www.jped.com.br
ORIGINAL
ARTICLE
Usability
of
an
internet-based
platform
(Next.Step)
for
adolescent
weight
management
夽
Pedro
Sousa
a,b,∗,
Helena
Fonseca
c,d,
Pedro
Gaspar
a,b,
Filomena
Gaspar
eaSchoolofHealthSciences,InstitutoPolitécnicodeLeiria,Lisbon,Portugal bHealthResearchUnit(UIS)oftheInstitutoPolitécnicodeLeiria,Lisbon,Portugal cFaculdadedeMedicina,UniversidadedeLisboa,Lisbon,Portugal
dPediatricObesityClinic,DepartmentofPediatrics,HospitaldeSantaMaria(HSM),Lisbon,Portugal eEscolaSuperiordeEnfermagemdeLisboa,Lisbon,Portugal
Received11February2014;accepted13May2014 Availableonline20September2014
KEYWORDS
Usability; Internet-based; Platform; Adolescents; Overweight; Weightmanagement
Abstract
Objective: Thecurrentstudyevaluatestheusabilityperceptionofane-therapeuticplatform (supportedbyelectronicprocessesandcommunication),aimingtopromotethebehaviorchange andtoimprovetheadolescenthealthstatusthroughincreasedandinteractivecontactbetween theadolescentandtheclinicalstaff.
Methods: Thiswasacorrelational studywithasample of48 adolescents(12-18years)who attendedaPediatricObesityClinicbetween JanuaryandAugust of2012. Participantswere invitedtoaccess,during24weeks,thee-therapeuticmultidisciplinaryplatform(Next.Step)in additiontothestandardtreatmentprogram.Ausabilityquestionnairewasadministeredand theplatformperformanceandutilizationindicatorswereanalyzed.
Results: The users’ perception of satisfaction, efficiency, and effectiveness regarding the Next.Step platformwas clearly positive. However, only 54.17%of theenrolled adolescents accessedtheplatform,withameantask-completionrateof14.55%(SD=18.853).Thehigherthe numberoftheplatformconsultedresources,thegreaterthetendencytoenjoytheplatform, toconsideritexcitingandquick,toconsiderthatthetimespentinitwasuseful,toconsider theaccess toinformationeasy,andtologineasier.Post-interventionassessmentrevealeda significantreductioninanthropometricandbehavioralvariables,includingbodymassindex z-score,waistcircumferencepercentile,hipcircumference,andweeklyscreentime. Conclusion: Theseresultshighlighttheimportanceofinformationandcommunication tech-nologies inthehealth informationaccessandthe healthcareprovision.Despitethelimited adherencerate, platform usersexpressed apositive overall perception ofitsusability and presentedapositiveanthropometricandbehavioralprogress.
©2014SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Allrightsreserved.
夽
Pleasecitethisarticleas:SousaP,FonsecaH,GasparP,GasparF.Usabilityofaninternet-basedplatform(Next.Step)foradolescent weightmanagement.JPediatr(RioJ).2015;91:68---74.
∗Correspondingauthor.
E-mail:pmlsousa@gmail.com(P.Sousa).
http://dx.doi.org/10.1016/j.jped.2014.05.010
PALAVRAS-CHAVE
Usabilidade; Nainternet; Plataforma; Adolescentes; Sobrepeso; Controledepeso
Usabilidadedeumaplataformanainternet(Next.Step)nocontroledepesode adolescentes
Resumo
Objetivo: Oestudoatualavaliaapercepc¸ãodeusabilidadedeumaplataformae-terapêutica (suportadaporprocessosecomunicac¸ãoeletrônicos),visandopromover amudanc¸a compor-tamental emelhorar oestadode saúde dosadolescentes atravésdo contatoaumentadoe interativoentreoadolescenteeaequipeclínica.
Métodos: Estudocorrelacional comuma amostra de 48 adolescentes(12-18 anos) que fre-quentaramumaClínicadeObesidadeInfantilentrejaneiroeagostode2012.Osparticipantes foramconvidadosaaceder,durante24semanas,àplataformamultidisciplinare-terapêutica (Next.Step)e,alémdisso,aparticipardoprogramadetratamentopadrão.Umquestionáriode usabilidadefoiadministradoeforamanalisadososindicadoresdedesempenhoeutilizac¸ãoda plataforma.
Resultados: A percepc¸ão de satisfac¸ão, eficiência e eficácia dos usuários com relac¸ão à plataforma Next.Step foi claramente positiva. Contudo, apenas 54,17% dos adolescentes inscritosacederam àplataforma,comuma taxamédiade conclusãodastarefas de14,55% (DP=18,853).Quandomaioronúmeroderecursosconsultadosnaplataforma,maiora tendên-ciadegostardaplataforma,considerando-aexcitanteerápida,considerandoqueotempogasto namesmaéútileconsiderandooacessoainformac¸õeseaoregistromaisfácil.Aavaliac¸ão pós-intervenc¸ãomostrouumareduc¸ãosignificativanasvariáveisantropométricase comporta-mentais,inclusivenoz-scoredoÍndicedeMassaCorporal,nopercentildecircunferênciada cintura,nacircunferênciadoquadrilenotempodetelasemanal.
Conclusão: Esses resultados destacam a importância das Tecnologias de Informac¸ão e Comunicac¸ãonoacessoainformac¸õessobresaúdeeprestac¸ãodecuidados.Apesar da limi-tadataxadeadesãoosusuáriosdaplataformaexpressaramumapercepc¸ãogeralpositivade suausabilidadeeapresentaramumprogressoantropométricoecomportamentalpositivo. ©2014SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Todososdireitos reservados.
Introduction
Healthcare is experiencing a cultural transformation, challenging physicians to change from a provider to a patient-centeredhealthcaremodelperspective.Thisswitch is made possible by the evolution of information systems in the field of health sciences and empowered by the e-healthapproach(healthcarepracticesupported by elec-tronic processes and communication), which contributes toamoreefficient,accessible, andaffordablehealthcare model.1 Therefore, internet plays an important role in this healthcareparadigm change, with patients becoming empowerede-consumers(consumersofelectronicprocesses andcommunication).
Therehasbeenagrowinguseoftechnologiesregarding thesearchforhealthinformation.2,3Oneofthebenefitsof e-healthinterventionsisitsflexibility,whichmayfacilitate theprovisionoftailoredmessagesbasedontheusers’ spe-cificculturalandindividualcontexts.Theinteractivenature of e-healthapplicationscanfurther enhancelearning and behavioralchange.4
Asystematicreviewontheeffectivenessofinformation and communication technology (ICT) in the treatment of obesechildrenandadolescentsintheUnitedStatesreported that75%oftheonlineinterventionprogramsyieldedclinical andstatisticalsignificantresults.Theseresultsunderscore the effectiveness evidence in reducing body mass index (BMI)andfatintakeandinincreasingphysicalactivity.5
Interactive technologies offer new opportunities to provide tailored health information. However, usability shouldbethemaingoalofaninteractiveproduct,sothatit canbeemployedforitsintendedpurpose.Increased usabil-itybringssignificantbenefits:increasedefficiency,improved productivity,reducederrors,lessneedfortraining,and bet-teracceptance.6Consideringusabilityasadynamicprocess, itsassessmentisdependentonhowitisdefined.
Therearedifferentapproachesregardingtotheusability indicators;Hix&Hartson,7whosevisionwasadoptedbythe International Organization for Standardization (ISO) 9241-11,8definesusabilityastheextenttowhichaproductcan beusedbyspecified userstoachieve specified goals with effectiveness(meaningboththeabilityofcompletingtasks throughthesystemandthequalityoftheachievedresults), efficiency(levelofresourcesconsumedinperformingtasks), andsatisfaction(subjectivereactionsofusersbasedonthe useofthesystem)inaspecifiedcontextofuse.
The current study evaluated the usability (satisfac-tion, efficiency, and effectiveness perceptions) of an e-therapeuticplatform(Next.Step),whichaimstopromote thebehaviorchangeandtoimprovetheadolescenthealth statusthroughincreasedand interactivecontactbetween theadolescentandtheclinicalstaff.
Methods
Sample
Participantswereadolescentsfollowedatahospital-based Pediatric Obesity Clinic, fulfilling the following inclusion criteria:aged between12 and18years, BMIpercentile≥ 85th,andwithinternetaccessatleastonceaweek.Sample
recruitmenthadthesupportoftheclinicalstaff.Alleligible adolescentswithappointmentsbetweenJanuaryandAugust of2012wereinvitedtoparticipateintheprogram.
Participants followed the standard treatment protocol and,additionally,receivedfreeaccesstothee-therapeutic platform (Next.Step) for 24 weeks. They were divided into two subgroups, depending on the study enrolment order:groupA(n=23)andgroupB(n=25).GroupAbegan the intervention in May 2012 and Group B in October 2012,aimingtoreducetheadolescents’waitingperiodto start the program. However, the procedure wasidentical in both groups, namely the treatment length, methods, content/resources,and functionalities.The case manager andtheclinicalteamwerethesameinbothgroups.
Procedures
This study was approved by the Ethical Committee for Health(Lisbon,Portugal)andfundedbytheFoundationfor ScienceandTechnology(PTDC/DTP-PIC/0769/2012).All eli-gibleadolescentsandrespectiveparentssignedaninformed consent where the study objectives were explained, fol-lowingtheethicalaspectsofconfidentiality andvoluntary participation.
Dataanalysis
Descriptive andinferentialstatistics were applied(paired and independent tests), considering the study aims and variables. Nonparametric tests (Spearman’s correlation, Mann-Whitney’sUtest, andKruskal-Wallistest) wereused ininferentialstatistics,duetothereducednumberofvalid responsesinseveralindicators.Allanalyseswereconducted usingbilateraltestsandalphasof0.05.Forthispurpose,was usedthesoftwareSPSS,version22.0(IBMCorp,NY,USA).
Measures
Surveymethods and platform functioning have been pre-viously described in detail elsewhere,11 as this study is part of an ongoing longitudinal research. Data were col-lected through different sources, namely: a) the clinical file (demographics, anthropometric, behavioral, and clin-ical variables); b) the Next.Step e-therapeutic platform (utilization rate, number of logins, consulted resources,
self-monitoring data, game scores, and participation in forums); c) a self-report instrument (Next.Step Usability Questionnaire[NSUQ]).
BMIassessment.Anthropometricdataweremeasuredby trained health professionals from the clinic. Adolescents wereclassifiedintooverweightandobeseaccordingtoBMI cut-offsendorsedbytheCentersofDiseaseControland Pre-vention (CDC).12 Forassessingplatform effectiveness, the WorldHealthOrganization(WHO)BMIcharts13wereusedin additiontothosefromCDC,toenablecomparisonofresults withstudiesusingbothapproaches.
Usabilityassessment.NSUQincludedauserprofile eval-uation section (internet access, amount of internet daily use,computeravailability)andasecondsectionregarding theevaluationoftheusabilityperception(27independent items, scored 1-5; the higher the index, the better the usability).Thequestionnairewasavailableontheplatform. Warningemailswithdirectlinkstotheinstrumentwere peri-odicallysentinordertoreducedropout.14
Next.Step platform. Participants were invited to get restrictedaccesstothee-therapeuticplatform(Next.Step). In additiontotheplatform manager(nurse),the program also had the direct support of an interdisciplinary team (includingapediatrician,nutritionist,exercisephysiologist, and psychologist) who intervened when requested by the casemanager.Interventionlengthwas24weeks,basedon acasemanagementmethodology.
The program was structured in ten thematic modules, with an average duration of twoweeks. A fictional story has been created, developed ineight episodes.The story tells the life events of a fictional character who fights against thestigma ofobesity and whodecides toembark in a quest which will finallylead to a healthierand hap-pier life, inspired by the magical book (the ‘Next.Step’). This is the motto for the platform, where the partici-pant can explore five key areas: ‘Magical Book’ (where he will find the tasks/missions for each level, discussion forums, and the Next.Step episodes); ‘Enchanted Chest’ (areareservedforresourcessuchasentertainment,games, quizzes,andcompetitions);‘LostPages’(virtualrepository of educational resources on health, glossaries, multime-dialibrary,andthematicstories);‘Secrets’(self-monitoring toolsarea,personaldiary,therapeuticgoalsdefinition,and questionnaires);and‘Help’(wheretheplatformcreditsare presented,technicalsupportprovided,andthevirtualclinic ofNext.Stepcanbefound).Fullpresentationoftheplatform featurescanbefoundindetailelsewhere.11
Results
Participants’characteristics
Table1 Variationofclinicaloutcomesat24weeks(WilcoxonSignedRankstest).
T0 T2 (T2-T0)
M SD M SD M SD Z p
Anthropometricvariables
BMIz-score 2.613 0.625 2.530 0.809 -0.084 0.262 -2.815a 0.005
Waistcircumferencepercentile 91.427 2.950 90.151 2.729 -1.276 2.197 -4.367a 0.000
Hipcircumference(cm) 108.938 7.440 10.763 6.373 1.824 2.329 -4.701a 0.000
Behavioralvariables
Weeklyphysicalactivity(h/w) 4.363 3.141 3.939 2.459 -0.424 1.893 -1.435 0.151
WeeklyScreentime(h/w) 21.77 9.598 19.802 10.759 -1.968 9.169 -2.528a 0.011
Weightlossmotivation 3.777 0.787 3.867 0.587 0.089 0.823 -0.975 0.329
BMI,bodymassindex;h/w,hoursperweek;T0,baselineevaluation;T2,post-interventionevaluation;,change;M,mean;SD,standard deviation;Z,Wilcoxonsignedranksteststatistic.
a p<0.01.
Satisfactionassessment(usability)
Theassessment ofNext.Stepparticipants’satisfactionis a crucialstepintheevaluationofitsusability.Table2presents the descriptiveresultsof the NSUQitems regarding satis-faction perception.All itemshad an averagescore higher
thanthree(between3.250and3.875),reflectingaclearly positiveperceptionofsatisfaction.
Thecorrelationbetweenthesatisfactionperceptionand theNext.Steputilization wasfurtheranalyzed,andit was observedthatthehigherthenumberofconsultedresources, thegreaterthetendencytoenjoytheplatform(rs=0.593,
Table2 DescriptivestatisticsofNext.StepUsabilityQuestionnaire(NSUQ)itemsandSpearmancorrelationwiththenumber ofNext.Stepconsultedresources.
Itemdescription Consultedresources
n M SD rs p
Satisfactionperception
1 Likeusingtheplatform 17 3.529 1.068 0.593a 0.025
5 Theplatformisnice 17 3.471 1.179 0.321 0.263
6 Theplatformisstimulating 17 3.353 0.996 0.581a 0.029
16 Theplatformisintuitive 16 3.250 1.125 0.264 0.383
15 Navigationspeed 16 3.875 1.088 0.743b 0.004
21 Timespentwasworthwhile 15 3.267 1.033 0.668a 0.017
Efficiencyperception
2 Easeofuse 17 4.059 1.144 0.083 0.779
3 Easeofinformationaccess 17 3.706 1.160 0.547a 0.043
7 Easetologin 16 4.125 1.088 0.773b 0.002
9 Easeofaccesstomessages 14 3.786 0.893 0.200 0.555
10 Easetodownloaddocuments 14 3.571 1.158 0.167 0.624
11 Easetocommunicatewithhealthprofessionals 16 4.125 0.885 0.529 0.063
13 Platformavailability 16 4.125 1.088 0.386 0.192
14 Platformaccessibility 16 3.813 1.276 0.618a 0.024
Effectivenessperception
17 Usefulnesstotreatment 16 3.625 1.258 0.480 0.097
18 Informationrelevancefortreatment 16 4.125 1.025 0.773b 0.002
19 Improvedabilitytomeettreatment 17 3.294 1.312 0.384 0.175
20 Increasedmotivationfortreatment 16 3.250 1.065 0.314 0.296
23 Motivationtodiscussionwithcolleaguesabout treatment
14 2.786 1.251 -0.410 0.211
24 Motivationtodiscussionwithhealth professionalsabouttreatment
14 3.143 1.167 0.038 0.912
n,numberofcases;M,mean;SD,standarddeviation;rs,Spearman’scorrelationcoefficient. Note:itemsscored1-5(thehighertheindex,thebettertheusability).
Table3 DescriptivestatisticsofNext.Stepefficiency indi-cators,regardingtherecordedactivityandtheparticipants’ scores.
Next.Stepefficiencyindicators n M SD
Recordedactivity
Logins 25 10.538 18.552
Consultedresources 23 8.087 9.115 Activeparticipationinforums 11 4.727 6.857 Passiveparticipationinforums 22 33.455 47.032 Task-completionrate 18 14.551 18.853 Personaldiaryentries 5 2.200 1.304 Settingpersonalgoals 8 1.250 0.463
Self-monitoring 8 6.750 5.312
Scores
‘‘MagicBook’’total 18 17.440 24.492
‘‘Secrets’’total 11 7.636 7.393
‘‘Next.Step’’total 26 63.305 100.588
n,numberofcases;M,mean;SD,standarddeviation.
p=0.025), consider it exciting (rs=0.581, p=0.029) and
fast(rs=0.743, p=0.004), andconsiderthe timespent in
Next.Stepuseful(rs=0.668,p=0.017).
Efficiencyassessment(usability)
Thesecond dimension ofNext.Stepusabilityreferstothe efficiency indicators. The overall results of the recorded activity in Next.Step during the intervention periodwere analyzed. There was a greater number of participations in the ‘‘Magic Book’’ and ‘‘Secrets’’ areas, especially in theforums (2,117views), in the wall of fame/score (388 views), and in the self-monitoring tools (328 views). The resourceswithlowerparticipationweretheplatformgames (92 views). Participants’ adherence decreased over time, withaslightincreaseinthethirdandfifthmonths.
Table 3 shows the descriptive results of the Next.Step efficiencyindicators, regarding the recorded activity and the participants’ scores. Only 26 out of the 48 adoles-cents assignedto the study accessed Next.Step(54.17%), andonly23consultedatleastonefeatureoftheplatform (47.92%).Amongtheactiveparticipants,theaverage num-berofloginsduringthesixmonthswas10.538(SD=18.552). Thepassiveparticipationinforumshadanaverageof33.455 (SD=47.032) views. The mean task-completion rate was 14.55%(SD=18.853).ThemeanoverallNext.Stepscoreper participantwas63.305(SD=100.588).
The analysis of the descriptive results of the items relatedtoNSUQefficiency perception.The average score washigherthan3(between3.571and4.125),reflectinga very positive perception of efficiency(Table 2). The cor-relation analysis between the efficiency perception and theNext.Steputilizationdemonstratedthatthehigherthe numberof consulted resources, the greater the tendency to consider the access to information easier (rs=0.547,
p=0.043),easiertologin(rs=0.773,p=0.002),andeasier
toaccesstheplatform(rs=0.618,p=0.024).
Effectivenessassessment(usability)
The effectiveness assessment is a key aspect of platform usability.Next.Stepprovidesitsusersaself-monitoringtool forweight,nutritionandphysicalactivitybutthistoolwas onlyusedbyeightadolescents,registeringanaverage vari-ation(final evaluation -baseline)of -1.684kg(SD=2.372) inweight,.250(SD=0.528)innutritionand.450(SD=0.691) in physical activity. Despite this favorable trend in all these three parameters, the Wilcoxon signed ranks test showedthatthedifferenceswerenotstatisticallysignificant (p>0.05).
The users’ perception of effectiveness was assessed throughsixNSUQitems(Table2).Onlytheitem23 (Moti-vationtodiscuss/sharewithplatformpeers)hadanaverage scoresmallerthan3(2.786±1.251),withalltheotheritems ratingabove (3.143to 4.125),showing a positive percep-tionoftheplatformeffectiveness.Correlatingtheseitems withthenumberofconsultedresources,itappearsthatthe greatertheuseoftheplatform,thegreaterthetendencyto considertheinformationpertinenttotreatment(rs=0.773,
p=0.002).
Attheendofthetrialperiod(24weeks),allparticipants underwent an objective re-assessment of anthropometric andbehavioral variables.A significant reduction(p<0.05) in the BMI z-score, waist circumference percentile, hip circumference, and weekly screen time wasobserved, as demonstratedinTable1.
Discussion
The current study sought toevaluate the usability of the Next.Stepplatform throughtheusers’perception, aswell astoanalyzetheplatformperformanceandutilization indi-cators.
Theusers’perceptionofsatisfactionwiththeNext.Step wasclearly positive. As expected,the higherthe number ofconsulted resources,thegreaterthetendency toenjoy theplatform, toconsideritexcitingandfast,andto con-sider that thetime spent in Next.Step wasuseful. These findingsareconsistentwiththeISO/IEC9126-1andprevious studies,whereitisclearlystatedthatonlinesystemusers’ satisfactioniscrucialtoitssuccessandtoincrease adher-encetothesetools.15---18Currentlythereisagrowingconcern withtheusersatisfactionandthequalityoftheinterfaces between thedifferent health servicesactors (bothhealth professionalsandpatients).
a clinical history withseveral weightloss failedattempts sinceanearlyage.Thesemaybesomeofthereasonsthat contributedtothehighdropoutrate.
The efficiencyperceptionwasverypositive;thehigher thenumberofconsultedresources,thehigherthetendency oftheparticipantstoconsidertheplatformeasiertoaccess. The development of more efficient communication chan-nelsbetweentheindividualandthehealthprofessionalshas beenunderlinedbydifferentauthors,20anditisan impor-tantrequisiteforamoreactiveroleinone’sownhealthcare. ThegrowingdisseminationofICTmaycontributetoraising the populationhealth standards througha moreeffective provisionofcare.ForGarridoetal.,21 healthcarehas ben-efited from the constant developments and technological innovationsinlifesciences.DuetoawidespreadICTaccess, healthinformationcanbeperceivedasagaininhealthcare autonomy.
Thethirdusabilitydomainunderanalysiswas effective-nessperception,namelytheusers’abilitytocompletethe tasks through the system and the quality of the results.7 The availableweight,nutrition,andphysical activity self-monitoring tool was only used by eight teenagers, who presentedaclearlypositivebutnotstatisticallysignificant progress.Thisnon-significancemaybeduetothereduced numberofvalidanswers.
Theusers’perceptionregardingtheplatform effective-nesswasingeneralpositive,withtheexceptionoftheitem onthemotivationtodiscuss/share withplatform peers.A possibleexplanationforthisresultmightbethatoverweight adolescents,even‘‘protected’’bytheanonymityprovided bythevirtualenvironment,stillpresentlimitedinteraction with their peers on sensitive topics. Despite these con-straints,intheauthors’opinion,peersupportisoneofthe featuresoftheNext.Stepplatformwithgreaterpotential. Peersupporthasbeen considered bymultiple authors22---24 ascrucialininterventionprogramsforobeseadolescents.
It wasalsofound thatthe greater theuse ofthe plat-form,thegreaterthetendencytoconsidertheinformation pertinenttothe treatment. These data arein agreement withtheconclusionsofLauterbach,3whofoundthat57%of individualsseekinghealthinformationontheinternet con-sider thate-healthinformationinfluencestheirtreatment options.Heunderlinesthatthisdoes notmeanthat physi-ciansarebeingreplaced.Infact,53%ofthesubjectsbelieve thattheirInternetresearchledthemtorequestmore infor-mationfromtheirphysicianorevenmakeanappointment. In the same direction, Andreassen et al.2 found that the useofe-healthinformationappearstocomplementandnot replaceotherhealthservices.
One of the most important findings of this study was the significant reduction in some objective anthropomet-ricand behavioralparameters,such asBMIz-score, waist circumference percentile, hip circumference, and weekly screentime.Theseresultsareinlinewithrecentsystematic reviewsone-healthinterventionsforprevention/treatment ofoverweightchildren/adolescents.5,25
The e-therapywasemployedasanadd-onandnotasa substitutetothestandardface-to-faceinterventionwiththe healthcareprofessional,basedonthemeta-analysisofReed etal.,26 wheretheypresentedveryrelevantfindings: indi-vidualswhoreceivedtheinterventionasacomplementto thestandardinterventionlostsignificantlymoreweightthan
thoseforwhomtheinterventionhasbeenasubstitute.For Baulchet al.,27 although the face-to-face modalitiesmay bepreferred, the high prevalence rates of obesity28 sug-gestthe urgency of expanding the treatment optionsand reducing the associated costs. For all these authors, the internetconstitutesaninnovativeandeffectivealternative orcomplementtotheface-to-faceprograms.29
The usability assessment is essential, although as con-sequence of the distinct/specific contexts, it is difficult tomake comparisons between thedifferent systems,and potentially misleading to generalize design features. The onlyexceptionmaylayintheareaof subjectiveusability, usuallyassedusingquestionnairesandattitudescales.18
Futureresearchshouldfocusonadditionalstrategiesto increase participants’ adherence and alternative recruit-mentsmethods.30
Funding
ThisworkwasfundedbyFundac¸ãoparaaCiênciaea Tec-nologia (PTDC/DTP-PIC/0769/2012) and supported by the PolytechnicInstituteofLeiria,Portugalandbythe Depart-ment of Pediatrics at Hospital de Santa Maria, Lisbon, Portugal.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgements
ThisworkwasfundedbyFundac¸ãoparaaCiênciaea Tec-nologia (PTDC/DTP-PIC/0769/2012) and supported by the PolytechnicInstituteofLeiria,PortugalandtheDepartment ofPediatricsat Hospitalde SantaMaria,Lisbon,Portugal. [Sugiro excluir, informac¸ão já dada na sec¸ão ‘‘Funding’’] Theauthorsgratefullyacknowledgetheclinicalstaffofthe PediatricObesityClinicandthe‘‘UnidadedeEnsinoà Dis-tância’’fortheirdedication.Theywouldalsoliketothank alltheadolescentsandparentsfor theirparticipationand collaboration.
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