Mobile technologies are increasingly being used to manage chronic diseases, including cancer, with the promise of improving the efficiency and effectiveness of care. Among the myriad of mobile technologies in health care, we have seen an explosion of mobile apps. The rapid increase in digital health apps is not paralleled by a similar trend in usage statistics by clinicians and patients. Little is known about how much and in what ways mobile health  apps are used by clinicians and patients for cancer care, what variables affect their use of mHealth, and what patients’ and clinicians’ expectations of mHealth apps are.This study aimed to describe the patient and clinician population that uses mHealth in cancer care and to provide recommendations to app developers and regulators to generally increase the use and efficacy of mHealth apps.Through a cross-sectional Web-based survey, we explored the current utilization rates of mHealth in cancer care and factors that explain the differences in utilization by patients and clinicians across the United States and 5 different countries in Europe. In addition, we conducted an international workshop with more than 100 stakeholders and a roundtable with key representatives of international organizations of clinicians and patients to solicit feedback on the survey results and develop insights into mHealth app development practices.A total of 1033 patients and 1116 clinicians participated in the survey. The proportion of cancer patients using mHealth  was far lower than that of clinicians . Accounting for age and salary level, the marginal probabilities of use at means are still significantly different between the 2 groups and were 69.8% for clinicians and 38.7% for patients using the propensity score–based regression adjustment with weighting technique. Moreover, our analysis identified a gap between basic and advanced users, with a prevalent use for activities related to the automation of processes and the interaction with other individuals and a limited adoption for side-effect management and compliance monitoring in both groups.mHealth apps can provide access to clinical and economic data that are low cost, easy to access, and personalized. The benefits can go as far as increasing patients’ chances of overall survival. However, despite its potential, evidence on the actual use of mobile technologies in cancer care is not promising. If the promise of mHealth is to be fulfilled, clinician and patient usage rates will need to converge. Ideally, cancer apps should be designed in ways that strengthen the patient-physician relationship, ease physicians’ workload, be tested for validity and effectiveness, and fit the criteria for reimbursement. Many would agree that mobile health  holds considerable promise for improving health care and the quality of life for people with cancer . With inIn 2017, there were 325,000 mHealth  apps with over 3.7 billion downloads [Although the potential benefits of mHealth seem particularly compelling for managing chronic conditions, where the overall efficacy largely depends on patient compliance that frequently occurs outside of the formal health care system, prolonged, regular, and intensive use still represents a major challenge . Apps spWhen patients are able to record their experiences in real time and combine them with passive data collection from sensors and mobile devices, this information can inform better care for each patient and contribute to the growing body of health data that can be used to draw insights for all patients.Preliminary research has addressed the interest of cancer patients in the use of mobile technologies to manage their disease ,14, wherIn summary, the interest in the use of mobile apps in cancer care is increasing, but there is little empirical insight into stakeholders’ perceptions. Therefore, to gain insight into key stakeholders’ perceptions of the value that mHealth app use creates, we distributed 2 surveys targeting 2 populations of mHealth app stakeholders—randomly selected cancer clinicians and patients who use internet-enabled mobile devices, such as smartphones. Through these surveys, we gathered data on the use of mHealth apps by patients and on how clinicians and cancer patients perceive the value of mHealth app use. In this study, we therefore aimed to describe the physician and patient population that utilizes mHealth in cancer care, the activities they perform, as well as the reasons for not using it.not applicable was provided. In the final version of the survey, we asked clinicians and patients up to 37 and 32 questions, respectively (some on the questions were dependent on previous answers).To investigate the use of mHealth in cancer care by patients and clinicians and the reasons for its use, we conducted a cross-sectional, international survey from July 2015 to February 2016. The survey included the European Big 5, that is, France, Germany, Italy, Spain, and the United Kingdom, as well as the United States. These countries exhibit some of the highest smartphone ownership rates and have mobile broadband penetration rates above 75% . ConcurrXM, a US-based company established in 2002 that allows researchers to conduct surveys in communities that are traditionally hard to reach. To construct the panel, potential respondents were recruited through the Web (using specific keywords) and outlined based on their characteristics, and a stratified sample was later invited to join the research panel.Eligible clinicians included oncologists who used smartphones and other devices for internet access, although not necessarily for mHealth. Similarly, eligible patients were those diagnosed with any kind of cancer who owned a smartphone that could access the internet. The survey was administered through qualtricsIn particular, patients were selected based on a population panel that provides recruitment via Web . Oncologists were reached out drawing on panels that are constructed by telephone recruitment or via recruitment portals starting from specialized databases—such as those of scientific communities.The survey was sent to 1800 oncologists and 1800 cancer patients consisting of a random sample of panelists stratified by country and age group. Both clinicians and patients were invited to participate in the study via email through Qualtrics and were provided with a link leading to the survey. The main screen of the online questionnaire provided all respondents with the aim of the study, the investigator information, and the expected time length of the survey (approximately 10 min). The respondents’ right to confidentiality was respected, and consent to participate in the survey was obtained.One concern when using online recruitment panels is that subjects rush through the online questionnaire without properly reading the provided instructions and questions. To increase the statistical power and reliability of our dataset, we screened respondents based on several criteria. First, we included control questions to detect spammers. Those study participants who failed to answer the control questions, answered all the questions in the same way, or filled in boxes with no-sense comments were excluded from our sample (28 clinicians and 68 patients). Second, we examined the time subjects took to fill out the questionnaire . Extreme deviations from the average time to complete the questionnaire were treated as outliers and excluded from further analysis. Thus, respondents within the lowest 1% percentile (less than 2.5 min) in terms of total time till survey completion were excluded. Furthermore, we checked whether the subjects’ internet protocol (IP) addresses overlapped. In such cases, duplicate entries from the same IP address were excluded from our analysis .The survey instrument included 4 different domains in both the clinician and patient versions: (1) sociodemographic variables , (2) mHealth utilization, (3) mHealth activities performed, and (4) reasons for not using mHealth. Both clinicians and patients were asked about their use of mHealth technologies for the management of cancer. Users, namely, individuals who owned a smartphone or any other mobile device and who used it for cancer-related purposes, were then asked to report for what purposes they used mHealth by choosing from a list of activities. These activities related to different degrees of pervasiveness of the technology aimed at highlighting different user expertise levels, based on a previously designed framework by Nasi et al . As a reDescriptive statistics were used to report respondents’ sociodemographic information and the degree of utilization of mHealth in managing cancer care. To measure the relation between specific sociodemographic information and the likelihood of being mHealth users, 2 possible sources of sample selection bias need to be addressed. First, as the survey was administered online, the results are influenced by the general digital divide in the population. Second, the survey was completed only by patients and clinicians using mobile technologies for any purpose, ie, if the respondent could access the internet but was not a user of mobile technologies , the survey was concluded, and no further questions were asked. In the first case, the sample selection bias is relevant but does not influence our results as the target population of mHealth technologies does not include people without basic technological endowments . The second source of bias, instead, is more relevant because it refers to the population having access to the Web but whose mobile endowment is low. Ideally, we should not exclude these respondents as they are a part of the potential target of mHealth. In our sample, only 21 out of 2170 respondents reported not using mobile technologies for any given purpose. To account for this potential bias that could still have a potential effect on our results, we used 2 different statistical approaches, namely, a propensity score–based regression adjustment (PSBRA) with weighting and a Heckman probit selection model (HPSM). For both the propensity score equation in the PSBRA and the selection equation in the HPSM, the independent variables were the age group, nationality, and salary level of the respondent. The choice of using 2 different procedures was motivated by the necessity of testing the robustness of the obtained estimations because of the disproportion between censored and uncensored observations. Analyses were conducted with STATA software, version 14 (Stata Corp).The main results from the survey were shared with several stakeholders to solicit input and feedback as well as develop policy recommendations for an appropriate spread of mobile technologies. An international workshop was organized in Milan, Italy, to facilitate interaction with over 100 stakeholders, including patients, clinicians, app developers, the pharmaceutical and medical technology industry, telecom industries, experts in medical communications and health education, payers, and policymakers.We announced the international workshop through different channels: (1) the general way, that is, by using the website and social networks normally used by our university (Bocconi University) to promote events and (2) a more specific way, that is, by compiling a mailing list of all potential stakeholders at the international and national levels. Participation was free of charge and travel expenses were covered by participants.The session was intended to focus on the discussion of the results arising from the survey. Specifically, 3 main questions were aimed toward participants: (1) why patients and clinicians do not use mHealth evenly, (2) what are the main barriers that have slowed the adoption of mHealth in cancer care, and finally (3) what is the likely effect of mHealth on clinicians’ activity and on patients’ quality of life. A member of the research team facilitated the workshop, ensuring the surfacing of diverse perspectives and a rich discussion of issues. The feedback from the workshop was used to develop a set of questions that we posed to an expert roundtable.The roundtable consisted of 4 participants who represented 2 leading patient and clinician associations: European Cancer Patient Coalition and the European School of Oncology in Europe and Healthwise Organization and the Multinational Association of Supportive Care in Cancer in the United States. The discussion was moderated by a member of the research team. Both the workshop and the roundtable were recorded and professionally transcribed.Valid responses were obtained from 1116 of the clinicians surveyed (62.00% response rate) and 1033 of the cancer patients interviewed (57.39%). The respondents’ characteristics are summarized in Of the 2149 participants surveyed, 1153 (53.65%) had previously accessed some sort of mobile technology for cancer-related purposes. Different mHealth access rates were observed in the 2 end-user groups. Among patients, 28.46% (294/1033) were mHealth users: nonusers were the majority in all countries assessed, although there were between-country differences. Clinicians, in contrast, were most often mHealth users: 76.97% of the respondents (859/1116) utilized mobile technology in their daily activity or in the management of cancer patients. The highest percentage was observed in the United States . Regarding the intensity of use, we observed that among clinician respondents, 32.26% (360/1116) were advanced users and 44.71% (499/1116) were basic users, whereas 18.39% (190/1033) of patients reported being advanced users versus 10.16% (105/1033) of basic users .Among the patients classified as mHealth user, approximately half of the respondents used mobile technologies for automation and decision-making support into activities such as scheduling an appointment , accessing personal information , and reading test results . Only approximately one-third of users and, therefore, about one-tenth of total patient respondents, supported treatment and follow-up phases through mHealth by either monitoring side effects , helping prevent further events , or taking medications as prescribed , the language , and the layout .With the aging of the population and the epidemics of chronic diseases, the financial sustainability of health care systems across the globe is at threat and calls for new paradigms where patients are empowered to stay healthy and/or to self-manage their conditions and hospitals only serve to treat the acute phases of diseases and to connect the community and patients’ home to deliver long-term chronic care. In such a context, mHealth, leveraging on the increase in mobile smartphone subscribers  and less often to support clinical decision making.Clinicians tend to use mHealth mainly in isolation, without mHealth-based interaction with patients. Indeed, clinician users reported that they access mHealth extensively to perform activities that support automation and data collection , represents a work instrument for clinicians who, for the sake of improving their performance, normally are prone to and represent the natural target for technological innovation ,34. HoweIn fact, this professional divide represents a barrier to mHealth effectiveness in cancer treatment. If the promise of mHealth is to be fulfilled, clinician and patient usage rates will need to converge. There is merit in incentivizing oncologists to adopt cancer apps in routine practice to encourage patients to access mHealth at greater length.To enhance clinician use, several different layers can be approached. The first dimension pertains to artifact design; ideally, cancer apps would need to be designed in such a way that would strengthen the patient-clinician relationship, and they should be tested for validity, accuracy, and self-efficacy to help clinicians and patients orient themselves in what now seems to be an app overload .App designers and developers must do more to bring their end users into the design process. Our findings point to the need for app developers to leverage toolkits to enable patients and physicians to more fully engage in the design and development process, each contributing with their own expertise . This wiFirst of all, these results suggest that designers and developers need to recognize that a one-size-fits-all approach will not work when it comes to apps dealing with conditions such as cancer. Specific apps that account for differences in types of patients, variance in the stage of the disease, and the kind of care one is receiving, as well as the expertise one has with using mobile technologies, will have better chances for increasing adoption and regular usage.Second, most health apps lack evidence of clinical effectiveness and do not undergo a formal validation and evaluation process ; the lacBehaviour change: digital and mobile health interventions) expected to be delivered in 2020 [Also, the National Institute for Health and Care Excellence in the United Kingdom has recently started a project aimed at providing guidance on the assessment of mobile technologies , the effectiveness of mHealth heavily depends upon patients playing an active role and using it at the same pace as clinicians.This is the first survey including a large, international sample size comparing 6 different countries in North America and Europe and, even more importantly, covering the two most important end users of mHealth: patients and clinicians. In fact, albeit scant, previous research has primarily addressed cancer patient needs and attitudes toward mobile technologies and not those of clinicians. Although past estimates exist for other specializations , to our However, this study suffers from some limitations that should be considered in subsequent studies. First, the study was based on a volunteer online access panel and, thus, is not entirely representative of the reference population as only individuals who possess some degree of digital competence could be reached and included. However, we believe that the online tool contributed to highlighting the smallest divide between clinicians and patients, which would likely be larger had we not used a digital tool. Moreover, the investigation in the user groups of the activities performed by patients and clinicians who use mHealth was self-reported and not based on actual records of their practice. Finally, this survey presents the limit of generalizability; thus, the divide and the models tested are valid in cancer and cancer supportive care only, and as much as the results are extremely significant, they might not hold true for other types of diseases.The use of mobile apps in health and in cancer care is literally booming but poor knowledge exists on who is using mHealth, for what purposes, what kind of apps are used, and what is the likely future of mHealth in clinical practice. In this study, we contributed to filling these gaps: our findings highlight 2 types of digital divides in cancer care—one mediated by socioeconomic and educational inequalities among patients and the other by the rift between how doctors and patients are deploying these technologies. For mHealth to yield its full benefits, it will have to integrate these two ends rather than foment the existing divide.


Pharmacotherapy remains one of the major interventional strategies in medicine. However, patients from all age groups and conditions face challenges when taking medications, such as integrating them into the daily routine, understanding their effects and side effects, and monitoring outcomes. In this context, a reliable medication management tool adaptable to the patient’s needs becomes critical. As most people have a mobile phone, mobile apps offer a platform for such a personalized support tool available on the go.understand and manage, instead of the conventional adhere to medication. This concept aims to engage and empower patients to be in charge of their health, as well as see medication as part of a broader clinical approach, working simultaneously with other types of interventions or lifestyle changes, to achieve optimal outcomes.This study aimed to provide an overview of available mobile apps, focusing on those that help patients understand and take their medications. We reviewed the existing apps and provided suggestions for future development based on the concept We performed a Web search in the iOS Apple App Store and Android Google Play Store, using 4 search terms: medication management, pill reminder, medication health monitor, and medication helper. We extracted information from the app store descriptions for each eligible app and categorized into the following characteristics: features, author affiliation, specialty, user interface, cost, and user rating. In addition, we conducted Google searches to obtain more information about the author affiliation.A total of 328 apps (175 Android and 153 iOS) were categorized. The majority of the apps were developed by the software industry , a minority of them were codeveloped by health care professionals  or academia . The most prevalent specialty was diabetes (23 apps). Only 7 apps focused on mental health, but their content was highly comprehensive in terms of features and had the highest prevalence of the education component. The most prevalent features were reminder, symptom tracker, and ability to share data with a family member or doctor. In addition, we highlighted the features considered innovative and listed practical suggestions for future development and innovations.We identified detailed characteristics of the existing apps, with the aim of informing future app development. Ultimately, the goal was to provide users with effective mobile health solutions, which can be expected to improve their engagement in the treatment process and long-term well-being. This study also highlighted the need for improved standards for reporting on app stores. Furthermore, it underlined the need for a platform to offer health app users an ongoing evaluation of apps by health professionals in addition to other users and to provide them with tools to easily select an appropriate and trustworthy app. With the population aging worldwide  and incrTaking several medications simultaneously or starting to take a medication that is prescribed for the first time may bring with it challenges for many users ,8. Theseon the go and in the required time [Mobile apps can offer users  tools to facilitate their engagement in the treatment and well-being ,14. In ared time ,18.App users as well as developers are realizing this potential, which is reflected in the mobile app market growth, with increasing numbers of MM apps available . Howeverunderstand and manage, as opposed to the conventional adherence to medication. This concept aims to engage users and empower them to be in charge of their health and well-being as well as to see medication as part of a broader clinical approach, working simultaneously with other types of interventions or lifestyle changes, to achieve optimal outcomes.This study aimed to provide an overview of the existing solutions in the mobile app marketplace, with a focus on apps that help users understand and take their medications. We reviewed the existing apps and provided suggestions for future development based on the concept understand and manage; and (3) create a framework to categorize the mobile health solutions. We believe that this framework may contribute to the understanding of the current landscape of MM apps and to the development of future solutions.We outlined the detailed characteristics of the available apps and sought to (1) identify who designed each app and whether health experts were involved in the development and design; (2) identify key features defined as (a) features that are most prevalent and (b) features that are novel or innovative and have the potential to address the concept Eliminating Personalization During the Search). The query consisted of the search term and the app store, for example, medication management site://play.google.com/store/apps/. The search terms used were medication management, pill reminder, medication health monitor, and medication helper. The selection of search terms was based on a panel discussion among the research team and terms used in previous studies. The final search terms were confirmed based on a preliminary search, when the selected terms showed greater relevance of results. The approach used in this study was based on the previous literature ,24,25. TEach term was searched separately in each app store, and 2 researchers performed identical searches independently. For all search results, the information available in the app store description was reviewed. The inclusion criteria were as follows: (1) user population consisting of patient and health consumers, including family or caregivers, and the eligible solution was written in lay language; (2) purpose—helping users take or understand their medication; and (3) the app was available in English. Apps were excluded from further review if professional language was used, they were intended for health care experts, and they did not have a clear focus on helping take medications and instead focused on other issues, such as purchasing medications or ordering refills.Solutions that met the eligibility criteria were selected by the researcher and their URLs were saved. After the independent search, the 2 researchers compared the lists of apps they identified as eligible and performed analyses to determine agreement between the 2 sets of results. Interrater reliability was determined based on Cohen kappa (0.81). In accordance with Landis and Koch statistics guidelines, the strength of the agreement between researchers was almost perfect (0.81-1.00).Only those apps that were considered ineligible by both researchers were excluded from further review. Discrepancies between the 2 researchers were reviewed (third opinion) and resolved. Subsequently, both researchers agreed on the final list of results for each search term .Duplicates on the same device platform were identified using Microsoft Excel and removed, whereas solutions that appeared across 2 different platforms were not considered duplicates . SubsequWe applied the following strategies to decrease the extent to which the search results were affected by personalization, app store search algorithm, and cookies. We used (1) Start page as the search engine, which uses results from Google while offering increased anonymity through Secure Sockets Layer encryption and limited data collection; (2) a different Web browser than is usually used on the computer; and (3) incognito mode or a private window of the browser ,30.Before data extraction, a preliminary framework of app characteristics was designed, based on a panel discussion of the research team and the previous literature ,24,31. LSubsequently, the 2 researchers assessed and categorized the apps. The first 20.1% (66/328) of the apps were categorized by the 2 researchers together. During this process, they came to an agreement in understanding the scope of the subcategories. Subsequently, they divided the remaining sample of apps (262) and each researcher extracted information for half of the sample. They assessed the apps at the same time and discussed any issue or uncertainty that arose.Information was extracted from the app store description and from the available screenshots. An exception was the category author affiliation. The developers rarely described their credentials or affiliation within the text of the app store description. Moreover, app stores provided only the name of the developer in most cases. Therefore, to find out more information about the author’s affiliation, we conducted Google searches using the name and the website provided by the app store.Other features. At the same time, researchers flagged those features, which they considered novel, interesting, and innovative. Upon completion of the solution assessment, the team of coauthors reviewed the flagged features and agreed on the final list, which is included in the study as the novel and innovative features.The app features were assessed in the following way. Features that were not part of the list of prevalent features were manually entered in the database as Once all the apps were coded, descriptive statistics were computed for each variable. Cohen kappa and selected descriptive statistics were computed using SPSS (IBM), version 25. The rest of the descriptive statistics and charts were prepared in Microsoft Excel, version 16.1.1 and Euler online application. The visualization through Euler diagram and related descriptive statistics were presented to add to the understanding of who authored the apps and which professionals collaborated during the app development.The initial app store search yielded 800 records, of which 297 were excluded based on the app store description because they did not meet the inclusion criteria. From the eligible apps, other apps were excluded later because they were duplicates or they were no longer available. A total of 328 apps were included in the final assessment. Categorization was carried out in December 2017. Between the search and categorization, 34 apps were discontinued. Therefore, the apps that were assessed and are the subject of this review are the ones that remained available on the app stores for a year. Both marketplaces were represented in the final list of apps: the Android store accounted for 53.8% (175/328) of the apps, and 46.6% (153/328) of the apps were from the Apple store. In terms of cost, the majority of the apps were available for free , some of which had options for in-app purchases  for extra content or features. The average price of paid apps  was US $3.77. The price range for the paid apps or in-app purchases was between US $0.99 and $24.55.Others, which consisted mostly of governmental organizations and nonprofits; for a longer list of institutions, see The majority of the mobile apps were developed by the software industry , which consisted of software companies (219/239) and independent software developers (20/239). In addition, 14.6% (48/328) were developed with the involvement of health care professionals. Very few apps were developed by, or produced in collaboration with, academic institutions . Furthermore, 5.2% (17/328) were developed by The most prevalent features of all reviewed apps are listed in Of the apps focusing on certain medical condition and its specific MM , most apps focused on diabetes (n=23), women’s reproductive health (n=20), and cardiovascular health , which means they were designed to help with general MM. These general MM apps may differ from the specialized apps by nature of their features, which are designed to address a wide spectrum of medications and health conditions. For example, the tracker of health data in a general MM app usually offers tracking of weight, heart rate, sleep, or exercise. Conversely, a specialized MM app for mental health may track some of the previously listed health data in addition to mood, thoughts, and social events. Some users may prefer the general MM apps. For example, a user taking several medications across a range of specialties can manage all their medications within one app and customize the settings accordingly.Another way of looking at the apps’ features is to see the relationship between features and medical specialty. Apps with only a static user interface accounted for 0.6% (2/328) of the sample. A definition of different user interfaces is provided in The user rating scale was slightly different for the Android and Apple stores. The Android store showed ratings with an accuracy of 0.1 star , whereas the Apple store reported ratings with an accuracy of 0.5 star . In both stores, 5 stars was the best possible score. Of the 275 rated apps, the average rating was 3.84 stars. The number of raters per app ranged between 1 and 152,011, with an average of 2658 raters. However, 50 apps in the Apple store and 3 apps in the Android store did not have rating information available.This review describes a comprehensive range of characteristics of available mobile solutions for MM, which help users understand and take their medication. An emphasis is placed on the functional features the current solutions offer and how this can inform future app development. Another main finding is related to the low transparency of information available in the app store description. We suggest that it is difficult for the user to identify the author’s affiliation and professional credentials, as reporting this information is not a standard in the app store descriptions.When searching for MM apps, we found over 300 unique apps on the Apple and Android stores. A study by Martínez-Pérez examining mobile apps for the most prevalent health conditions reported that there were more than 1000 apps focusing on diabetes or depression . This reWhen one looks for an online solution for their health condition, well-established requirements for health interventions, such as providing evidence-based content and clinical effectiveness become pivotal, in addition to the qualities that are commonly sought out in any apps, such as user-friendliness and engagement ,34.seller in the Apple store and developer in the Android store) and website if available. However, listing the qualifications or affiliations of the author is currently not a store requirement. Therefore, very few apps include this information in the app store description. Similarly, many other studies reviewing mobile apps for a variety of health conditions described that author affiliation and reporting of content sources in the app store description were infrequent [Another aspect of the health apps that would be helpful for the user to know during the process of choosing an app is the topic-related credibility of the author. However, during the solution assessment, we observed that the majority of apps did not mention the credentials of the author or professionals who helped codevelop the app in the app store description. Currently, the 2 main app stores require app authors to list their name  in app development. Furthermore, even fewer apps were codeveloped by academia. In addition, a few apps were authored by other organizations such as charities, nonprofits, government organizations, insurance companies, or pharmaceutical companies. Conversely, the majority of solutions were developed by software developers or tech companies. The previous literature widely indicates that there is a lack of involvement of health professionals or academics in the development of health apps -39.One of the most prevalent features was symptom or vital tracker. It provides a unique record of health outcome details over time that can prove helpful to both users and their health care providers. We suggest that tracking symptoms may also be beneficial within a broader treatment approach, where medication is an integrated component of a comprehensive strategy . In such cases, tracked health outcomes provide insight into the effects and synergies of the interventions and may help optimize the treatment for each user. Future development could offer alternatives to automatically track data through wearables or new upcoming technologies, increasing and facilitating utilization of tracking features as a result.There is an increasing number of apps  with the option to synchronize data from the MM app with a different app or device, including wearables . A similar review from 2013 did not report synchronization as a prevalent feature , which mA majority of the reviewed apps offered a medication reminder. A study by Ahmed et al focusing on adherence apps has also described other adherence strategies such as gamification, in addition to the common reminder . AnotherIn addition to features helping users take their medication, almost one-fifth of the apps included an education component to help users understand the medication or the treatment process. Examples include information about correct usage, side effects, and interactions. For future development, we suggest also covering common patient concerns (legitimate vs myths) and desired treatment outcomes based on the evidence. The education section could be written in an easy-to-understand language and provide an added value compared with the patient information sheet, which is usually provided together with a prescription medication.Some of the interesting novel features identified in this study were easier data entry for new medication , correlations based on data entry, providing warnings if safe dosage exceeded, communication with health professional, and safety plan for acute or emergency situations. In addition, an increasing number of apps included in their tracking and journaling features options supporting healthy lifestyle choices such as physical activity; social interactions; food diary; awareness of emotions, mood, and thoughts; accomplishments; and triggers. Many of the novel features could inform future development, especially ones that make the use of mobile MM increasingly effortless, for example, easier data entry options, and features empowering the user, for example, individualized and improved tracking features.Although most of the apps were not specialized for MM of a particular drug or condition, there were several apps with a focus on a specific medical condition or specialty. The greatest number of apps were for MM of diabetes and apps helping women keep track of their reproductive health, including reminders for contraceptive pills.When looking at the distribution of prevalent features by different specialties, diabetes apps had the greatest variety of features. When this fact is taken into consideration alongside the advancement in engagement and gamification ,41, MM aunderstand and manage their medication with the support of a mobile app. The pivotal first step for the user is to select an appropriate app.This study offers an overview of the app market for professionals in the field of eHealth and can inform development of new innovative solutions. On the other hand, the perspective of the user  remains crucial. For them, a highly dynamic approach including up-to-date transparent overviews of characteristics and evaluations of solutions would be very beneficial and would empower them to crowd-sourcing collaborative approach, similar to Wikipedia, as a potential solution [There are several initiatives aiming to help users navigate the app market, such as Apps Library by the National Health Library in the United Kingdom, RankedHealth or Psyberguide -44. Healsolution ,48.critics) including an evidence-based score, and reviews by users, all in one place.A future direction could be an online registry and review aggregation website, similar to Metacritic, which is used for film and other media. The future platform could contain structured overviews of various characteristics, reviews by professionals  and time of submission of the publication, considering the fast-evolving landscape of the app market. Moreover, there was also a 1-year time difference between the search and categorization. The disadvantage of this is that 34 apps were discontinued during this period. The advantage might be that the rest of the apps (328) that were categorized, and their characteristics are outlined in this study, are the sustained ones that remained available over a year. Third, identification of app duplicates was limited to the duplicates within one app store. As store requirements are different between the Android and Apple store, we were not able to reliably identify duplicates across 2 different platforms.The inclusion criteria included English language. Therefore, the findings are not representative of all MM apps available in the global market offered in languages other than English. Moreover, both researchers were physically present in Canada during the search process. Even though substantial effort was put into increasing the anonymity during the search, a search in another country may have returned different results. Similarly, despite these efforts, the search results may also be affected by the app stores’ algorithms. Specifically, the ranking of the results may be affected by various factors, including but not limited to how many people have clicked on the app title before, the user rating, increase of downloads in the past month, or the number of downloads per day.Mobile apps have the potential to empower patients with personalized immediate support and improve compliance with the treatment and engagement in long-term well-being. However, searching for an appropriate MM app is challenging because the marketplace offers hundreds of solutions which makes it difficult for the user to filter through. To find a trustworthy app, it would be beneficial for the user to have the information about the content source or author affiliation easily available during the search. However, this study found a lack of reporting of the author affiliation in app store descriptions. Therefore, the study highlights the need for improved standards for reporting on app stores. In addition, it underlines the need for a platform to offer users of health apps an ongoing evaluation by health professionals in addition to other users. The aim of such efforts would be to provide users with tools to readily assess the credibility of eHealth solutions before making their choice.The study reports that prevalent features of available MM apps were reminder, symptom tracker, and ability to share data with a family member or doctor. The results presented in the study help inform the theoretical and practical approach for app development, in particular, decisions related to the content selection process. Building on the existing experience, it is important to start working on the next generation of solutions, which will improve engagement of users in the treatment process. Future development may include improved tracking features to optimize treatment for each user based on their exact treatment outcome data, as well as components making the use of mobile MM increasingly effortless . Moreover, emphasis could be put on a broader comprehensive treatment approach framing medication as its integrated component instead of a stand-alone intervention.


The authors point out the additional frailties low- and medium-income countries have to face with in case of natural disasters. They discuss the risks related to the massive population growth in Asia, with the development of “megacities,” where entire neighborhoods arise in at-risk areas within a few years, such as flood-prone areas or high-risk seismic or geological areas. These frailties, of course, together with the socioeconomic vulnerabilities, make these countries even more vulnerable to natural disasters.The article by De Guzman and Malik2 This implies that an increasing number of patients with chronic cancer might need medical and social assistance in the future. Our group has already experienced natural disasters; we described the many problems that our home care service handled after an earthquake in 2009.3 Indeed, Italy is a country with among the highest risks for seismic and hydrogeological activity, and we have already tried to look for some answers.4Unfortunately, the reported natural disasters have increased worldwide over the decades, until their incidence peaked at the beginning of the 2000s.5 the main public health threats vary according to the magnitude of the earthquake, the environment, and the secondary effects of the earthquake. The effects can be summarized in terms of how they relate to immediate health  and medium-term impacts on health ; the latter is the condition of patients with cancer.According to the World Health Organization’s technical hazard sheet on earthquakes,1 correctly state that disaster management is predominantly a reactive response, and that national health systems still lack proactive attitudes to improve early warning systems, to build resilience, and, most important, to address people with special needs such as patients with cancer.We have appreciated the discussion regarding the critical conditions of patients with cancer during and after natural disasters. De Guzman and Malik6 Similar results were also reported among Australian surgeons.7 Even if cancer care professionals and oncologists are not the first clinicians called to face natural disasters and large-scale emergencies, they probably are crucial in later phases, when restoring the continuity of care becomes a priority. A recent systematic review by Man et al8 summarized the problems that patients with cancer and health care professional have to face after a disaster: the health care infrastructures, the health care workforce, patient relocation, and data dispersion.In our opinion, the lack of preparedness is the biggest problem. National health systems of high-income countries are totally unprepared to face natural disasters. Preparedness of health care professionals is a hot topic in the field; a recent survey conducted among anesthesiologists revealed that few receive sufficient education and training in disaster medicine.9 which clearly states that in case of a disaster, patients with chronic conditions are considered in policy and plans, ensuring they have access to lifesaving services. The problems regarding management of patients with chronic illness, and patients with cancer, in particular, are the same for low-, middle-, and high-income countries. The question is: Why we are determined to plan and prevent only when the nature forces us to face these problems? Enhanced disaster preparedness must be a shared goal of institutions and scientific societies worldwide. The optimal goal would be to prepare specialized medical response teams for immediate and medium-term health impact. Communities are often the first responders, so we think it is crucial to invest as well in the preparedness of general practitioners and all cancer care professionals.In 2015, the United Nations member states adopted the Sendai Framework for Disaster Risk Reduction: 2015–2030,


While trust in physicians has been rigorously investigated regarding its concept, measurement, and factors, the studies have mainly focused on the attributes of the physicians. This approach can lead to a limited understanding of trust in physicians as trust is based on the relationship, an interaction of both parties: patients and physicians. This study aimed to investigate the factors for trust in physicians among the Koreans by focusing on patients’ traits which are related to their subjective perceptions.t-test and analysis of variance (ANOVA) were performed to examine the difference in trust in physicians among the different groups in each variable of patient characteristics. An ordinal logistic regression model was employed to examine the association between trust in physicians and patient attributes.A web-based survey was conducted between August and September 2016 among 1000 Korean adults aged 18 to 59 years. Survey participants were selected by a proportionate quota sampling based on age, sex and place of residence. The Negative health-related traits, such as stress and low self-rated health, were likely to lower trust in physicians, and women were less likely to trust physicians. The negative attitudes toward the current health care system were strongly associated with low trust in physicians. Meanwhile, recent experience of hospitalization or outpatient visit was positively associated with trust in physicians, and experience of not being able to use health facilities showed no significant association. These results suggest that trust in physicians is more likely to be lowered by negative perception than by the objective conditions or experience.In investigating the factors for trust in physicians, the patients’ predispositions, which make them less likely to trust physicians, should be considered. The attributes of the patients in Korea, which could negatively affect trust in physicians, need to be investigated in consideration of the recent changes in patient-physician relationships and the medical environment in Korea.The online version of this article (10.1186/s12875-018-0875-6) contains supplementary material, which is available to authorized users. Trust is to believe that the other acts in the best interest of the one and to entrust oneself to the other. Given the significance that medical practice has on human life by concerning life and death directly  and the While trust in physicians has been rigorously investigated regarding its concept , 5, 8, 9In that respect, Korea, where a large gap exists between objective health indices and the public’s perception of them, provides an intriguing condition for study of trust in physicians. Korea’s health care system has distinguishable features which seem mutually contradicting. While health status in Korea, as shown in high life expectancy at birth and low infant mortality, holds a high rank in the Organisation for Economic Co-operation and Development (OECD) member countries, the perceived health status of the Koreans places it low. And trust in physicians among the Koreans, in spite of the high level of health status they attained and high frequency of health care utilization, ranked low compared with the other countries , 20. InvThis study aimed to investigate the factors associated with trust in physicians among the Koreans. Rather than focusing on the physician behaviors, which were the main issue in the previous studies, we attempted to investigate patients’ traits which can affect their subjective perceptions, focusing on their health-related conditions, behaviors and attitudes as well as their demographic and socio-economic characteristics.This study is based on the survey conducted with 1000 adults aged 18 to 59 years in Korea from August 28 through September 4, 2015 , 22. SurThe dependent variable in our study is general trust in physician. In most prior studies from the US, trust in physicians is based on the concept of my physician . HoweverWe selected variables which could affect trust in physicians on the basis of previous studies and our study hypothesis , 17. Thet-test and analysis of variance (ANOVA) to examine the difference in trust in physicians among the different groups in each variable of patient characteristics. An ordinal logistic regression models was employed to assess the relationship between patient trust and patient characteristics. For data acquisition and analysis, IBM SPSS Statistics (version 22) and Stata (version 13) were used.We performed the The results of univariate analysis between trust in physicians and the characteristics of the study subjects are presented in Table We investigated the patient factors affecting trust in physicians Table . Women wThis study investigated the relationship between trust in physicians and patient characteristics and explored the factors that affect trust in physicians. Health indicators related to bad health, such as frequent smoking, stress and low self-rated health, were found to lower trust in physicians. The recent experience of outpatient visits or hospitalization was associated with higher trust in physicians. The negative attitudes toward the current health care system were strongly associated with low trust in physicians. Our study results can be discussed in terms of two questions: 1) Which factors are associated with trust in physicians? 2) What are the factors that may lower trust in physicians among the Koreans?First, women were less likely to trust physicians. This seems contrary to prior studies where female and male did not show a significant difference in trust in physicians , 13. HowThe factors, which could negatively affect health, were found to be strongly associated with low trust in physicians. These health-related factors can be divided into objective and subjective measures. Smoking is an established cause of bad health . Stress,However, considering that self-rated health and stress have subjective attributes which could result from one’s own perception, regardless of their objective conditions, the negative relationship between these variables and trust in physicians is suggestive of the association between lower trust in physicians and the propensity to develop negative attitudes independently of the objective conditions. This argument is convincing given that the level of perceived health among Koreans is the lowest among the OECD countries despite their high level of health conditions and high frequency of health services utilization . These cAs seen in the high correlation between trust in physicians and patient characteristics, which seem to be based on subjective perceptions, the low trust in physicians among the Koreans is likely to be attributed more to negative perception than external conditions. Patient experience is known to be the strongest predictor of the attitudes toward the health care system . HoweverBased on the discussion hitherto performed, the factors that lower trust in physicians among the Koreans can be explained as follows: First, the low trust in physicians can be a result of the general negative attitudes, which are pervasive among other areas in Korean society . For exaLastly, the physician factors need to be scrutinized. If trust in physicians is more likely to result from public opinion than the individual experiences with the physicians , the lowHowever, these changes alone cannot explain the negative public opinion about the physicians in Korea. Physicians in Korea have been in conflict with the government in recent years concerning the payment methods and national health insurance fee schedule. The conflicts have been much publicized, and that caused the physicians to be recognized as a group which puts their interests first. In addition, the patient-physician relationship has become unfriendly. The amount of medical litigation has continued to grow in recent years , and patThere are some caveats to be addressed in this study. First, unlike most prior studies of trust in physicians, the concept of trust in this study is for physicians in general and not for patients’ own physicians. In Korea, patients can freely visit physicians who practice in different types of health care facilities , and theThis study investigated the factors for trust in physicians among the Koreans in terms of the patients’ attributes. We found that the negative health-related traits, such as stress and low self-rated health, were likely to lower trust in physicians and that these traits were likely to be based more on the negative perception than on the objective conditions. The fact that the negative attitudes toward the current health system were the strongest factor that was likely to lower trust in physicians suggests that the subjective attributes of the patients could have contributed to lowering trust in physicians. The subjective attributes of the patients, which could negatively affect trust in physicians, should be investigated more in consideration with the recent changes in patient-physician relationships and the medical environment in Korea.Additional file 1:The survey questionnaire for measuring trust in physicians and associated factors. (DOCX 17 kb)


We would like to thank Drs. Wang and Wu  for theiFirst, the authors commented on the types of chili peppers analyzed in our study. We did not include sweet capsicum and black pepper in the analysis as they do not contain high levels of capsaicin, the active component of chili. In our survey, we did not differentiate fresh from dry chili, and this limitation has already been acknowledged. On the other hand, dry chili is usually used as a spice in Chinese cuisine, and the consumption of dry chili is relatively lower than fresh chili. Therefore, it can be assumed that misclassification of chili consumption levels is random and will not affect our findings on the association between total chili consumption and cognition.p < 0.01) for men and 0.60 (p < 0.01) for women [Second, Yang Y and Wu D commented about the dietary assessment method in our study. Our study used the combination of food weighing and 24 h food recording in the household setting. This method is widely used in population nutrition studies in China  and hasThird, the authors questioned the validity of the outcome measurement in regards to using composite scores of memories, counting back and subtraction scores, especially among those with low education. However, the face-to-face cognitive screen test is widely used in epidemiological studies. Among participants attending the first cognitive function test, 85.3% of those with a low education attained a full score of the subtraction test. The main difference of the cognition score was from the memory test. In the memory test, the ten words used were mainly related to daily living  and less likely to be affected by education. Furthermore, our findings are less likely confounded by age. Among those with a global cognitive score below 7 (18.0% among those attending the first cognitive function test), the mean age of those with a high intake of chili, self-reported memory decline or poor memory was lower than non-consumers of chili . This miFourth, the authors were concerned about the significant loss in the follow-up sample and the exclusion of those who attended only one survey. We agree that loss of follow-up is a limitation in the study. However, the main reason for the loss of follow-up was due to the rapid economic development in China and migration, but not cognition related diseases. In our analysis, we used a stepwise approach to examine the association between chili intake and cognition. We included those that participated in one survey in most of our multivariable models. The exclusion of those who only participated in one survey did not change the finding. The fifth comment concerned the lack of adjustment for chronic diseases and medication use. As chili consumption is inversely associated with obesity and hypertension, adjusting for chronic conditions may lead to over adjustment. However, adjustment for hypertension, obesity, diabetes, and stroke did not change the association between chili intake and cognitive function. We agree with the authors that the lack of adjustment of medication is a limitation. In conclusion, the study provided the most comprehensive dietary intake data in population studies to assess the association between chili intake and cognition, suggesting that high chili consumption might lead to early onset of cognitive impairment. Future studies should consider differentiating between fresh and dry chili intake, using more objective and multidimensional cognitive assessments, as well as controlling for more confounders to further confirm the relationship between chili intake and cognition.


Patient information materials and decision aids are essential tools for helping patients make informed decisions and share in decision-making. The aim of this study was to investigate the quality of the written patient information materials available at general practices in Styria, Austria.We asked general practitioners to send in all patient information materials available in their practices and to answer a short questionnaire. We evaluated the materials using the Ensuring Quality Information for Patients (EQIP-36) instrument.A total of 387 different patient information materials were available for quality assessment. These materials achieved an average score of 39 out of 100. The score was below 50 for 78% of all materials. There was a significant lack of information on the evidence base of recommendations. Only 9 % of the materials provided full disclosure of their evidence sources. We also found that, despite the poor quality of the materials, 89% of general practitioners regularly make active use of them during consultations with patients.Based on international standards, the quality of patient information materials available at general practices in Styria is poor. The vast majority of the materials are not suitable as a basis for informed decisions by patients. However, most Styrian general practitioners use written patient information materials on a regular basis in their daily clinical practice. Thus, these materials not only fail to help raise the health literacy of the general population, but may actually undermine efforts to enable patients to make shared informed decisions. To increase health literacy, it is necessary to make high quality, evidence-based and easy-to-understand information material available to patients and the public. For this, it may be necessary to set up a centralized and independent clearinghouse. The health literacy of 36% of the U.S. population is either basic or below basic . The sitCriteria defining high quality patient information materials are well established and instruments to analyze structural quality have long been available –9. PartiGeneral practitioners are not only the first port of call of patients , they arExisting studies of the quality of patient information materials generally only deal with specific diseases –19 and rThe systematic collection of data and the evaluation of the structural quality of the patient information materials and decision aids that are available to patients in primary care have not previously been carried out in Austria.To determine the quality of the patient information materials used in Austrian general practices.The principal aim of this study was:To what extent are patient information materials used on a day-to-day basis in general practices?Who publishes such patient information materials and are differences in quality dependent on the publisher?Are evidence sources provided and cited in patient information materials?Further aspects that were investigated were:The study was carried out with the help of the Styrian general practitioners (GPs) that had indicated in a previous survey that they would be interested in participating in general practice research . In a shInformation materials were considered to be relevant to this study when “declarations were made on the consequences of diseases, the effects of preventive and diagnostic measures, and on therapies for diseases.” Information materials were not taken into account when they referred to the provision of services at specific sites or were purely for advertising purposes.The long version of the Ensuring Quality Information for Patients (EQIP-36) instrument was used to evaluate the remaining patient information materials . The insFirst of all, relevant metadata was extracted . The EQIP instrument was then used to analyze the materials and a score was calculated.One reviewer evaluated each of the information materials, while a second independent reviewer controlled a randomly selected sample of 10 % of the materials. Significant differences in the evaluation were resolved via discussion.Microsoft Excel 2016 MSO (Version 1712) was used to perform a descriptive statistical analysis of the data pseudoanonymously.Of the 96 GPs we contacted, 57 completed the questionnaires and 58 returned a copy of each of the patient information materials they used in their practices (response rate 60%). Overall, 1092 leaflets and brochures were sent back. After excluding identical materials and information materials that did not fulfil the inclusion criteria, 387 written patient information materials remained for evaluation  said they used the submitted materials on a day-to-day basis, and 51 (89%) made active use of them during consultations. In 53 (93%) of the practices, the doctors only provided the patients with selected information materials, whereas in four practices, the doctors made all the materials at their disposal available. Reasons provided for not making patient information materials available to patients were content (68%), too little space in the general practice (58%), publisher (32%) and lack of integrity or intelligibility in the opinion of the doctor (19%).Of a total of 387 leaflets and brochures, 268 provided general information on diseases, 216 information on medications and medicinal products, 72 information on tests, operations screenings and interventions, 34 information on services, five information on follow-up treatments, and 170 on other topics. Some of the materials dealt with several subjects. None of the information materials fulfilled the criteria required to be considered a decision aid.Overall, 372 (96%) of the brochures and leaflets provided information on the publishers. Most of the materials (60%) were published by producers of pharmaceuticals and other medical products. Other publishers were professional societies, associations, and initiatives (14%), health and social security funds (6%), media enterprises and publishing groups (3%) and others (11%). A further 10 % of the materials had been written by the doctors themselves.Figure The overall average score for all categories of publisher was below 50. A separate evaluation of the materials was also carried out for individual publisher categories see Fig. , wherebyNo sources of evidence were disclosed for 327 (84%) of the leaflets and brochures. Some source information was disclosed for 26 (7%) of the materials  and only 34 (9%) provided full disclosure of sources. The frequency of source disclosure varied insignificantly between categories of publisher.Patient information materials are used in physician-patient communication in Styrian family practices on a daily basis. Most of these materials are provided by producers of pharmaceuticals and medical products. However, about a tenth of the materials are written by the doctors themselves. Overall the materials are of low quality. They especially lack information on the potential benefits and harms of specified medical services, on financing, and on the evidence base for the provided medical information and recommendations.Our results are similar to those identifed in several international studies, which also identified serious quality shortcomings in patient information materials , 19, 22.Patients increasingly wish to play an active role in the decision-making process , 23, andProviders of health information should prepare and update health information materials on the basis of existing quality criteria. In particular, benefits, risks and side effects should be provided, and references should be included. In order to ensure the quality of health information is high, minimum standards for reliable health information should further be established by law.It would be helpful if GPs and doctors in training were trained to evaluate patient information materials themselves. However, in view of the large number of available materials, it is unlikely that doctors will be able to find the time to select the best quality materials themselves. It is therefore necessary to establish a central, independent clearinghouse to examine and prepare brochures and leaflets based on international criteria for “good patient information” .A Cochrane Review has shown that a combination of verbal and written information can improve patients´ knowledge and satisfaction more effectively than verbal information alone . DoctorsSince May 2018, the implementation of these suggestions has been progressing as part of a new project financed by the Styrian health fund  .It is necessary that the broader public be made aware that the use of information materials of inferior quality can lead to a number of problems.The question remains as to what extent the objective quality criteria used by the EQIP instrument are the same as patients’ subjective expectations of information materials, and this is a limitation of our study.Furthermore, most of the GPs that participated in our study had already shown an interest in general practice research, and it is possible that the involvement of another sample of GPs would have led to different results. However, existing studies on the subject have identified very few differences between GPs that are interested in research and those that are not –28.In their consultations, doctors also use patient information materials they have prepared themselves, or they provide materials as summaries of, for example, diet recommendations and gymnastic exercises. As these materials are generally not designed to be comprehensive, it is unclear whether the EQIP instrument is suitable for evaluating them, especially when specific details on their planned use are not taken into consideration.Patient information materials are essential tools for supporting patient-physician communication, and raising health knowledge, and they provide a valuable basis for shared decision making. To achieve this, however, it is necessary that they are reliable and of good quality. As this is not true of the majority of current information materials, it is important to find ways to ensure that high quality materials are available in sufficient quantities in the future.Additional file 1: Questionnaire.Additional file 2: Table S1. Demographic characteristics of the participating GPs.


Stress during childhood can have mental and somatic health influences that track throughout life. Previous research attributes stress-reducing effects to natural environments, but has mainly focused on adults and often following leisurely relaxation in natural environments. This pilot study explores the impact of natural environments on stress response during rest and mental load and cognitive performance in 47 children aged 10–12 years in a school context. Heart rate variability measures indexing tonic, event, and phasic vagal tone and attention scores were compared across classroom and natural environments. Tonic vagal tone was higher in the natural environment than the classrooms, but no differences were found in event or phasic vagal tone or cognitive performance measures. These findings suggest a situational aspect of the conditions under which natural environments may give rise to stress-buffering influences. Further research is warranted to understand the potential benefits in a real-life context, in particular with respect to the underpinning mechanisms and effects of accumulated exposure over time in settings where children spend large proportions of time in natural environments. The World Health Organization estimated that more than half the global population in 2015 was living in urban environments, with an expected growth rate of approximately 1.84% per year between 2015 and 2020 . SimilarThere is convincing evidence that early-life stress can influence mental and cognitive health and the individual’s response to stressors throughout their lifetime . AdditioA growing body of research has shown that living close to natural landscapes is associated with enhanced social and mental health , wellbeiWhile most child-oriented research has utilized parental reports and is acknowledged to be susceptible to bias , recent In this study, the children were exposed to the same mental load in the natural and classroom environments to isolate the effects of the environments on psychosocial stress indexed by so-called tonic and phasic vagal tone. Tonic cardiac vagal tone is considered to indicate the modulation of the vagus nerve, that is, the contribution of the parasympathetic nervous system, on the HR during sitting or supine rest ,27. PhasWhile it may not be the primary function of schools to improve children’s wellbeing and bolster against cumulative stress during early life , there iThe primary purpose of this pilot study was to investigate the differential effects of natural environments compared to classroom environments on the psychophysiological stress system, indicated by vagal tone, in a school context. Further, we investigated whether an effect of the natural environment is also observed in terms of the children’s cognitive performance, and whether vagal tone mediates this effect.We applied a quasi-experimental, within-subjects design in which the participating children performed the same activities and cognitive tasks to retain a similar mental load across the two types of environment. Sequence order was counter-balanced to reduce order effects. The data were generated between April and June 2016.Development of Udeskole” [To avoid reactivity to the new situation, that is, the novelty effect , our popdeskole” , and locdeskole” , five chThe classroom environments utilized in School A were similar: the spaces were airy and colored in mainly white and gray tones with high-quality furniture, fixtures, equipment, and views of green surroundings. One classroom had a few plants, the other did not. All children from School A went to the same forested area, where activities were performed at the top of a grassy slope surrounded by trees on three perimeters overlooking a lake. Only a single permanent bench was available, so the children brought yoga mats on both occasions. It was windy and chilly during the visit to the natural environment for the children of class A1 and warmer and clear for those of class A2. The School B classroom was darker, more crowded, noisier, and had no plants and limited view to greenery. Furthermore, the classroom had no ventilation or air conditioning, which was emphasized by the hot weather on the day of measurement. On the day of measurement in the natural environment, the weather was sunny and the ambient temperature was comfortable. The natural environment was shaded and sheltered by trees encircling the benches that were located there permanently.Polar Team2 Pro  chest-strapped HR monitors were used to record the children’s inter-beat R-R intervals with millisecond accuracy. The mobile devices for the measurement of R-R intervals by Polar generally show excellent agreement with measurements obtained from electrocardiography (ECG) for both adults ,53,54 anRecordings were generated during five minutes of supine rest and the attention task, for a total of four minutes and 40 seconds. Raw R-R intervals were exported from the Polar Team2 software to Microsoft Excel, where a manual data check of the epochs of interest was performed. Artefacts and ectopic beats in the data were interpolated by replacing the artefactual R-R interval with the average of three neighboring R-R intervals. If artefactual R-R intervals made up more than 20% of the selected data segment, the data were considered of poor quality and eliminated. Data processing and analysis were performed with the free professional HRV analysis software of the University of Kuopio, Finland . FollowiRoot mean square of successive differences (RMSSD) was calculated from the data during supine rest, to indicate tonic cardiac vagal tone  the total number of symbols processed . Preliminary analyses were performed on the primary measures, including exploration of the data for normality and outliers. The main measures included tonic, event, and phasic vagal tone, and three cognitive performance parameters: TN-E, TN and E.For each primary measure an estimate of the fixed effect of the individual environments was calculated utilizing generalized estimating equations (GEE), using the GENLIN procedure in SPSS . A majorPsychophysiological variable residuals were not normally distributed, as indicated by histograms, P-P plots, and the Shapiro-Wilk test (statistics not reported here). To meet the assumption of normality of response variables in GEE, psychophysiological measures were log-transformed . One class of 14 children was first exposed to the natural environment and two classes with a total of 34 children had their first day of measurement in the classrooms.p = 0.031), but not event  and phasic  vagal tone while controlling for age, gender and condition sequence (see p = 0.013) and event vagal tone (p < 0.000) than the girls.The GEE indicated that the environments predicted tonic vagal tone , TN , nor E  appeared to be predicted by the environment factor while controlling for age, gender and condition sequence, as well as random subject influences. Condition sequence appeared to predict all the variation (p < 0.000) for both TN-E and TN in favor of the second time the children performed the attention task. Since we did not identify an effect of the natural environment on the attention scores, we did not perform a mediation analysis.Neither TN-E  and having more space facilitated a more relaxing environment. Noteworthy contributions to understanding the mechanisms have been made exploring social aspects, for example, experiencing nature alone or with a friend ,73, typeA concern in the present study relates to potential unmeasured confounding effects from differential external factors, for example, temperature and humidity. Ambient temperature, for example, has been linked to HRV with indications that warmer temperatures may be related to higher ratios of sympathetic to parasympathetic nerve activity , althougA strength of this study is the method used to access stress response. By using chest-strapped HR monitors, the method provides dynamic measures of stress response that do not depend on accurate recall and which bypass self-representation, social desirability, and social norms . The metGiven the relatively small sample size utilized in this pilot study, future studies are required to substantiate the understanding of the phenomenon. While the findings in the study are provisional, we wish to draw attention to the possible practical implications of this study for the organization of education and the challenges involved with urban lifestyles in which the majority of children grow up. The present study took place during quasi-experimental conditions in a school setting, where contact with nature had become routine. The participating children were recruited from schools that practiced EOtC and were positioned in close proximity to natural environments. As such, it is likely that the children also resided in proximity to natural environments. These children and schools are likely not representative of the general population and direct transfer of the findings to children who reside in urban areas or are not accustomed to EOtC may not be possible. It is unknown whether children residing in urban areas with larger exposure environmental stressors would be more or less susceptible to the potential benefits of nature when integrated into the school day. Therefore, there is a need for further studies including children who are not regularly exposed to EOtC in natural environments and schools that are not positioned in natural environments to ascertain potential benefits more widely. Additionally, while the main aim of the study was to explore dynamic aspects of stress response and cognitive performance, it remains unclear whether and how effects endure beyond the acute time and space, and during activities that are more similar to everyday school activities. Dettweiler et al.  providedThe aim of our study was to investigate whether exposure to natural environments in a school setting was associated with reduced stress and improved cognitive performance in comparison to classroom environments. Results indicated that tonic vagal tone, but not event or phasic vagal tone, was higher in the natural environments compared to the classroom environments. These findings suggest a situational aspect of the conditions under which natural environments may have stress buffering influences. In other words, potential stress buffering benefits may be accumulated during breaks and not cognitively demanding exercises. Boys exhibited lower levels of stress response than girls, across both environments. Although observed cognitive performance scores were relatively higher in the natural environment, GEE analysis showed that the difference was due to condition sequence, suggesting a practice effect. Since more children performed the cognitive task for the second time in the natural environment, the practice effect inflated observed cognitive scores in the natural environment. In other words, we could find no evidence to support that the children’s cognitive performances were improved in the natural environments compared to classrooms. This pilot study provided a tentative, quasi-experimental account of the stress buffering potential for utilizing natural environments in a school context. Further research is warranted to understand the potential benefits in a real-life context, in particular with respect to the underpinning mechanisms and effects of accumulated exposure over time in settings where children spend large proportions of time in natural environments.