***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE : To examine binge eating , depression , weight self-efficacy , and weight control success among obese individuals seeking treatment in a managed care organization . DESIGN : Gender-stratified analyses of associations between binge eating , depression , weight self-efficacy , and weight change , using data from a r and omized clinical trial that compared low-cost telephone-based , mail-based , and usual care interventions for weight loss . SUBJECTS : A total of 1632 overweight individuals ( 460 men , 1172 women ; mean age : 50.7 y ; mean body mass index : 34.2 kg/m2 ) were recruited from a large Midwestern US managed care organization . MEASUREMENTS : Height and weight were measured by study personnel at baseline , and self-reported weight was assessed at 6 and 12 months ; self-reported depression status , binge eating , and self-efficacy for weight control were assessed at baseline . RESULTS : Lifetime prevalence rates for depression and probable binge eating disorder were high . Weight self-efficacy was inversely related to weight in both men and women . For women , depression was associated with lower weight self-efficacy and higher body weight . Women reporting depression or lower weight self-efficacy at baseline had less weight loss success at 6 and 12 months . Depression , binge eating disorder , and weight self-efficacy were not significantly associated with weight loss success in men . CONCLUSION : Negative emotional states are highly prevalent and predict poor treatment outcomes , particularly for obese women . As obese women with clinical depression typically are excluded from intervention studies , further research on how to address the intersection of obesity intervention and mood management may be warranted CONTEXT Rapid increases in access to the Internet have made it a viable mode for public health intervention . No controlled studies have evaluated this re source for weight loss . OBJECTIVE To determine whether a structured Internet behavioral weight loss program produces greater initial weight loss and changes in waist circumference than a weight loss education Web site . DESIGN R and omized , controlled trial conducted from April to December 1999 . SETTING AND PARTICIPANTS Ninety-one healthy , overweight adult hospital employees aged 18 to 60 years with a body mass index of 25 to 36 kg/m(2 ) . Analyses were performed for the 65 who had complete follow-up data . INTERVENTIONS Participants were r and omly assigned to a 6-month weight loss program of either Internet education ( education ; n = 32 with complete data ) or Internet behavior therapy ( behavior therapy ; n = 33 with complete data ) . All participants were given 1 face-to-face group weight loss session and access to a Web site with organized links to Internet weight loss re sources . Participants in the behavior therapy group received additional behavioral procedures , including a sequence of 24 weekly behavioral lessons via e-mail , weekly online su bmi ssion of self-monitoring diaries with individualized therapist feedback via e-mail , and an online bulletin board . MAIN OUTCOME MEASURES Body weight and waist circumference , measured at 0 , 3 , and 6 months , compared the 2 intervention groups . RESULTS Repeated- measures analyses showed that the behavior therapy group lost more weight than the education group ( P = .005 ) . The behavior therapy group lost a mean ( SD ) of 4.0 ( 2.8 ) kg by 3 months and 4.1 ( 4.5 ) kg by 6 months . Weight loss in the education group was 1.7 ( 2.7 ) kg at 3 months and 1.6 ( 3.3 ) kg by 6 months . More participants in the behavior therapy than education group achieved the 5 % weight loss goal ( 45 % vs 22 % ; P = .05 ) by 6 months . Changes in waist circumference were also greater in the behavior therapy group than in the education group at both 3 months ( P = .001 ) and 6 months ( P = .005 ) . CONCLUSIONS Participants who were given a structured behavioral treatment program with weekly contact and individualized feedback had better weight loss compared with those given links to educational Web sites . Thus , the Internet and e-mail appear to be viable methods for delivery of structured behavioral weight loss programs Background Self-guided , Web-based interventions for  depression  show promising results but suffer from high attrition and low user engagement . Online peer support networks can be highly engaging , but they show mixed results and lack evidence -based content . Objective Our aim was to introduce and evaluate a novel Web-based , peer-to-peer cognitive re appraisal platform design ed to promote evidence -based techniques , with the hypotheses that ( 1 ) repeated use of the platform increases re appraisal and reduces depression and ( 2 ) that the social , crowd source d interactions enhance engagement . Methods Participants aged 18 - 35 were recruited online and were r and omly assigned to the treatment group , “ Panoply ” ( n=84 ) , or an active control group , online expressive writing  ( n=82 ) . Both are fully automated Web-based platforms . Participants were asked to use their assigned platform for a minimum of 25 minutes per week for 3 weeks . Both platforms involved posting descriptions of stressful thoughts and situations . Participants on the Panoply platform additionally received crowd source d re appraisal support immediately after su bmi tting a post ( median response time=9 minutes ) . Panoply participants could also practice reappraising stressful situations su bmi tted by other users . Online question naires administered at baseline and 3 weeks assessed depression symptoms , re appraisal , and perseverative thinking . Engagement was assessed through self-report measures , session data , and activity levels . Results The Panoply platform produced significant improvements from pre to post for depression ( P=.001 ) , re appraisal ( P<.001 ) , and perseverative thinking ( P<.001 ) . The expressive writing platform yielded significant pre to post improvements for depression ( P=.02 ) and perseverative thinking ( P<.001 ) , but not re appraisal ( P=.45 ) . The two groups did not diverge significantly at post-test on measures of depression or perseverative thinking , though Panoply users had significantly higher re appraisal scores ( P=.02 ) than expressive writing . We also found significant group by treatment interactions . Individuals with elevated depression symptoms  showed greater comparative benefit from Panoply for depression ( P=.02 ) and perseverative thinking ( P=.008 ) . Individuals with baseline re appraisal deficits showed greater comparative benefit from Panoply for depression ( P=.002 ) and perseverative thinking ( P=.002 ) . Changes in re appraisal mediated the effects of Panoply , but not the expressive writing platform , for both outcomes of depression ( ab=-1.04 , SE 0.58 , 95 % CI -2.67 to -.12 ) and perseverative thinking ( ab=-1.02 , SE 0.61 , 95 % CI -2.88 to -.20 ) . Dropout rates were similar for the two platforms ; however , Panoply yielded significantly more usage activity ( P<.001 ) and significantly greater user experience scores ( P<.001 ) . Conclusions Panoply engaged its users and was especially helpful for depressed individuals and for those who might ordinarily underutilize re appraisal techniques . Further investigation is needed to examine the long-term effects of such a platform and whether the benefits generalize to a more diverse population of users . Trial Registration Clinical Trials.gov NCT02302248 ; https:// clinical trials.gov/ct2/show/NCT02302248 ( Archived by WebCite at http://www.webcitation.org/6Wtkj6CXU ) BACKGROUND The Internet provides us with tools ( user metrics or para data ) to evaluate how users interact with online interventions . Analysis of these para data can lead to design improvements . OBJECTIVE The objective was to explore the qualities of online participant engagement  in an online intervention . We analyzed the para data in a r and omized controlled trial of alternative versions of an online intervention design ed to promote consumption of fruit and vegetables . METHODS Volunteers were r and omized to 1 of 3 study arms involving several online sessions . We created 2 indirect measures of breadth and depth to measure different dimensions and dynamics of program engagement based on factor analysis of para data measures of Web pages visited and time spent online with the intervention material s. Multiple regression was used to assess influence of engagement on retention and change in dietary intake . RESULTS Baseline surveys were completed by 2513 enrolled participants . Of these , 86.3 % ( n = 2168 ) completed the follow-up surveys at 3 months , 79.6 % ( n = 2027 ) at 6 months , and 79.4 % ( n = 1995 ) at 12 months . The 2 tailored intervention arms exhibited significantly more engagement than the untailored arm ( P < .01 ) . Breadth and depth measures of engagement were significantly associated with completion of follow-up surveys ( odds ratios [ OR ] = 4.11 and 2.12 , respectively , both P values < .001 ) . The breadth measure of engagement was also significantly positively associated with a key study outcome , the mean increase in fruit and vegetable consumption ( P < .001 ) . CONCLUSIONS By exploring participants ' exposures to online interventions , para data are valuable in explaining the effects of tailoring in increasing participant engagement in the intervention . Controlling for intervention arm , greater engagement is also associated with retention of participants and positive change in a key outcome of the intervention , dietary change . This paper demonstrates the utility of para data capture and analysis for evaluating online health interventions . TRIAL REGISTRATION NCT00169312 ; http:// clinical trials.gov/ct2/show/NCT00169312 ( Archived by WebCite at http://www.webcitation.org/5u8sSr0Ty ) Background Increased access to the Internet and the availability of efficacious eHealth interventions offer great promise for assisting adults with diabetes to change and maintain health behaviors . A key concern is whether levels of engagement in Internet programs are sufficient to promote and sustain behavior change . Objective This paper used automated data from an ongoing Internet-based diabetes self-management intervention study to calculate various indices of website engagement . The multimedia website involved goal setting , action planning , and self-monitoring as well as offering features such as “ Ask an Expert ” to enhance healthy eating , physical activity , and medication adherence . We also investigated participant characteristics associated with website engagement and the relationship between website use and 4-month behavioral and health outcomes . Methods We report on participants in a r and omized controlled trial ( RCT ) who were r and omized to receive ( 1 ) the  website alone ( n = 137 ) or ( 2 ) the website plus human support ( n = 133 ) that included additional phone calls and group meetings . The website was available in English and Spanish and included features to enhance engagement and user experience . A number of engagement variables were calculated for each participant including number of log-ins , number of website components visited at least twice , number of days entering self-monitoring data , number of visits to the “ Action Plan ” section , and time on the website . Key outcomes included exercise , healthy eating , and medication adherence as well as body mass index ( BMI ) and biological variables related to cardiovascular disease risk . Results Of the 270 intervention participants , the average age was 60 , the average BMI was 34.9 kg/m2 , 130 ( 48 % ) were female , and 62 ( 23 % ) self-reported Latino ethnicity . The number of participant visits to the website over 4 months ranged from 1 to 119 ( mean 28 visits , median 18 ) . Usage decreased from 70 % of participants visiting at least weekly during the first 6 weeks to 47 % during weeks 7 to 16 . There were no significant differences between website only and website plus support conditions on most of the engagement variables . In total , 75 % of participants entered self-monitoring data at least once per week . Exercise action plan pages were visited more often than medication taking and healthy eating pages ( mean of 4.3 visits vs 2.8 and 2.0 respectively , P < .001 ) . Spearman nonparametric correlations indicated few significant associations between patient characteristics and summary website engagement variables , and key factors such as ethnicity , baseline computer use , age , health literacy , and education were not related to use . Partial correlations indicated that engagement , especially in self-monitoring , was most consistently related to improvement in healthy eating ( r = .20 , P = .04 ) and reduction of dietary fat ( r = -.31 , P = .001 ) . There was also a significant correlation between self-monitoring and improvement in exercise ( r = .20 , P = .033 ) but not with medication taking . Conclusions Participants visited the website fairly often and used all of the theoretically important sections , but engagement decreased over 4 months . Usage rates and patterns were similar for a wide range of participants , which has encouraging implication s for the potential reach of online interventions . Trial Registration NCT00987285 ; http:// clinical trials.gov/show/NCT00987285 ( Archived by WebCite at http://www.webcitation.org/5vpe4RHTV Background There has been limited study of factors influencing response rates and attrition in online research . Online experiments were nested within the pilot ( study 1 , n = 3780 ) and main trial ( study 2 , n = 2667 ) phases of an evaluation of a Web-based intervention for hazardous drinkers : the Down Your Drink r and omized controlled trial ( DYD- RCT ) . Objectives The objective was to determine whether differences in the length and relevance of question naires can impact upon loss to follow-up in online trials . 
    Output:
    
A conceptual framework is proposed in which engagement with a DBCI is influenced by the DBCI itself ( content and delivery ) , the context ( the setting in which the DBCI is used and the population using it ) and the behaviour that the DBCI is targeting .
The context and “ mechanisms of action ” may moderate the influence of the DBCI on engagement .
Engagement , in turn , moderates the influence of the DBCI on those mechanisms of action .