In Briefs

Abstract

		Editorial
Paul E. Terry	13	On the Need for an Association for Vaccinated Person's RightsCOVID-19 has been more difficult to contain in the United States than in other countries due, in part, to our nation's rootedness in preserving individual freedoms, sometimes in defiance of the need for social accountability for health. With growing evidence that anti-vaccination proponents are increasingly organized, funded, and influential, this editorial argues that the right to health should transcend individual freedoms that have a likely probability of spreading harm to others. An association for vaccinated person's rights, much like ANSR, an association for non-smokers rights, may be needed to counter antivaccination rights organizers. Advancing a goal of mostly “vaccinated and fully immunized populations' would make members of such a group ‘VIP-ers.'”
THE SCIENCE OF INDIVIDUAL AND COLLECTIVE WELL-BEING
		Critical Issues and Trends
Ronli LeviRonit RidbergMelissa AkersHilary Seligman	18	Survey Fraud and the Integrity of Web-Based Survey ResearchWeb-based surveys serve as a valuable resource for conducting socially distant public health research. However, web-based surveys may be susceptible to fraudulent responses in the form of online bots and ill-intentioned humans, which can threaten a study's data integrity. As more research is conducted online, it is especially important to understand and mitigate the unique challenges that these methodologies present. We describe the impact that survey fraud has had on our research study, the safeguards we adopted to preserve our data integrity, and implications for future public health research.
		Quantitative Research
Kristie RuppCiarán P. Friel	21	Changes in Health Behaviors Associated With Weight Gain by Weight Classification During the COVID-19 PandemicPublic health policies implemented to mitigate the spread of COVID-19, including prolonged social-distancing, resulted in major disruptions to health behaviors and led to societal concerns for weight gain, or the “quarantine-15”. Through a cross-sectional survey of 502 US adults, we found that adults with obesity, but not overweight, were significantly more likely to report deleterious changes to their health behaviors, in comparison to their healthy weight peers, during the pandemic. Specifically, adults with obesity were more likely to report decreases in fruit/vegetable consumption and physical activity, increases in processed food consumption and caloric intake, and deterioration in sleep quality. Our findings suggest that adults with obesity may be at greater risk for weight gain during a pandemic. Targeted efforts to improve health behaviors, which may have deteriorated during a pandemic among adults with obesity, are warranted to limit further weight gain that could exacerbate existing health risks.
		Quantitative Research
Ming ChenSatya SurbhiJames E. Bailey	29	Association of Weight Loss With Type 2 Diabetes Remission Among Adults in Medically Underserved Areas: A Retrospective Cohort StudyRandomized controlled trials demonstrate that intensive weight loss can lead to type 2 diabetes remission, but little is known from real-world settings. Using population-based cohort design and comprehensive electronic medical records, the purpose of this study is to examine the association between weight loss and type 2 diabetes remission among a vulnerable population in medically underserved areas of the Mid-South of the United States. Our findings suggest that weight loss is significantly associated with diabetes remission among patients living in medically underserved areas, but complete remission is rare. Primary and specialty care providers can do much more to improve diabetes outcomes by adopting evidence-based approaches to support weight loss and diabetes remission in populations at risk of disparities. Further studies are needed to evaluate alternative pragmatic outpatient care-based interventions to support weight loss and increase rates of diabetes remission among vulnerable populations.
		Quantitative Research
Natalia I. HerediaTianlin XuMinJae LeeLorna H. McNeillBelinda M. Reininger	38	The Neighborhood Environment and Hispanic/Latino HealthNeighborhoods can influence health, though there is a limited research on neighborhood environment and health in Hispanics/Latinos. The purpose of this study is to assess the relation of neighborhood environment with health variables in Hispanic/Latino adults, including physical activity (PA), depression, anxiety, type 2 diabetes, metabolic syndrome, and C-reactive protein (CRP). Participants were randomly-selected from a Hispanic/Latino cohort on the Texas-Mexico border. The sample (n=495) was mostly female and without insurance. Crime, no streetlights, and traffic were all significantly associated with anxiety. Only traffic was significantly associated with depression. A lack of nearby shops and no one out doing PA were both significantly associated with almost 50% lower odds of meeting PA guidelines. A lack of nearby shops was associated 30% increase in the CRP value. The neighborhood environment is a meaningful contextual variable to consider for health-related interventions in Hispanic/Latino adults, though more study is needed regarding the magnitude of the estimates.
		Quantitative Research
Puneet Kaur ChehalLivvy ShaferSolveig Argeseanu Cunningham	46	Examination of Sleep and Obesity in Children and Adolescents in the United StatesPoor sleep may be linked to obesity in children and adolescents, but it is not yet clear whether short duration and inconsistent bedtime patterns puts children at risk of obesity. This study examines the associations between hours of sleep, consistency of bedtime, and obesity among children and adolescents in the US. Data are from the 2016-17 National Survey of Children's Health, an annual study of a representative sample of US non-institutionalized children. An additional hour of sleep was associated with 10.8% lower odds of obesity, net of consistency in bedtime. Relative to children who always went to bed at the same time, children who only usually went to bed at the same time on weeknights had lower odds of obesity (24.8%) after controlling for sleep duration.
		Quantitative Research
Lei ChaiJia Xue	55	Weight, Weight Perceptions, and Health and Well-Being Among Canadian Adolescents: Evidence From the 2017-2018 Canadian Community Health SurveyThe present study examines the extent to which (mis)matched weight and weight perceptions predict adolescents' self-rated health, mental health, and life satisfaction. We select Canadian adolescents aged between 12 and 17 (n= 8,081) from the 2017-2018 Canadian Community Health Survey (CCHS)—a nationally representative sample collected by Statistics Canada. We find that overweight adolescents with overweight perceptions are more likely to report poorer self-rated health, mental health, and life satisfaction compared to their counterparts with normal weight and normal weight perceptions. Similar patterns have also been observed for normal weight adolescents with overweight perceptions (e.g., normal weight adolescents with overweight perceptions are more likely to report poorer self-rated health). The findings suggest that normal weight adolescents are not immune to adverse health and well-being consequences because their weight perceptions also contribute to health and well-being.
		Qualitative Research
Natalie FennCheyenne ReyesKathleen MonahanMark L. Robbins	64	How Ready Are Young Adults to Participate in Community Service? An Application of the Transtheoretical Model of Behavior ChangeCommunity service engagement has been associated with positive mental health outcomes, yet research has not examined the processes by which individuals begin and maintain community service. Using cross-sectional data from an online survey, the current study utilized the transtheoretical model (TTM) of behavior change to examine community service readiness in a sample of collegiate young adults (N=314). Results showed that there were significant differences between higher and lower readiness groupings on all main outcome variables, F(20, 1012) =10.34, p < .001; Wilks' Λ = 0.54, η² = .14. Specifically, those exhibiting higher readiness reported fewer cons, greater pros, higher self-efficacy, more overall civic engagement, and greater well-being compared to lower readiness individuals. Findings are consistent with other TTM applications. Results may be used to inform readiness-tailored interventional work for increasing community service.
		Quantitative Research
Md Irteja IslamFakir Md YunusEnamul KabirRasheda Khanam	73	Evaluating Risk and Protective Factors for Suicidality and Self-Harm in Australian Adolescents With Traditional Bullying and Cyberbullying VictimizationsBullying is associated with mental health problems including suicidality and self-harm. However, the factors associated with suicidality and self-harm among adolescents who experienced traditional bullying and cyberbullying are lacking. This study, therefore, aimed to identify and compare risk and protective factors associated with suicidality and self-harm in adolescents with traditional bullying and cyberbullying victimizations. Overall, 2125 Australian adolescents aged 14–17-year-olds were analyzed from the cross-sectional nationwide survey: Young Minds Matter (YMM). Bivariate analysis and binary logit models were employed to examine the association between predictor variables (demographic, risk, and protective factors) and outcome variables of interest (suicidality and self-harm in bullying victims). The results found girls were more often bullied and likely to experience suicidal and self-harming behavior than boys. Parental distress, mental disorder and psychosis were found to be potential risk factors for suicidality and self-harm in both bullying victim groups (p<0.05). Eating disorders in traditional bullying victims and history of sexual activity in cyberbullying victims were significantly associated with suicidality and self-harm, respectively. While positive mental health/resilience and adequate sleep were found to be associated with less reporting of suicidality and self-harm in all groups (p<0.05). Further, results indicate identifying risk and protective factors among bullying (traditional and cyber) victims is worthwhile to prevent suicidality and self-harm, and ultimately suicide in adolescents.
		Quantitative Research
Julie S. CannonElizabeth K. FarkouhLiana B. WinettLori DorfmanA. Susana RamírezSpencer LazarJeff Niederdeppe	84	Perceptions of Arguments in Support of Policies to Reduce Sugary Drink Consumption Among Low-Income White, Black and Latinx Parents of Young ChildrenThis study assessed racial/ethnic differences in perceptions of strength of arguments in favor of sugar-sweetened beverage (SSB) marketing restrictions and penny-per-ounce tax policies among parents within communities targeted by the SSB industry. The large (n=1485) national sample is entirely lower-income (<$40k) and two-thirds Black and Latinx/Hispanic. Race/ethnicity was not a significant predictor of the perceived strength of a composite of marketing arguments (p_Black=0.07,p_Latinx=0.10); however, it was a significant predictor of the perceived strength of tax arguments (p_Black=0.01,p_Latinx=0.01). Findings further reveal a need for deeper understanding of how to approach discussions of racial injustice and inequity associated with current industry practices, as white parents held relatively low perceptions of strength about arguments that emphasized industry racial/ethnic targeting. However, across racial/ethnic groups, these communities perceive strength in arguments emphasizing benefits of marketing restrictions and tax policies to parents and communities. Thus, emphasizing community benefits may move constituents toward policy support.
		Quantitative Research
Jeanne M. FerranteAaron LullaJulie D. WilliamsonKatie A. DevinePamela Ohman-StricklandElisa V. Bandera	94	Patterns of Fitbit Use and Activity Levels Among African American Breast Cancer Survivors During an eHealth Weight Loss Randomized Controlled TrialAfrican American breast cancer survivors (AABCS) who participated in a mHealth/eHealth weight loss program were highly adherent with wearing activity trackers (median of over 6 days per week throughout 12-months). Simply providing a physical activity tracker to many AABCS may be a convenient, efficient, and efficacious tool to increase their physical activity and decrease sedentary time. However, certain subgroups (those older than age 60 years, retired, have BMI over 40, and higher number of comorbidities or household members) will need more intensive multimodal interventions.
		Quantitative Research
Minal PatelEmily M. DonovanMichael LiuMorgan Solomon-MaynardBarbara S. Schillo	106	Policy Support for Smoke-Free and E-Cigarette Free Multiunit HousingSecondhand exposure to cigarette smoke and e-cigarette aerosol is associated with health harms; tobacco free policies, including those implemented in multiunit housing (MUH), can reduce secondhand exposure to these harms. This study is one of the first to examine policy support for restricting use of cigarettes and e-cigarettes in multiunit housing among a nationally representative sample of US adults. We found that among a nationally representative sample of 3,415 US adults, 76.9% support prohibiting cigarette use and 74.0% support prohibiting e-cigarette use in MUH. Subgroup analyses identified majority support for both policies among MUH residents, across all income levels, and across all racial and ethnic minorities. Current cigarette and e-cigarette use predicted lower support for both policies; current smokers (OR=0.44, p<0.001; OR=0.59, p<0.01) and current e-cigarette users (OR=0.42, p<0.001; OR=0.22, p<0.001) had lower odds of support. However, while smokers supported prohibiting both cigarette (51.4%) and e-cigarette use in MUH (51.1%), 48.1% of current e-cigarette users were in favor of prohibiting cigarette use and 34.5% were in favor of prohibiting e-cigarette use in MUH (34.5%). The overall high support for restricting cigarette and e-cigarette use in MUH is promising for policy development and ultimately reducing sociodemographic disparities in exposure to secondhand tobacco. However, the lower support among e-cigarette users needs to be examined, as increased e-cigarette use in the US may be shifting norms related to tobacco use and tobacco control.
		Quantitative Research
Kelly A. RomanoKristin E. Heron	117	Examining Race and Gender Differences in Associations Among Body Appreciation, Eudaimonic Psychological Well-Being, and Intuitive Eating and ExercisingIn the present sample of young adult college students (N=1,228), greater body appreciation was generally associated with greater eudaimonic psychological well-being and, in turn, different intuitive eating and intuitive exercising behaviors. However, notable variations in this pattern of results were identified based on the particular type of intuitive eating and exercising behavior under investigation, and participants' racial identities. For example, greater eudaimonic psychological well-being strictly mediated a positive association between body appreciation and reliance on hunger and satiety cues intuitive eating behaviors among participants who identified as Black, but not White. The present findings suggest that increasing adults' eudaimonic psychological well-being may help improve health-promoting eating and exercise behaviors, and should be assessed as a mechanism of change in future clinical research.
		Quantitative Research
Daniel J. SchoberSusana ShresthaJessica C. Bishop-Royse	129	The Effects of Exposure to Domestic Violence on Sleep Among Urban AdultsDomestic violence contributes to poor health including sleep disruptions, which has been associated with risk for chronic conditions and ultimately, premature mortality. The present study examined how witnessing domestic violence affected sleep duration among urban neighborhoods of color. We surveyed adults (N=1,543) across ten of Chicago's seventy-seven community areas. Over 49% of participants reported a Hispanic ethnicity, 34.8 percent were non-Hispanic Black and 14.2 percent were non-Hispanic White. Results show that participants who reported witnessing domestic violence were significantly less likely to report getting 7-8 hours of sleep per night, even after controlling for history of abuse, demographic factors and health status. Non-Hispanic Blacks were significantly less likely to report not meeting sleep recommendations. These findings document an important potential contributor to racial health disparities across the United States and highlight the need to promote healthy sleep behavior among Black communities.
		Quantitative Research
Eric S. KimYing ChenJulia S. NakamuraCarol D. RyffTyler J. VanderWeele	137	Sense of Purpose in Life and Subsequent Physical, Behavioral, and Psychosocial Health: An Outcome-Wide ApproachGrowing evidence indicates that a higher sense of purpose in life (purpose) is associated with reduced risk of chronic diseases and mortality. However, epidemiological studies have not evaluated if change in purpose is associated with subsequent health and well-being outcomes. We evaluated if positive change in purpose was associated with better outcomes on 35 indicators of physical health, health behaviors, and psychosocial well-being. We used data from 12,998 participants in the Health and Retirement study—a prospective and nationally representative cohort of U.S. adults aged >50. Over the four-year follow-up period, positive change in purpose was associated with a broad range of physical health outcomes, health behaviors, and psychosocial outcomes. Importantly, purpose was not associated with some other physical health outcomes, health behaviors, and social factors. These results suggest that purpose in life might be a valuable target for innovative policy and intervention work aimed at improving health and well-being.
		Qualitative Research
Enid Chung RoemerKaren B. KentRon Z. GoetzelChris CalitzDrew Mills	148	Reliability and Validity of the American Heart Association's Workplace Health Achievement IndexThis article shares findings from the reliability and validity evaluation of American Heart Association's (AHA) updated Workplace Health Achievement Index (WHAI), a freely available online tool for employers to assess how well they are doing at promoting the health and wellbeing of their employees.
		Qualitative Research
Michelle S. WilliamsTonia PoteatMelverta BenderPrecious UgwuPaul A. Burns	155	Revitalizing HIV Prevention Programs: Recommendations From Those Most Impacted by HIV in the Deep SouthThe incidence of new HIV infections is disproportionately high among Black men who have sex with men (BMSM) in Mississippi and other states in the Deep South Region of the US. The ACCELERATE! initiative was launched with the ultimate goal of reducing the number of new HIV infections among BMSM in Jackson, Mississippi. We conducted a mixed methods evaluation of the ACCELERATE! initiative to assess its impact on the target population. We also explored factors that may act as barriers to and facilitators of BMSM's engagement in HIV prevention interventions. We conducted interviews with BMSM and non-grantee key informants who worked in the field of HIV in Mississippi participated. Using the data from the interviews, we identified 10 key recommendations that can be used to revitalize HIV prevention interventions in the Deep South. In addition, the results of our evaluation indicate that more effort is needed to ensure that HIV prevention interventions are inclusive of all at-risk populations and more interventions aimed at reducing HIV- and LGBT-stigma in healthcare settings.
		Applied Research Brief
Mariah KornbluhShirelle HallumMarilyn WendeJoseph RayZachary HerrnstadtAndrew T. Kaczynski	165	Examining Disparities in Food Access Between Historically Black Colleges and Universities and Non-Historically Black Colleges and UniversitiesThis is the first study to explore disparities in food access between Historically Black Colleges and Universities (HBCUs) and public non-HBCUs on a national scale. Using geospatial techniques to capture food environments and census tract sociodemographic data, we examine if HBCUs (N=98) are more likely to be located in low food access areas (LFAs) compared to public non-HBCUs (N=777) within the U.S. Drawing from national databases, a multilevel logistic regression was employed to examine the relationship between university type and food access classification. University type was significantly associated with LFA classification (B=0.71;p=.0036). Specifically, the odds of an HBCU being located in a LFA were 104% greater than for a public non-HBCU (OR=2.04;95% CI=1.26,3.29). Findings highlight the disparity in food environments between HBCUs and public non-HBUCs on a national scale and underscore the need for environmental and policy interventions to promote food justice.
		Applied Research Brief
Kristi Rahrig JenkinsEmily StiehlBruce W. ShermanSusan L. Bales	169	Supporting Employee Health at Work: How Perceptions Differ Across Wage CategoryThis study uses a retrospective, cross sectional analysis to examine the association between sources of stress and perceptions of organizational and supervisor support for health and well-being across several wage bands of employees at a large university in the mid-western United States. Results from this analysis suggest that stressful job responsibilities and work relationships are associated with lower perceptions of supervisor and organizational support for health and well-being across all wage bands. Favorable perceived support for personal stressors only among high wage earning employees may suggest a need for improved equity of perceived support for these stressors among lower wage workers.
		Applied Research Brief
Shan QiaoCheuk Chi TamXiaoming Li	175	Risk Exposures, Risk Perceptions, Negative Attitudes Toward General Vaccination, and COVID-19 Vaccine Acceptance Among College Students in south CarolinaThe current study investigated how risk exposures and risk perceptions of COVID-19 as well as negative attitudes toward general vaccination were related to COVID vaccine acceptance among college students based on online survey data from 1062 college students in South Carolina. Hierarchical linear regression was used to examine the association of these factors with COVID-19 vaccine acceptance controlling for key demographics. Our study suggests that perceived severity of COVID-19 was positively associated with vaccine acceptance. Higher level of risk exposures and negative attitude toward general vaccination were associated with low vaccine acceptance. Policy makers and practitioners may target high risk groups among college students by assessing their perceived risks of COVID-19, tailor the vaccine communication messages based on college students' psychological dynamics of decision-making and addressed their concerns, particularly pay attention to those reported high risks exposures to virus while showed low intention to vaccine uptake.
		Applied Research Brief
Robert P. LennonMeg L. SmallRachel A. SmithLauren J. Van ScoyJessica G. MyrickMolly A. MartinData4 Action Research Group	180	Unique Predictors of Intended Uptake of a COVID-19 Vaccine in Adults Living in a Rural College Town in the United StatesIn this study, we used a cross-sectional survey of rural adults to explore COVID-19 vaccine confidence. We measured COVID-19 vaccine intention, vaccination attitudes, norms, efficacy, past behavior, trust in the vaccination process, and sociodemographic variables of education, financial standing, political viewpoint, and religiosity. The completion rate was 96% (n=950), with 55% “very likely” and 20% “somewhat likely” to take a coronavirus vaccine. The strongest predictors of vaccine acceptance were trust in the system evaluating vaccines and perceptions of local COVID-19 vaccination norms. The strongest predictors of negative vaccine intentions were worries about unknown side-effects and positive attitudes toward natural infection. Sociodemographic factors, political views, and religiosity did not predict vaccine intentions. Our data indicates that traditional sociodemographic factors may not be effective predictors of COVID-19 vaccine uptake in some rural Americans, and suggests that traditional public health vaccination campaigns based on sociodemographic characteristics may not be effective.
		Applied Research Brief
Bhagyashree KatareShuoli ZhaoJoel CuffeyMaria I. MarshallCorinne Valdivia	185	Preferences Toward COVID-19 Diagnostic Testing Features: Results From a National Cross-Sectional SurveyCOVID-19 diagnostic testing remains a critical tool in identifying, treating, and isolating infected individuals and curbing the spread of the virus. A national survey study was conducted to evaluate individual preferences toward COVID-19 diagnostic testing methods, locations, and monetary incentives. Based on a national-representative sample of 1,505 respondents, results from discrete choice analysis identified four preferences patterns: 34% preferred comfortable testing options, 27% were willing to trade off comfort or convenience for a monetary incentive to undergo testing, 20% avoided testing altogether, and 19% would only test at convenient locations. Respondents in these groups differed significantly in terms of demographic characteristics, political affiliation, and religious identification. Additionally, substantial monetary incentives lead to only small gains in the percentage of testing avoiders who would be willing to test. Among convenience seekers, however, monetary incentives effectively help overcome a dislike of less convenient testing locations. The results of this study uncovered heterogeneity in preferences for COVID-19 diagnostic testing features, which should be considered in the design and implementation of mass testing campaigns and policies for the ongoing pandemic.
		Applied Research Brief
Adolfo G. CuevasMichael V. StantonKeri CarvalhoNatalie EckertKasim OrtizShervin AssariYusuf Ransome	190	Stressful Life Events and Obesity in the United States: The Role of Nativity and Length of ResidenceStressful life events (SLE) have been implicated as a health risk factor that may have a role in explaining the risk of obesity. However, there is scant research examining of the role of nativity status and length of residence in the relationship between SLE and obesity. Using Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions ((2004-2005) [n=34,653]), we conducted a two-way interaction (stressful life events × nativity and length of residence) on obesity, adjusting for sociodemographic factors and health-related behaviors (smoking status and alcohol abuse). We found a significant interaction between SLE and nativity status and length of residence. Based on stratified analyses, SLE were associated with greater odds of obesity for US-born individuals and foreign-born individuals living in the US for >20 years. There was no evidence that SLE were associated with greater odds of obesity for foreign-born individuals living in the US <10 years and 11-19 years. SLE may be a risk factor for obesity, particularly for US-born adults and foreign-born adults living the US >20 years. However, further research is needed to understand the pathways that may link SLE to obesity among these groups.
		Applied Research Brief
Brianna L. DumasSeung Hee LeeDiane M. HarrisAmy L. YarochMary A. PomeroyHeidi M. Blanck	194	Characteristics Associated With Self-Reported Worry Among Adults About Food Availability and Food Safety During the COVID-19 Pandemic—United States, June 2020 Survey DataFood availability and food safety are key tenets of nutrition security, with important implications for population health. The COVID-19 pandemic has contributed to some disruptions in the U.S. food system, however U.S. retailers have reported few major, sustained disruptions in food accessibility, and risk of getting COVID-19 from food and food packaging is considered very low. Even so, consumer behaviors related to food availability and food safety during the pandemic have been documented. Findings from this study underscore the importance of messaging and communications that address real and perceived threats, and the safety and availability of the food supply, during the COVID-19 pandemic.
		Applied Research Brief
Jennifer M. SacheckEmily F. BlakeHannah PressQiushi HuangCatherine M. WrightKarina R. LoraAllison C. SylvetskyAmanda J. VisekLoretta DiPietro	197	Understanding Physical Activity Patterns Across the School Day in Urban Pre-Kindergarten and Elementary SchoolchildrenDespite national recommendations that children accrue at least 30 minutes of physical activity during the school-day, children are not meeting these guidelines given numerous barriers that exist. This study explored school-day activity patterns spanning the pre-kindergarten (pre-K) and elementary school years to identify opportunities for additional physical activity engagement. Physical activity and sedentary time were assessed among pre-K through 5th grade students from lower-income urban schools using accelerometry. Only 34.6% of elementary and 25.3% of pre-K students met the school-time recommendations, with girls accruing less physical activity across all years examined. Bouts of physical activity were largely accrued during recess and physical education with extended bouts of sedentary time occurring throughout the day, especially among pre-K children. Findings illuminate opportunities for simple, low-cost strategies for additional movement time to help children meet recommendations, especially as children return to school post-pandemic.
		Literature Review
Suzi B. ClaflinShannon KlekociukHannah FairEmmanuelle BostockMaree FarrowKathleen DohertyBruce V. Taylor	201	Assessing the Impact of Online Health Education Interventions From 2010-2020: A Systematic Review of the EvidenceThis article systematically reviews the evaluation and impact of online health education interventions: assessing the approaches used, summarizing main findings, and identifying knowledge gaps. Twenty-six studies met the inclusion criteria. Overall, interventions that were available to all (e.g., on YouTube) consistently attained a large global reach, and knowledge was consistently improved. However, the impact on other outcomes of interest (e.g., health literacy, health behaviours) remains unclear. A greater understanding of who online interventions work for and what outcomes can be achieved is crucial to determine, and potentially expand, their place in health education.