title: Efficacy and External Validity of Electronic and Mobile Phone-Based Interventions Promoting Vegetable Intake in Young Adults: Systematic Review and Meta-Analysis.
abstract: BACKGROUND
  Young adults (18-35 years) remain among the lowest vegetable consumers in many western countries. The digital era offers opportunities to engage this age group in interventions in new and appealing ways.
  
  
  OBJECTIVE
  This systematic review evaluated the efficacy and external validity of electronic (eHealth) and mobile phone (mHealth) -based interventions that promote vegetable intake in young adults.
  
  
  METHODS
  We searched several electronic databases for studies published between 1990 and 2015, and 2 independent authors reviewed the quality and risk of bias of the eligible papers and extracted data for analyses. The primary outcome of interest was the change in vegetable intake postintervention. Where possible, we calculated effect sizes (Cohen d and 95% CIs) for comparison. A random effects model was applied to the data for meta-analysis. Reach and representativeness of participants, intervention implementation, and program maintenance were assessed to establish external validity. Published validation studies were consulted to determine the validity of tools used to measure intake. We applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to evaluate the overall quality of the body of evidence.
  
  
  RESULTS
  Of the 14 studies that met the selection criteria, we included 12 in the meta-analysis. In the meta-analysis, 7 studies found positive effects postintervention for fruit and vegetable intake, Cohen d 0.14-0.56 (pooled effect size 0.22, 95% CI 0.11-0.33, I(2)=68.5%, P=.002), and 4 recorded positive effects on vegetable intake alone, Cohen d 0.11-0.40 (pooled effect size 0.15, 95% CI 0.04-0.28, I(2)=31.4%, P=.2). These findings should be interpreted with caution due to variability in intervention design and outcome measures. With the majority of outcomes documented as a change in combined fruit and vegetable intake, it was difficult to determine intervention effects on vegetable consumption specifically. Measurement of intake was most commonly by self-report, with 5 studies using nonvalidated tools. Longer-term follow-up was lacking from most studies (n=12). Risk of bias was high among the included studies, and the overall body of evidence was rated as low quality. The applicability of interventions to the broader young adult community was unclear due to poor description of external validity components.
  
  
  CONCLUSIONS
  Preliminary evidence suggests that eHealth and mHealth strategies may be effective in improving vegetable intake in young adults; whether these small effects have clinical or nutritional significance remains questionable. With studies predominantly reporting outcomes as fruit and vegetable intake combined, we suggest that interventions report vegetables separately. Furthermore, to confidently establish the efficacy of these strategies, better-quality interventions are needed for young adults, using valid measures of intake, with improved reporting on costs, sustainability and long-term effects of programs.
  
  
  BACKGROUND
  PROSPERO International Prospective Register of Systematic Reviews: CRD42015017763; http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015017763 (Archived by WebCite at http://www.webcitation.org/6fLhMgUP4).
authors.affiliation: School of Life and Environmental Sciences, University of Sydney, Sydney, NSW, Australia. mnou2973@uni.sydney.edu.au.
authors.forename: Monica
authors.identifier: http://orcid.org/0000-0003-0971-3181
authors.initials: M
authors.lastname: Nour
authors.forename: Juliana
authors.identifier: http://orcid.org/0000-0003-2844-6947
authors.initials: J
authors.lastname: Chen
authors.forename: Margaret
authors.identifier: http://orcid.org/0000-0002-6478-1374
authors.initials: M
authors.lastname: Allman-Farinelli
mesh_terms: D000328:Adult; D040421:Cell Phone; D004032:Diet; D005260:Female; D005638:Fruit; D006293:Health Promotion / Q000379:methods*; D006801:Humans; D008297:Male; D011446:Prospective Studies; D017216:Telemedicine; D014675:Vegetables; D055815:Young Adult
keywords: eHealth; mHealth; social marketing; vegetable consumption; young adults