal of Medical Internet Research. The most frequently used keyword for the topic was “mHealth.” The average number of times an article had been cited, including self-citations, was above 2.8.Out of 1797 articles having “digital health” as a keyword, published mostly between 2016 and 2019, 277 articles (32.3%) were published by JMIR Publications journals, mainly in the The reflection of “digital health” as a keyword in JMIR Publications journals has increased noticeably over the past few years. To maintain this momentum, more regular bibliographic and bibliometric analyses will be needed. This would encourage authors to consider publishing their articles in relevant, high-visibility journals and help these journals expand their supportive publication policies and become more inclusive of digital health. Digital health has become an advancing phenomenon in the health care systems of modern societies . As a keGlobally, many academics and researchers are increasingly being involved in doing research on, utilizing, evaluating, or taking advantage of the benefits of digital health and its various related technologies for their studies on individuals, populations, or health organizations. This increasing involvement has reflected itself in the utilization of “digital health” as a keyword in published peer-reviewed literature. More specifically, in the past two decades, a growing number and diversity of research projects, study protocols, publications, and dedicated journals have played important roles in the digital health domain . In addiOver the past two decades, various digital health options, technologies, and innovations have been introduced; many of them are still being investigated and evaluated by researchers all around the globe . These rThis study aimed to take a more methodical approach to answering this question, by conducting a bibliographic-bibliometric analysis on the publications focused on using “digital health” as a keyword. We evaluated the trends, topics, and citations of research publications in different journals, with the hope to identify, and ultimately help to increase, the share and contribution of major relevant journals in publishing articles on digital health. Thereafter, for the purpose of providing an unbiased comparison among different journals on the trends and visibility of their publications, we conducted detailed subgroup analyses, individualized to specialized journals or journal publishers. This paper summarizes the specific outcomes of our analyses on articles published by JMIR Publications. The main reasons behind focusing on JMIR Publications in this study are the following: (1) JMIR Publications has been an active publisher in the digital health space since 1999, which overlaps entirely with the intended time frame of our study; (2) it has a collection of correlated journals, which covers diverse aspects of digital health research; and (3) it publishes open-access articles, which gives the authors more chances of visibility and knowledge translation and the readers more chances of verifying the results of all analyses.On the basis of expert opinions, “digital health” is considered a relatively new term in research publications, as its appearance as a keyword seems to have increased fairly recently in peer-reviewed articles. Before this trend becomes commonplace, keywords such as “Internet research,” “cybermedicine,” “eHealth,” or “mHealth” have been (and are still being) used by authors and editorial boards of various scientific journals, including journals by JMIR Publications.To address this recency in the adoption of “digital health” as a more common term, we followed a staged, multistep literature search strategy, implemented separately for each journal or journal group or publisher, to ensure that using “digital health” as an identifying keyword does not harm the inclusiveness of numerous options, technologies, and innovations in this space. An effort was made to find the sensitivity of using “digital health” as a keyword in identifying articles that could have otherwise been classified differently under internet search, cybermedicine, mHealth, or similar keywords had “digital health” not been assigned as a keyword by the authors or the databases.The time frame of search was January 2000 to August 2019.Owing to its open-access nature, we decided to use PubMed database to identify general and specialized journals and find articles published in English language, in which the focus was on using “digital health” as a keyword.The initial, implicit assumption was that if “digital health” has been mentioned by the authors as a keyword in an article or assigned by the database organizer, for example, as Medical Subject Heading (MeSH)–assigned keyword, the topic of the article will be related to digital health. However, as mentioned above, to reduce the bias in finding relevant articles because of the recency of “digital health” being used as a term, we followed a staged search strategy, which is summarized below.This stage involved finding all articles with “digital health” in their metadata: (1) Searching with only the keyword “digital health” in All Fields to identify all articles in PubMed, which could have the term in their metadata and (2) importing the results to a library in a bibliographic management software.This stage involved identifying keywords/topics/subjects relevant to digital health: (1) Performing a subject bibliography analysis by extracting all author-assigned plus MeSH-assigned keywords, sorted according to their decreasing frequencies of appearance and (2) identifying and refining keywords/topics/subjects relevant to the definition of “digital health,” as provided by Murray et al  and lateThis stage involved finding all articles that had used any of the keywords identified in the previous stage: Searching PubMed, using OR between all the keywords from This stage involved finding all articles published by JMIR Publications: Searching with only the keyword “JMIR” in All Fields to identify all articles in PubMed, which were published by JMIR Publications.This stage involved combining stage 3 AND stage 4: Searching PubMed, using OR between all the keywords from This stage involved comparing the results of stage 5 and stage 4: Determining the difference between the number of articles retrieved in stage 4 and stage 5 to check the inclusiveness of our terms list., which have the word “digital health” assigned to any of their metadata; (2) importing the results to the same library in the bibliographic management software; and (3) basing the bibliographic-bibliometric analysis on this last group of articles.This stage involved combining stage 1 and stage 4: (1) After ensuring the sensitivity of our search strategy, on the basis of the outcome of stage 6, we searched with the keyword “digital health” in All Fields AND the keyword “JMIR” in All Fields to identify all articles by JMIR Publications.A flowchart summarizing the outputs of this staged literature search is available in Multimedia Appendix 2For bibliographic management and analysis of the references, we used EndNote X8 (Thompson Reuters Inc) software, mainly its “Subject Bibliography” functionality.For bibliometric analysis to quantify the trends and visibility of published articles using “digital health” as a keyword, we used one of the free, publicly available Web-based solutions, that is, the Profiles Research Networking (PRN) Software by the Harvard Clinical and Translational Science Center . The detOverall, with August 31, 2019 as the last publication date, we found 1797 articles indexed in PubMed, with “digital health” being assigned as one of the keywords in their metadata.Exporting the keywords from 1797 articles provided a list of 5138 author-assigned and MeSH-assigned keywords, out of which 312 keywords were directly relevant to “digital health” options, technologies, and innovations ., JMIR Publications had 7556 articles indexed in PubMed, mainly in the Journal of Medical Internet Research and its sister journals. Using OR between the 312 relevant keywords AND JMIR, we were able to identify 7468 (98.8%) of articles by JMIR Publications, an indicator of the high sensitivity of “digital health” as a keyword in an article to represent a diverse range of technologies discussed in their corresponding articles.In the same time frameOut of the 1797 articles, 277 articles had both characteristics of (1) being published by JMIR Publications and (2) having “digital health” as an assigned keyword. The rest of the bibliographic-bibliometric analysis was performed on these 277 articles.Journal of Medical Internet Research , JMIR mHealth and uHealth , and JMIR Research Protocols .Using EndNote’s Subject Bibliography, a total of 1101 MeSH- and author-assigned keywords were extracted for assessing the topics of articles. All articles were classified under “medical informatics” as the most frequent field/discipline of focus.Both trends and visibility of research publications containing “digital health” in their keywords and published by JMIR Publications journals increased dramatically, especially over the past 2 to 3 years, with more than two-third of the articles being published in 2018 and 2019. This important finding shows how “digital health” is becoming a mainstream theme and an established terminology in peer-reviewed publications.Journal of Medical Internet Research had the highest number of articles and longest duration of publication in this time frame, among all the journals of JMIR Publications. This reflects the overall aim and willingness of the editorial board to lead in peer review, and ultimately in the publication, of the manuscripts that are focused on digital health to disseminate their ideas and research results. It may also reflect improvement in the methodologies of the published articles [The articles , which mInterestingly, “mHealth” and “mobile health” as specific keywords, appeared in 96 out of 277 articles (34.6%), followed by “Telemedicine” and “Internet,” both appearing in 57 (20.5%) and 42 (15.2%) articles, respectively. In addition, there appeared to be cumulatively repetitive or redundant keywords, either author-assigned or MeSH keywords , all appearing with different frequencies in collective articles. We decided to present these keywords as raw as possible in The dramatic increase in the cumulative number of citations over the study years is a helpful indicator of the overall interest in referring to the articles pertaining to the keyword “digital health.” Moreover, an H-index of 12, plus an average number of citations of all articles being >1.6 times more than the expected number of citations, highlights the increasing interest in referring to articles on digital health.Journal of Medical Internet Research as ranking first in the category “Medical Informatics” in Journal Citations Report, highlights the suitability of this study to be presented to the audiences of the journal.Expectedly, “medical informatics” was found to be the most frequent field/discipline of focus in research publications having “digital health” as a keyword. This finding, in addition to considering the Journal of Medical Internet Research and JMIR Research Protocols had the highest ratio of average number of citations (no self-citations) to expected number, matched on journal, year, and publication type (PT). This highlights the higher visibility of research publications in the abovementioned journals.The We followed the hints provided by the PRN Software team  to increThe PRN Software compares the average number of authors per article and the average number of times the articles have been cited with an expected value, which is “the averages of all articles in PubMed, matched on journal and year of publication” . To contIn addition, if self-citations are included in the analysis subsections, they are explicitly being noted.To determine the field/discipline of a specific journal, the NLM assigns Broad Journal Heading values to the journal, which are MeSH terms, summarizing the overall subjects of that journal. Similar to PT, a journal can be assigned to multiple Broad Journal Headings; consequently, a single publication of that journal might be listed more than once in the output tables about filed/discipline, causing the Num Pubs field to add up to more than the total number of publications. This was not the case in our analysis as all the journals by JMIR Publications were classified under Medical Informatics by the NLM.Our study focused on English language–based journals that were indexed in PubMed as a freely available database and published by JMIR Publications. PubMed is not essentially a citation-tracking database. However, solutions such as the bibliometric solution that we used in our methodology, that is, the PRN Software by the Harvard Clinical and Translational Science Center, have been developed, which provide bibliometric outputs on PubMed-indexed articles. Other citation-based databases, specifically subscription-based bibliometric databases, such as Scopus and Web of Science, could be included in future research projects to expand the scope of this analysis.Another main reason behind focusing only on PubMed, apart from being freely available to the public, was that PRN Software only accepts PubMed IDs for citation analysis. This held us back from using other bibliographic databases as they could not have any PubMed ID for non-PubMed-indexed journals.In addition, the citation metrics by PRN Software were coming from one publicly available free data source and were limited to commonly used parameters. For the provision of a comprehensive bibliometric outlook on publications by JMIR Publications having the keyword “digital health,” other citation databases and metrics could also be utilized in future studies.The reflection of “digital health” in JMIR Publications journals has been on the rise over the past few years. More comprehensive and comparative bibliographic and bibliometric analyses, with broader ranges of keywords to include eHealth, mHealth, and similar concepts, would be needed to visualize whether “digital health” continues to remain a rising keyword in the future or not.


The goal of adaptation is to maintain the effectiveness of the original intervention by preserving the core elements that account for its success while delivering an intervention that is tailored to the new community and/or cultural context.The current study describes the process of adapting an evidence-based smoke-free homes (SFH) intervention for use in American Indian/Alaska Native (AI/AN) households.We followed a systematic adaptation process. We first assessed the community through focus groups coordinated in collaboration with tribal partners. Because our team included the original developers of the intervention, the steps of understanding the intervention, selecting the intervention and consulting with experts were simplified. Additional steps included consulting with stakeholders through a national work group and collaboratively deciding what needed adaptation.A number of key themes pertinent to the adaptation of the SFH intervention were identified in the focus groups. These included the gravity of messaging about commercial tobacco use; respect, familialism, and intergenerationalism; imagery, including significant symbolism, colors, and representative role models; whether and how to address traditional tobacco; and, barriers to a SFH not adequately addressed in the original materials.surface structure changes such as appearance of role models and deep structure changes that addressed core values, and beliefs and traditions.Adaptation of an intervention to create smoke-free homes in AI/AN families necessitated both The online version of this article (10.1186/s12889-019-7301-4) contains supplementary material, which is available to authorized users. This study illustrates a participatory process for adapting a research-tested intervention with tribal partners. High quality adaptation processes conducted collaboratively with tribal partners are relatively rare.The process aligns with common adaptation steps identified in a recent scoping review on adaptation of evidence-based interventions.Given traditional uses of tobacco in American Indian communities, both surface and deep structure changes were required in this cultural adaptation of a research-tested intervention.surface structure changes, or changes such as “ethnicity or appearance of role models” in the intervention, and deep structure changes, or “changes addressing the core values, beliefs, norms, and other more significant aspects of the cultural group’s world views and lifestyles”  as traditional, it shouldn’t be funny anyways. It should be more serious” (Michigan Nonsmoker (NS). This sentiment was repeated several times. Others found that the theme did not resonate, for example, saying, “I don’t think it’s funny. I don’t think a dog peeing on the couch is funny. It wasn’t funny to me” .Focus group participants felt that messaging surrounding SFHs, commercial tobacco use, and traditional tobacco should not include humor, because of the gravity of the subject itself. The original Smoke-Free Homes materials include a comedic theme including the placement of items, pets, and children in the home who are doing things that disrupt the indoor environment, with the theme “Some Things are Better Outside.” AI/AN participants generally reacted negatively to this, saying, for example, “not asking particular individuals, including elders, to stop smoking in their home. Participants identified respect as a powerful theme for messaging, particularly when combined with the importance of familialism and intergenerationalism. These manifested in sharing and passing on knowledge, respecting elders and the history of communities, and ensuring the health of future generations. As one participant said, “We have stories that we’ve told through generations, and … there’s always a really important message” . Referring to the use of respect, familialism, and intergenerationalism in messaging about the “Respect the Past, Protect our Future” mock-up, another participant said,“I like it because it’s respecting like -- it has like elders up here and it’s saying respect our past, and then of course everybody -- the reason why we all don’t allow smoking in our homes is for the benefit of our children’s health, I think everybody would agree that we want to protect our children, protect our children’s health, and that’s -- I think everybody would agree that we want to protect our children, protect our future, protect our health. ... Because without the children, there’s no future of the tribe.” (Michigan NS).Respect was a cross-cutting theme in discussions regarding tobacco, particularly as a reason participants did not allow smoking in their home, a reason they were hesitant to smoke in the homes of others, or as a justification for Put the trees, put the river out there but -- mountain, something outside ” - and particularly nature that was recognizable to each community receiving the materials: “[You can use] the general [respect theme mailing] that was in the envelopes and then for each region, for each like population that you’re targeting, you can just add a little [regional] thing” .Focus group participants noted in their review of the original and mocked-up SFH intervention materials that they would prefer the use of recognizable imagery, symbolism, and colors, so as to customize the materials better for their communities. This included images of nature- “Additionally, focus group participants recommended the use of the medicine wheel imagery within the materials, both to customize them to AI/AN communities, and to bring forward the emphasis on health. Similarly, use of the colors of the medicine wheel- red, yellow, black, and white- were suggested for integration into the color scheme of the materials.The importance of role models and images of people within the SFH materials that are identifiably AI/AN was emphasized throughout the focus groups, not only for customizing the materials to be applicable to their communities, but also to show children within their community role models they can relate to. One participant expressed the importance of this both to her and her son, saying:“…it’d be nice to have things individually tailored to each area, but if I opened a thing and was just like oh my gosh, this is made for Natives, I mean, I’d just be so blown away, you know, because now my son watches TV and he’ll say there’s an Indian on -- I’ll be like well, that’s really a Mexican, but I’m glad that you’re excited … So I think yeah, it’d be good to have an individual component, but at the same time if you just got something that was like wow, they took the time to make this for a Native, you know, I think that that would kind of be like -- because we’re usually just -- not a race, but – [other].” .A related theme was the recommendation to acknowledge diversity within tribal communities and that some AI/AN families have members with a range of racial and ethnic backgrounds.“There are a lot of campaigns already about keep tobacco sacred, so I think if you add [something about traditional tobacco], I think that would be a start for sure” . Similar comments were heard in other focus groups: “I would say material like this is -- would be pretty accepted in tribal communities. … saying use tobacco in a sacred way or … things like that, like you’ll see it from time to time, but for like on a national level, something like this would be effective, I’d say” (Michigan Smoker).Participant’s opinions varied as to whether or not traditional use of tobacco was pertinent to an intervention to create SFHs; however, most came to the conclusion that while they would not consider smoke created from the use of traditional tobacco to fall under SFH rules, it should still be addressed within the intervention materials. One participant commented, Really, like if it’s raining or if it’s cold, I don’t go outside. I don’t smoke. So typically in the winter I’m not a smoker unless I’m at the casino. So yeah, so if I smoke at home, I’m on my porch or my sister’s porch, yeah” (Oklahoma Smoker). Alternatively, another participant described how this prevented them from establishing a SFH home, saying,“Well, if we’re sitting there in the middle of winter and we have people over, I’m like listen, if you want to go away from us from smoking, because they will, that is the norm. You don’t go outside. Just go in the living room or in the kitchen, and then my house is very large, and by now we just already know the problem.” (Michigan NS).Finally, participants in the focus groups brought up a previously unaddressed barrier to SFH creation- the difficulty of smoking outside in cold weather . A participant described this, saying it reduced their tobacco intake: “Following analysis of the focus group data and consultation with the work group, we hired an American Indian graphic designer to make an adapted set of intervention materials. The changes included both surface changes and deep changes, as outlined in Table This paper describes the process of cultural adaptation of an EBI focused on creating smoke-free homes. Alterations made to the SFH intervention are derived from the recommendations made and themes discussed by focus group participants in five diverse AI/AN communities, as well as with consideration for the previous body of literature on cultural adaptations for AI/AN populations. Many of these changes revolved around content, persons, and context as specified in cultural adaptation models . These cThe changes made to the SFH materials span the scope of the intervention. Select changes were made in response to direct commentary by the focus groups regarding the original intervention materials, such as the alteration in messaging to exclude humor, the use of language focusing on respect, and the integration of nature imagery. Other changes, however, reflect broader recommendations for appropriate cultural adaptation of interventions for AI/AN communities.The importance of visual depictions of AI/AN individuals and communities, acknowledging diversity within and across these communities, and accuracy and contemporaneity of these depictions has been noted repeatedly in literature on interventions in AI/AN populations, and is confirmed once again in this adaptation , 30–33. While there is clear support in the literature for addressing sacred uses of tobacco in intervention materials targeted towards AI/AN communities, –31, 35 tWhile many of these themes are relevant across tribes, we acknowledge the heterogeneity of culture across tribes, including traditional uses of tobacco, prevalence of smoking, language, beliefs, and history. Because it would be cost-prohibitive to create a completely different set of materials for each tribe interested in using the intervention, we have developed a general AI/AN set of materials with pieces that can be tailored to local tribal culture, including the envelopes that depict natural scenes from different regions of the country  and an insert that can be modified to accurately portray traditional uses. The window cling can also be easily adapted for specific tribes, allowing for modifications for personal context or environment . InteresOur approach to adaptation has a few limitations. All of our focus groups were conducted in rural areas, as a result, we did not obtain perspectives from urban AI/AN. This is an important omission given that a significant proportion of the AI/AN population lives in urban areas. A second limitation stemmed from the quality of the materials we presented in the focus groups. While they were sufficient for generating a reaction, after the first couple of focus groups we knew that the reaction would generally be negative. For the “Some Things are Better Outside” theme, it was difficult to know if participants were reacting to the theme itself or the low-quality draft materials. As in all focus groups, the dynamic may have also influenced the group, with more outspoken member leading the group toward or away from a particular reaction. In one community, the focus groups were very large making it difficult to manage the group dynamics and ensure that all voices were heard. Lastly, the moderator was an outsider as a non-Native faculty member from Atlanta. While local partners were present, the outsider status of the moderator may have decreased trust and willingness to share the full range of perspectives on the topics covered.Despite these limitations, and both deep and surface changes to selected materials, we postulate that the intervention should still be effective given the core elements  remain essentially the same as does the underlying theoretical approach , 5–7. FuOur adaptation study has potential to inform both research and practice about how to undertake cultural adaptations when scaling up an EBI for different populations. The remaining steps in the adaption process are to pilot test, implement and evaluate the adapted intervention , 36. IdeAdditional file 1Standards for Reporting Qualitative Research Checklist. (DOCX 21 kb)


Respondents with depression and alcohol problems were more likely to be current vapers both daily  and monthly . Vaping was more likely at monthly level for those with severe obesity , cancer , and concerns about future effects of smoking . Positive associations were also found between chronic pain and concerns about past health effects of smoking and daily vaping. Only having heart disease was, in this case negatively, associated with use of vaping products on their last quit attempt . Self-reported health condition or reduced health associated with smoking is not systematically leading to increased vaping or increased likelihood of using vaping as a quitting strategy.This study examines whether having health conditions or concerns related to smoking is associated with use of vaping products. Data came from the 2016 wave of the International Tobacco Control Four Country Smoking and Vaping Survey. Smokers and recent quitters ( Cigarette smoking harms almost every organ of the human body and causes a broad range of diseases, including cardiovascular disease, respiratory disease, cancers, some mental health issues, and other health problems ,2. HavinHaving smoking-related illnesses such as cancers has been found to be associated with high rates of smoking cessation ,7. PersoPeople with mental health problems  are more likely to smoke, and to smoke more heavily, than the general population ,14,15. TWe hypothesized that those having health conditions or concerns about them related to smoking would be generally more likely to use/keep using NVPs to avoid the adverse effects of smoking and would thus be more likely to use them as a smoking cessation strategy.n = 12,022) consisted of the following respondent groups: (1) Adult smokers and quitters who responded to previous ITC-4C surveys [n = 1490; Canada: n = 3576; England: n = 4220; and the US: n = 2058). The data came from Wave 1 of the International Tobacco Control (ITC) Four Country Smoking and Vaping (4CV) Survey conducted in Australia (AU), Canada (CA), England (EN), and the United States (US) from July to November 2016. The valid core sample ( surveys  and wereRespondents (both current smokers and recent quitters) were asked whether they were currently being treated for, or had been diagnosed (current diagnosis) with health problems of three types that are related to smoking cigarettes: (1) Those that are mental health related ; (2) those where there are strong causal links  and chronic lung disease ); and (3) those with more complex associations . Their answers were coded as “yes, selected” vs. “not selected/don’t know”. In England, respondents were asked about lung cancer and other types of cancer separately; and instead of chronic lung disease, asked about four specific conditions: Asthma, emphysema, chronic bronchitis or tuberculosis. Reporting any (either) was coded as having the general condition. We also conducted supplementary analysis on a composite of having any of the three mental health conditions  and any of the three conditions most commonly caused by smoking . In addition, participants were asked “To what extent, if at all, has smoking cigarettes damaged your heath?”, and (current smokers only) “How worried are you, if at all, that smoking cigarettes will damage your health in the future?” The response options for both were: “not at all”, “just a little”, “a fair amount/moderately”, “a great deal”, and “don’t know”. Responses were recoded into at least moderately vs. all lesser responses and “don’t know”. All respondents were asked whether they had ever used a vaping product, and those ever used were asked whether they currently vaped . Current vapers were then asked whether they planned to continue vaping or to stop using sometime in the foreseeable future (“definitely/probably keep using” vs. “definitely/probably stop using/might or might not keep using/don’t know”). Quit attempts were assessed by asking current smokers who reported ever making quit attempts: “How many times, if any, have you tried to quit in the past 12 months?” (“no attempt” (including never tried) vs. “1 or more attempts”). Those who reported having made at least one quit attempt in the last 12 months were then asked about their use of vaping products (“yes” vs. “no/don’t know”) for their last quit attempt. Demographic measures were sex  and age . Due to the differences in economic development and educational systems across countries, only relative levels of income and education were used. “Low” level of education referred to those who completed high school or less in Canada, the US, and Australia, or secondary/vocational or less in England; “moderate” meant community college/trade/technical school/some university (no degree) in Canada and the US, college/university (no degree) in England, or technical/trade/some university (no degree) in Australia; and “high” referred to those who completed university or postgraduate studies in all countries. Household income was also grouped into “low”   per year), “moderate” ), “high” categories ), and “no information”. Cigarette smoking status was also asked and recoded into current smokers (at least monthly) and recent quitters . p-value < 0.05 was considered statistically significant. All analyses were conducted using Stata Version 14.1. The analysis was weighted, and the stratified sampling design was accounted for. The prevalence/percentages of key measures are reported. To compare self-reported health conditions by demographics and vaping activities, and to examine the associations between health conditions and vaping, for each health condition separately, we employed logistic regression, controlling for covariates which were age, sex, education, income, smoking status, and country. We also tested for interactions by health condition with smoking status, sex, age, and country but only included interaction effects in the models we report when they were significant. In all analyses, a Ethics approval: The survey protocols and all materials, including the survey questionnaires, were cleared for ethics by Institutional Review Board, Medical University of South Carolina (ORE #: 20803); Research Ethics Office, King’s College London, UK (ORE #: 20803 and RESCM-17/18-2240); Office of Research Ethics, University of Waterloo, Canada (ORE #: 20803 and ORE #: 21609); and Human Research Ethics, Cancer Council Victoria, Australia (ORE #: 21609 and HREC 1603).n = 11,344), 3433 respondents were currently vaping (using at least monthly). There were more males than females in the sample. The Australian respondents were least likely to be current vapers, whereas respondents from England were most likely to be so. The majority of the sample were current smokers (smoked at least monthly). Characteristics of the sample are provided in p < 0.05; these results are not reported in the table), compared to females. Respondents from England were more likely to be monthly vapers , whereas Australian respondents were less likely to be so , compared to their Canadian/US counterparts. Current smokers were not more likely to be monthly vapers, compared to recent quitters . In multivariate analyses where all the measures in n = 1425) with all others. We found that current smokers were less likely to be daily vapers , compared to quitters. Overall, those aged 40 and older were more likely to be daily vapers , compared to those under 40. Again, respondents from England were more likely to be daily vapers , whereas Australian respondents were less likely to be so . No gender differences were found in daily vaping .We repeated this analysis this time comparing daily vapers ; and 1425 respondents were current daily vapers. p < 0.001) were more likely to be daily vapers compared to those without obesity; whereas for recent quitters, the differences between those with and without the condition were not significant ; in Canada  and the US , those with severe obesity were more likely to be daily vapers, compared to those without the condition; but the differences were not significant in England  and Australia . By contrast, for chronic pain, vaping was more likely only at daily level , but there were by condition interactions with both sex  and country (p < 0.05) were more likely to be daily vapers compared to those without the condition; whereas for males, the differences between those with and without the condition were not significant .Respondents with depression and alcohol problems were more likely to be current vapers both daily  and monthly . For severe obesity, vaping was more likely at the at least monthly level , but this was not significant for daily where there were by condition interactions with smoking status  and country (see  country . When anp < 0.01) were more likely to be monthly vapers compared to those without the condition; whereas for those aged 40 and over, the differences between those with and without the condition were not significant . For daily vaping, the relationship was not significant, although given the small number of cases with cancer, power is low. Those with concern about future health effects (smokers only) were more likely to be current monthly vapers  but no more likely to be daily. The other significant positive effect was for those concerned that smoking had damaged their health where daily vaping was more likely  in the context of significant by condition interactions with age  and smoking status . When analyzed separately, we found those who were under 40 and with concern  were more likely to be daily vapers compared to those without concern; and recent quitters with concern  were also more likely to be daily vapers compared to those without concern. Those with diabetes  were marginally more likely to be daily vapers when controlling for a condition by age interaction. When analyzed separately, we found that for the group under 40, those with diabetes  were more likely to be daily vapers compared to those without the condition; whereas for the group aged 40 and over, those with diabetes  were less likely to be daily vapers.Those with cancer  were more likely to be current monthly vapers, although there was also an age by condition interaction. When analyzed separately, we found that younger cancer sufferers under 40  and monthly , compared to those without. Having “any” of the three smoking-caused conditions  was not associated with either level of vaping. In the supplementary analyses grouping conditions, those having “any” of the three mental health conditions  were more likely to be current vapers, both daily  said they planned to keep vaping. Current smokers were more likely to plan to keep vaping , compared to ex-smokers; and respondents from England  and the US  were more likely to plan than their counterparts in Canada and Australia; no sex differences were found in planning to keep vaping. The only significant effect found was an age by diabetes interaction effect  were less likely to plan to keep vaping than those without the condition; whereas for the group aged under 40, there was no significant difference . There was no significant association between “any mental health conditions” or “any smoking-caused conditions” and planning to keep vaping.Overall, 58% of current monthly vapers (n = 4339), we examined whether having a health condition was related to use of vaping products (see p < 0.05).Finally, for those current daily smokers who reported having made at least one quit attempt within the last 12 months , and not those from England and Australia. A similar condition by country interaction was found for daily vaping among those suffering from chronic pain. These were the only two condition by country interactions we found, hinting at something specific to conditions where smoking may play a significant self-management role (regardless of its efficacy). That said, it is unclear why this country difference occurs. Given that England and Australia are at opposite poles on the prevalence of vaping and its social acceptability, this difference is hard to interpret in terms of the different regulatory environment. There were also other different interactions for the two conditions. For obesity, the difference in daily use is almost entirely among current smokers, and for chronic pain, it was entirely among females. Again, in neither case were those with the condition more likely to use vaping products to quit.Turning now to the three health conditions where smoking is a major cause , the only significant effect was for any current use for those with cancer, largely because young (under 40) cancer sufferers were much more likely to report some level of vaping, but there was no significant effect for daily use; however, the relatively large odds ratio suggests that this may be a function of low power rather than the necessary absence of any effect. It may be something about getting cancer at a young age that encourages a search for alternatives. There was a significant negative effect on use of vaping for heart disease. One possibility for the negative association with vaping as a cessation aid may be because of concerns about the role of use of nicotine as a cardiovascular stimulant and concerns about the risks of using it, particularly with people with unstable heart disease.Turning now to diabetes, a group of diseases that is exacerbated by smoking. There was marginally more daily vaping in those with diabetes. However, there was a very strong age-related effect for both outcomes with those over 40 being both less likely to be daily vapers and less interested in continuing to vape, whereas for the under 40s, we found the reverse. We have no ready explanation for these findings but, given that diabetes is a chronic disease, it may be related to their long-term relationships with health professionals and/or knowledge that their smoking is likely to be increasing their risk of problems. However, this does not explain why those under 40 are more likely to be engaged with vaping while those over 40 are less likely.Finally, those people who believe that smoking had already damaged their health were overall more likely to be daily vapers, but this only appeared to be the case for ex-smokers and for those under 40. For the related question (only asked to smokers) about concern that smoking may damage their health in future, the majority who expressed concern were more likely to be vaping at least monthly, but not daily, suggesting it may be motivating some experimental use of vaping products, but not high level use, and this is consistent with vaping not being more likely to be used to quit.Given the differences above, it is unwise to draw any general conclusions. We think that the results point to the potential utility of exploring in more detail how the availability of vaping might be influencing smokers with mental health problems, people with diabetes, and more generally those who were concerned about the health damage their smoking has done or might be doing. The main weakness of this study is that it is reliant on self-report for the conditions and we have little information about the management of the diseases and the attitudes of their health professionals to vaping. Where issues identified here are of concern, or interest, they may need to be pursued with clinical samples. There were also differences in how NVP users were sampled in the continuing part of the sample compared to the replenished part, and although we tried to control for this with weighting, we cannot be sure the ex-smokers are fully representative as a function of vaping status. This precludes drawing any conclusions about differential effects on quit success. The main strength of the study is the broad focus across conditions and the comparisons we were able to make. There can be gaps between what respondents identify as having and what they have, which can be affected by the level of education about their conditions, the terminology used (and how it related to the terms used in our questions), and a range of other factors. These concerns are less of an issue in relating conditions that people self-report in relation to their smoking as where links exist, smokers with such conditions or at heightened risk of developing them should know about the additional risks they are subjecting themselves to.In conclusion, having a health condition or reduced health associated with smoking is not systematically leading to increased vaping or increased likelihood of using vaping as a quitting strategy. Among those with some conditions, younger sufferers were more likely to be vaping, but not always regularly.


Online reviews can make or break a mobile app. Various studies have shown that reviews, especially when their valence is primarily positive, can contribute to the survival of a particular app in a stiffly competitive market. Hence, it is in the best interest of app developers to gain insights into the motivations of app users to review apps they have used. To address the question on the factors influencing people’s intention to write reviews for apps, an extended version of the Theory of Planned Behavior (with the inclusion of various writing functions as predictors) was tested with data from 203 German mobile app users. Results of structural equation modeling reveal that people’s intention to review certain apps is a function of four factors, namely their attitude towards writing reviews, subjective norm, and review writing’s ego-defensive and emotional expression functions. Furthermore, both review writing’s ego-defensive and emotional expression functions positively influence app users’ attitude towards writing reviews. Online reviews benefit not only consumers but also sellers. For customers devoid of prior experience with a certain product or service, other customers’ narratives about their experience with a product or experience would certainly suffice as a relevant information source. One point that reverberates in the literature on online reviews is the critical role those reviews play in shaping customers’ purchase decisions.Online reviews, specifically when their valence is positive, have been reported to significantly shape customers’ attitude towards the reviewed product  will be primarily employed to gain insight into the predictors of app users’ inclination to review an app for public consumption. Additionally, the centrality of TPB in studies into the factors influencing customers’ intention to review online products , TPB postulates that people’s actual performance of a certain behavior is a function of their intention to perform that behavior, which, subsequently, are predicated on three factors, namely, attitude towards the behavior, subjective norm, and perceived behavioral control Ajzen .“Attitude towards the behavior” refers to a person’s inclination to either favorably or unfavorably appraise the behavior of interest Ajzen , while “The wide applicability of TPB is evidenced by its centrality in various researches into different forms of behavioral intention  attitude towards writing reviews, (b) subjective norm, and (c) perceived behavioral control.Daugherty et al.  claim thIn another empirical study into customers’ engagement in online word-of-mouth communication, which is practically similar to an online review  utilitarian, (b) social, (c) ego-defensive, and (d) emotional expression. The “emotional expression” is an extension of Daugherty et al.’s value-expressive motive and covers Hennig-Thurau et al.’s concern for others motive, as writing reviews predicated on the need to release one’s feelings towards an app may also serve the function of informing potential users of the app’s merits and flaws. From these points, the second set of hypotheses is proposed.Hypothesis 2: Mobile app users’ intention to write reviews for a mobile app is predicated on four functions, namely, (a) utilitarian, (b) social, (c) ego-defensive, and (d) emotional expression.A meta-analysis of various research using TPB reveals that of the three TBP factors hypothesized to influence behavior intention, attitude is a much better predictor of intention than subjective norm and perceived behavioral control  utilitarian, (b) social, (c) ego-defensive, and (d) emotional expression.Figure The hypotheses proposed for this study were tested with data collected from German mobile users through an online survey. To reach the intended respondents for the study, a snowball sampling technique was used, which involved sending an e-mail containing a link to the questionnaire to one of the researchers’ social networks. Recipients of the link were then requested to send it to individuals in their social networks.The survey link was also posted on online social networking (OSN) sites and online forums to collect data from as many respondents as possible. More importantly, prior to the actual collection of survey data, the approval of the ethics committee of the university where the researchers are affiliated was secured.For this study, the focus was only on a group of respondents who have already installed apps into the mobile phones since these are the individuals who are highly likely to write reviews for mobile apps. Based on a recent statistical data on smartphone penetration in Germany, there are 55,492,000 smartphone users in a country with a population of 80,636,000  and female respondents  was almost achieved. Majority of the respondents belonged to the age cluster 18 and 34 , with over half of the total number of survey respondents having a 4-year bachelor’s degree or higher . Furthermore, in terms of mobile app type respondents regularly used, approximately 65% (n = 132) are frequent users of social networking apps. Presented on Table In terms of respondents’ gender, a balance between male respondents  are doing. Hence, subjective norm in this research is operationalized in terms of the appraised trendiness of the reviewing act as an impetus for a person’s disposition to write a review. Three items inspired by statements originally formulated by White et al.  were use“Utilitarian function” was measured with four items that were substantially modified versions of the statements originally formulated by Daugherty et al. . The remFour originally formulated items were used to measure the dependent variable “intention to write a review.” All the items  used for the different research constructs are presented on Table 2 (325) = 2469.87, p = .001] indicated that the correlations among the items were adequate for the performance of PCA.To determine the constructs’ discriminant validity, items measuring both the independent and the dependent variables were subjected to a principal component analysis (PCA). The Kaiser-Meyer Olkin Measure of Sampling Adequacy was pegged at 0.79, higher than the recommended value of 0.60 Kaiser , while BResults of PCA indicate that the construct “social function” has a highly questionable validity, as the items selected to measure it loaded with “ego-defensive function” items. Merging the two sets of items was deemed inappropriate as they were supposed to measure two conceptually different constructs. This led to the decision to exclude social function from the research model, which means that hypotheses 2b and 3b could not be tested.2 (276) = 2247.54, p = .001]. The remaining constructs proved to have strong discriminant validity, as evidenced by the patterns of item loadings and the loading values. Table A second PCA was eventually performed, which resulted in a Kaiser-Meyer Olkin Measure of Sampling Adequacy value of 0.79 and a Bartlett’s Test of Sphericity value of [XSubsequently, structural equation modeling (SEM) technique using AMOS 22.0 was employed to test the model proposed for this research. In testing the research model, the two-step approach recommended by Anderson and Gerbing , in whic2/df), whose value must not exceed 5 for the model to be interpreted as acceptable  and composite reliability (CR) values are good indicators of the constructs’ convergent validity, those values were also calculated. Recommended values for AVE and CR must be higher than 0.50 , social influence , and review writing’s expressive function . However, the hypothesized effects of review writing’s utilitarian  and ego-defensive functions  and perceived behavioral control  are not statistically significant.Regression estimates show that German app users’ intention to write reviews for a specific app is predicated on three factors, namely, a positive attitude towards review writing (p < .001) and expressive function . The hypothesized effect of utilitarian function  on review writing intention, however, is not statistically significant.Additionally, analysis indicates that German app users’ positive attitude towards review writing are anchored on two factors only, namely, ego-defensive function , subjective norm , and the emotional expression function of review writing  remained significant predictors of review writing intention, despite a reduction in the paths’ beta values. Hence, hypotheses 1a, 1b, and 2d are supported, respectively.The modification of the research model did not alter the results for the hypothesis testing segment of the study, as attitude . This result subsequently supports hypothesis 2c.What is worth noting, however, is that the removal of “attitude” and perceived behavioral control as predictors of “intention” resulted in ego-defensive function having a significant effect  and emotional expression  functions as predictors of attitude towards mobile app review writing. Thus, hypotheses 3c and 3d are also supported, respectively.Furthermore, the elimination of utilitarian function as a possible determinant of attitude did not alter the roles of both ego-defensive . However, to effectively stimulate app users to write reviews for certain apps, app developers ought to have insights into what would trigger users to write reviews.Results of this study clearly indicate that app users’ intention to write reviews for mobile apps are predicated on two TPB factors, namely, attitude towards review writing and subjective norm. The fact that only two of three TPB factors play a role in people’s decision to review an app somehow confirms Ajzen’s  assertioGiven the statistically insignificant effect of perceived behavior control on review writing intention, it can be assumed that the intention to perform the behavior of interest is not hinged on serious considerations of time availability and the ease of doing the act. For one, writing an app review is hardly a complex task that requires specialized skills, just as reviewing does not have to be a literary or journalistic endeavor demanding high-level writing aptitude and a sizable chunk of time. Moreover, the platform for review writing is relatively uncomplicated, which reduces the need to consult a voluminous user instruction guide.What is apparent from the results, however, is that mobile users’ disposition to write reviews for certain apps is predicated on two factors, namely, a positive attitude towards the review writing act and an awareness of the extent to which individuals within one’s social environment write reviews. Mobile users will be inclined to review mobile apps when they regard the action as something positive, pleasant, or good. This seems indisputable given the impact of attitude on people’s propensity to perform various forms of behaviors across different contexts and situations.Additionally, the pivotal role of subjective norm or social influence also merits attention considering the rather public component of the action’s consequence. Reviews are supposed to be written for public consumption; thus, the process of review writing has a strong public component making it possible for an individual to assess the intensity and the popularity of the act, as evidenced by the number of other individuals who have written reviews.As previously mentioned, it is unrealistic to suppose that people’s decision to write a review would be based on their estimation of what their strong ties expect them to do, since review writing is not entirely an act whose performance is supposed to conform to societal norms. Unlike socially desirable actions with a strong ethical dimension , review writing somehow lacks a strong moral dimension, unless one succumbs to the notion that reviewing an app is simply a moral thing to do. These points prompted the decision to re-conceptualize subjective norm not as an urge to conform to communal expectations but as an attempt to mimic the behavior of others.A point that resonates from the results is that mobile app users would be predisposed to write reviews when others within their immediate social circles are doing the same. This finding is hardly new, as a recently published study also reported that people’s willingness to create user-generated contents for consumption in the environment  is influenced by users’ awareness that individuals within their social groups also share . The results of this study would probably be different when the focus would be on a very specific type of mobile app, considering that variations in the experience of using a specific type of app might trigger variations in emotional responses, thereby resulting in variations in motivations for writing reviews for apps.Results of this research have several implications for how mobile app designers can convincingly motivate app users to post reviews for certain apps. The pivotal role of attitude as a determinant of writing intention signifies the need for app developers to employ appropriate strategies to boost mobile users’ positive attitude towards review writing.Based on results of this research, app developers can shape users’ attitude towards review writing by emphasizing the emotional expression and the ego-defensive benefits that can be derived from the writing act. One possible concrete action that could be taken is to underscore that reviewing app enables users not only to honestly express their views on the app but also to possibly notify potential users of an app’s merits and shortcomings. Framing the second point as a sort of helping behavior might appeal to the better senses of individuals who feel a strong urge to help others. Furthermore, positioning the review writing act as an ego-enhancing pursuit also has the potential to nudge users to positively view review writing.


However, having an advantaged situation with regard to school, peers, or spare time appeared to protect against the detrimental influences of disadvantaged circumstances in the family context on subsequent health. This suggests that health-promoting interventions may benefit from focusing on contexts outside the family in their effort to strengthen processes of resilience among disadvantaged youths.Disadvantaged circumstances in youth tend to translate into poor health development. However, the fact that this is not always the case has been seen as indicative of differential resilience. The current study highlights factors outside the context of the family with the potential to counteract the long-term negative influences of social and material adversity in adolescence on general health status. This study was based on two waves of questionnaire data from the Northern Swedish Cohort. From the wave in 1981 (age 16), indicators of social and material conditions as well as factors related to school, peers, and spare time were derived. From the wave in 2008 (age 43), information about self-rated health was used. Ordinal logistic regression models ( Childhood is pivotal to life chances, including adult health, and the empirical research linking early experiences of adversity to later health outcomes has proliferated over the past decade ,5,6,7,8.In order to address the above-mentioned gaps in the literature, the current study aims to examine multiple factors related to the school, peers, and spare time and whether these factors may buffer against the possible long-term negative health influences stemming from social and material adversity in youth. The analyses are based on a cohort study of around 1000 boys and girls of 16 years of age who were living in a Northern Swedish town in 1981, and they were followed up until their early 40s, with almost no loss to follow-up.Different models have been proposed to explain how and under what conditions childhood disadvantage may influence adult health. We take our point-of-departure in the theory of cumulative advantage/disadvantage . FocusinThe notion of dandelion children is largely what has guided the inquiry into resilience, from its place within the larger field of developmental psychology, over the past 40 years. Examples of pioneering research into resilience encompass Norman Garmezy’s studies of “atypical” patterns among youth at risk of psychopathology, the seminal work by Emmy Werner on protective factors among infants born in the Hawaiian island of Kauai, and Michael Rutter’s clarification of processes behind resilience in terms of risk effect reduction . While rChildren who grow up in families burdened by disadvantage, e.g., unemployment, poverty, or poor health, are sometimes referred to as an at-risk population or a vulnerable population . GainingIs social and material adversity in youth is associated with poorer self-rated health in midlife?Are protective factors present to a lesser extent among adolescents with experience of adversity?Is the absence of protective factors associated with poorer self-rated health in midlife?Do the protective factors modify the association between social and material adversity in youth and self-rated health in midlife?Against this backdrop, the aim of the current study is to explore factors outside the context of the family with the potential to counteract the long-term negative influences of social and material adversity in adolescence on general health status in midlife. The factors were chosen to broadly reflect advantageous conditions with regard to the school, peers, and spare time, hereafter referred to as “protective factors”. The research questions are as follows:n = 1083) [The data used was the Northern Swedish Cohort, defined as all individuals who attended the last year of compulsory school (age 16) in 1981, in schools located in the municipality of Luleå ( = 1083) . InformaThe measure of “Self-rated health” at T2 was based on the question “How would you assess your general health status?” The response options were “Good”, “Poor”, “Somewhere in between”. For the analysis, it was coded so that higher values indicated poorer health.Derived from the questionnaire at T1, six types of family-related circumstances were used to calculate an index of “Social and material adversity”: parental loss, residential instability, parental illness, poor material standard of living, residential crowding, and parental unemployment. Each of these items were dichotomised so that the value 1 indicated the presence of the adverse condition whereas the value 0 did not. The operationalisation of these items has been described elsewhere ,26. The The study included 11 measures that reflected an advantageous situation with regard to contexts outside that of the family, e.g., the school, peers, and spare time. Cut offs were chosen to identify the 25% of individuals who were best off in terms of each specific indicator. Due to vast differences in the distributions of the categorical variables, however, this goal was not accomplished for all indicators. The first four indicators were derived from the class teacher interviews at T1: “Educational prospects”, “Work prospects”, “Peer popularity”, and “Scholastic ability”. Of these, two were based on the queries “Try to assess the student’s prospects regarding future studies” and “Try to assess the student’s prospects regarding the labour market”. The response option “Very good” was coded as 1, whereas all remaining options (ranging from “Good” to “Very poor”) were coded as 0. Next, “Peer popularity” was derived from a scale ranging from 1 to 6, where the lowest value reflected non-popularity among peers and the highest value represented popularity among peers. The value 6 was recoded as 1, whereas the remaining values were coded as 0. The indicator of “Scholastic ability” was based on the assessment of the student’s general ability to perform at school. The value “Very high” was coded as 1, whereas all remaining options (ranging from “High” to “Very low”) were coded as 0. The fifth indicator was “School marks”, which was derived from register data on average school marks in the ninth grade (age 16). Values above the 75th percentile were coded as 1 and the remaining values as 0. From the questionnaire distributed to the cohort members at T1, five more items were derived. The first three were “Enjoyment of lessons”, “Enjoyment of breaks”, and “Enjoyment of classmates”, where the response option “Very much” was coded as 1 and the remaining options  were coded as 0. The item “Association/club membership” was derived from the question “Are you a member of any association/club?” The student could tick multiple options, e.g., sports club, sobriety club, scout association, religious association, political association, music association/choir/orchestra, student council, hobby groups, or other associations/clubs. Those who had ticked at least one of these options were coded as 1, whereas the rest were coded as 0. The last item reflected “Quality of spare time” and was based on the question “Is your spare time meaningful to you?” The response option “Yes, to a high extent” was coded as 1, whereas the remaining options  were coded as 0. Apart from the ten separate factors specified above, a variable with the summative score was calculated, referred to as the “Protective index”.Control variables were gender and health at T1. Gender had the value 0 for “Man” and 1 for “Woman”. Since the questionnaire at T1 did not include a question about self-rated health, we used two summary indices reflecting health status. The first was “Internalising symptoms”, consisting of three items reflecting worry/anxiousness, anxiety/panic, and feeling sad/low. The second was “Functional somatic symptoms”, constructed from ten items of physical symptoms including headache, stomach ache, nausea, backache, fatigue, breathlessness, dizziness, overstrain, palpitations, and sleeping difficulties. Details of these indices have been reported in a previous study . In the As evident in Between T1 and T2, 6.7% of the original cohort were lost to follow-up (including 12 cases of premature death) . Of the p-values  had five or more protective factors, whereas the corresponding percentage among adolescents without any on the studied adverse living conditions was 31%. Focusing on each separate factor, however, the results suggested that adversity was not significantly related to the three items reflecting the enjoyment of lessons, breaks, and classmates, or to the quality of spare time. The former finding can be due to the relatively high prevalence of strong enjoyment—it was uncommon in this sample to not report enjoyment at all—which could suggest that these indicators (when reversed) may work better as risk factors. The latter finding is more difficult to interpret. Hypothetically, it is possible that adolescents who face difficulties at home feel more at ease outside the context of the family and therefore might see their spare time as more meaningful. As a consequence, the differences in quality of spare time between them and peers who do not experience social and material adversity would be mitigated. Adversity showed statistically significant negative associations with the six remaining factors: future prospects regarding education and work, popularity among peers, school marks, and being member of an association/club. This is in line with past research .Third, adolescents for whom protective factors were present were less likely to rate their health as poorer in midlife. This was reflected by the fact that the “Protective index” showed decreased odds of poorer self-rated health in midlife. With the exception for the item reflecting the cohort members’ quality of spare time, all specific protective factors showed negative associations with poorer self-rated health. The association with health was slightly stronger for the factors assessed by the teachers compared to the items from the student questionnaire. All in all, the associations found here correspond well to our previous studies focusing on future prospects, scholastic ability and school marks , popularr = 0.66 and r = 0.55, respectively) and “School marks” , as well as to each another (r = 0.77). Many studies have nevertheless shown, even after adjusting for previous academic achievements, that young people actually achieve higher levels of academic success if teachers see them as capable and expect them to perform well [r = 0.24). Previous research, based on youths living in the industrialized parts of the world, has considered five areas of spare time activities that may be meaningful [Fourth, the results showed that the association between adversity in youth and health in midlife was moderated by most of our investigated factors related to school, peers, and spare time. More specifically: among individuals for whom the studied protective factors were absent, the association between adversity and midlife health was robust and statistically significant, whereas it was weak and in many cases statistically non-significant among individuals for whom the factors were present. These findings were formally tested through interaction analysis, where three factors were found to significantly interact with social and material adversity in their influence on subsequent health: “Educational prospects”, “Work prospects”, and “Quality of spare time”. Here, it is necessary to reflect upon what these factors really measure. The former two were based on the class teachers’ assessments and were most likely guided by rather holistic judgements of the students’ competences and performance at school. For example, correlation analysis revealed that these two measures were quite strongly correlated with “Scholastic ability”  to better capture stability and change across the life course. Furthermore, although we are able to control for functional somatic symptoms at baseline, there could still be unmeasured confounding. Another limitation concerns our measurement of social and material adversity which is relatively crude. For instance, we do not know what kind of illness the parents were suffering from or how long the parents had been unemployed. It is possible that the protective factors in fact reflect the degree of severity of the adverse conditions, in the sense that the presence of one or more protective factors could be the result of an environment that is in fact not as adverse as it may appear. In a similar vein, rather than being protective factors, aspects such as scholastic ability and school marks could act as mediators between adversity and health in midlife, and could thus reflect successful resilience rather than being the causes of resilience. This is nevertheless something that will be difficult to disentangle using observational data.To conclude, the present study found that social and material adversity in youth was associated with poorer health in midlife. The results also indicated that protective factors related to peers, school, and spare time, were present to a lesser extent among adolescents with experience of adversity and that their absence was associated with poorer subsequent health. Finally, the association between youth adversity and adult health was weaker among those for whom protective factors were present. Although resilience in this study was defined as the extraordinary capacity of human beings to prevail over adversity, the protective factors we found to be the most influential—as reflected through educational prospects, work prospects, and quality of spare time—do not require fostering of any superhero skills, just some “ordinary magic” . This is