Lower than expected recruitment and retention rates are common challenges in parenting trials—particularly for community-based trials targeting parents of young children that rely on face-to-face recruitment by frontline workers. Recruitment requires parental informed consent, yet information sheets have been criticized for being lengthy and complex, and particularly challenging for parents with low literacy. Recent innovations include ‘talking head’ information videos. This paper aims to explore parent perceptions of using a ‘talking head’ video to support informed consent, recruitment, and retention procedures in parenting trials.We conducted semi-structured interviews with a sample of 24 mothers recruited after their final follow-ups in two different parenting trials in Denmark. Before consenting to participate in the trials, parents were invited to view a video of a member of the study team giving information about the study, and again before the interviews for the current study. The audio data was transcribed and thematic analysis was conducted.We identified three overarching themes: (1) general impression of the video, (2) thoughts on participation in research, and (3) recruitment and retention. Participants were generally positive in their appraisal of the two talking head informational videos. We found that participants felt that a mix of paper-based and video-based sources of information would enable them to make an informed choice about whether to participate in a research study. We also found that a professionally produced video featuring a key member of the study team produced a feeling of commitment to the study that could impact retention rates.Informational videos are acceptable to parents; however, co-production or participant/patient involvement in the development of such videos is recommended. Informational videos may not increase recruitment but have the potential for improving retention. Key design recommendations are to ensure a ‘professional’ look to the video, to supplement videos with paper-based information, to keep the length to < 3 min, and for the ‘talking head’ part to feature a key member of the study team.The online version contains supplementary material available at 10.1186/s13063-021-05826-0. Although randomized controlled trials are the ‘gold standard’ for testing the effectiveness of parenting programmes in real-life settings, recruitment and retention of participants can be problematic and act as major barriers to successful completion of a trial; for instance, only a small proportion of UK trials successfully recruit to time and target –4. ThereParent refusal to consent to participate is a key barrier for successful recruitment targets of trials involving children . There iTrials of real-world parenting programmes delivered in community settings oftentimes rely on frontline staff  to identify and, in some cases, recruit participants during routine contacts , 24. PerAlthough modern technology can support the quick and inexpensive production of videos, costs could quickly escalate if relying on a filmmaker or animation company. Once produced, the video has the potential for a wide reach . Costs wInformational videos may be easier to understand and more user-friendly than the traditional, and most likely more lengthy, PIS, although there is a recent move towards shorter PIS .This paper aims to explore parent perceptions of using a ‘talking head’ video to explain the background, aim, and process of the study to participants in two studies undertaken in Denmark. Specifically, we examine if ‘talking head videos’ are acceptable and useful as a replacement, or supplement to, written participant information sheets and whether parents think that informational videos could increase engagement and retention to a trial.We undertook a qualitative telephone interview study with 24 parents in Denmark who participated in one of two parenting trials. The qualitative study was conducted after the parents had received the interventions and all outcomes were collected.Participants were recruited from two separate randomized controlled trials of parenting interventions: (1) the Incredible Years Parents and Babies (IYPB) trial (2013–2015) and (2) the Parent Management Training Oregon (PMTO) trial (2013–2016). The IYPB trial was aimed at a universal sample of parents of infants whereas the PMTO trial was aimed at a more clinical group of parents of school-aged children with behaviour problems. In both trials, frontline workers were responsible for recruiting parents. All parents received a traditional PIS leaflet with information about the study from the frontline worker. The information in the leaflets was relatively easy to read and included pictures, names, and contact information of the principal investigator (PI) and a second member of the research team. We used relatively similar talking head information videos to support recruitment in both studies, and it was voluntary to watch the video. The videos were included in the recruitment process for the following reasons: (1) to increase the probability of front workers providing families with the correct information about the trial and (2) to ensure that families received and understood the information. Both mothers and fathers were invited to participate in both trials, but in most cases, it was the mother’s email or mobile number that was available. As the qualitative study on recruitment was not a part of the original ethics approval, we obtained supplementary ethics approval from the internal review board at SFI—the Danish National Center for Social Research . Only mothers accepted the invitation to participate in the interviews. All interviews were conducted in Danish in the period February to May 2017.The IYPB pilot trial examined the effect of the IYPB programme offered to a universal group of 112 parents of infants aged 0–4 months –30. HealThe PMTO trial examined the effect of PMTO offered to 128 parents of children aged 3–13 years with behaviour problems , 32. EliWe conducted the interviews via telephone. Telephone interviews are commonly used in survey research, but can also be used in smaller qualitative studies as it is less time consuming and flexible than face-to-face interview methods , 34. Whehttps://www.youtube.com/watch?v=wgb99I6mDmY (IYPB) and https://www.youtube.com/watch?v=j7PXRg8w2mI&t=3s (PMTO). The videos were accessed 88 times (IYPB) and 150 times (PMTO) during the trial recruitment period, but we have no further information on who accessed the videos, or how many times an individual may have accessed the videos.The communication department at SFI produced a short video for each trial. Both videos were recorded in the same room and followed the same structure. The IYPB trial video lasted 2:45 min and featured the PI, whereas the PMTO trial video lasted 2:13 min and featured the head of the department who was responsible for both trials. The visuals and audio were further supported by text on the screen to highlight the important messages. The videos could be accessed on the SFI homepage when the trials were running. This homepage no longer exists but the videos can be accessed (in Danish) at The 24 interviews were semi-structured and consisted of six overall questions with sub-questions and prompts. See Additional file All participants gave consent to record the interview with a voice recorder. The research assistant who conducted the interviews transcribed the interviews in full. Data files and transcriptions were stored on a safe drive and only researchers involved in the project had access to the files. MP and JS analysed the data according to thematic analysis . We baseWe interviewed 24 mothers who had participated in either of the two trials. All mothers were Danish except for one. Based on the coding of the interviews, we identified the following three overarching themes: (1) general impression of the video, (2) thoughts about participation in research, and (3) recruitment and retention. For each theme, we identified one or more sub-themes.All mothers watched the video before the interview in the current study, but many of them did not recall watching the video before recruitment to the trial they participated in (IYPB or PMTO). Three mothers were either sure or almost certain they had seen the video as part of the recruitment process for the trial.All participants expressed a positive general impression of the video and the information it provided. They found that the videos were informative and explanatory and that they contained useful information. A participant noted: “I think that it [the video] explains the things that you need to know before you agree to participate” [mother 2]. When asked about their general opinion of the videos, several of the participants expressed that it was “fine”—a word, which in Danish indicates a moderate positive and satisfactory attitude towards something, e.g. “It is short and describes what it is supposed to. I think that it’s fine” [mother 3]. Throughout the interviews, the mothers elaborated on this topic, highlighting both pros and cons of the recruitment videos.The videos were perceived as a trustworthy source of information by the participants. This is exemplified by this quote: “It is more trust-based to see a video than to see a leaflet, that you don’t really know who wrote” [mother 8]. A few mothers pointed out that the video was a bit boring and not very exciting to watch. When asked about the length of the video, almost all participants (21) agreed that it was appropriate (2:45 min for the IYPB and 2:13 min for the PMTO). Only one mother felt that the video should be longer. A few participants pointed out that there was a risk of losing focus if the video was longer, and six mothers stated that the video should not be longer. This is clearly expressed by mother 5 who said: “It should not be longer - then I think people would not like to see it”.All participants expressed that they thought it would be beneficial to use video for recruitment. Most mothers provided several reasons for this. They felt that the video was catchy and enjoyed the visual inputs. This is exemplified by a mother who said that “the information is less dry compared to getting it in a leaflet” [mother 9]. They also highlighted the accessibility of the video. At a practical level, they liked that all information was easily accessible just with a click on a link or a QR code. At a more abstract level, they expressed that it was easy to comprehend the content and information in the video. Similarly, nine participants perceived the video as straightforward and easy to understand.The mothers felt that using an informational video in the recruitment process had advantages over other formats. Some mothers felt that it was more time-efficient because it was faster to watch the video than reading the info leaflet and because they could do it at a time that was convenient for them, e.g. while doing the dishes. This comes clearly through in this quotation from mother 2: “Then there is the time factor in that it is faster and easier to watch a video. You usually have a busy schedule with children and work and all of that then it is easier and more manageable just to see a video than it is to have to read a lot of papers or something”.Some mothers felt that a video is easier to remember than written information and one mother felt that the spoken word is harder to misunderstand than the written. She explained it this way: “When you read something, you sometimes read it the wrong way, while when it is spoken, at least I find it easier to hear what needs to be heard and not read something that was not there” [mother 8].A point that several participants highlighted was that using a video was a clear advantage for participants with low literacy. This was expressed by both a mother with reading difficulties and a mother with attention deficit hyperactivity disorder (ADHD) but also by mothers who did not necessarily have low literacy themselves. By using a video, parents with low literacy can understand the information as easily as parents without literacy problems. The mother with ADHD expressed it this way: “It is easier to reach everyone [with a video] … it can sometimes be hard to write it in a way so that you reach those who are not so academically strong … you reach everyone no matter if you are a good or bad reader because everyone can understand what she is saying and it is a simple explanation which would be harder to write in a leaflet” [mother 7].Although participants were generally positive, they also pointed out various disadvantages of the videos. Several mothers were concerned that participants would overlook the link to the video in the information leaflet and thereby not use the video. Another participant felt that a link sent in an email was easier lost than a physical leaflet that she could have on the desk. Although most participants found the length of the video appropriate, some expressed that the videos missed important information such as a description of the interventions they could be randomized to, and practical information about the process of the study. This is exemplified by mother 5 who said: “I maybe missed a bit more practical information in the video. You know, more information on what exactly what going to happen for instance that you received a questionnaire that you should fill out…”. One participant stated that she needed more information about how the research would be used.Some of the participants commented on the video format and set-up. One found that it looked like a quick fix and was non-professional. For some participants, it was distracting that the editing of the video was not professional, that the room was disorderly, and that the audio did not correspond completely with the written text shown on the videos. Some of the interviewed mothers had suggestions of how to improve the video. Suggestions included distributing the video through text message or social media and including a presentation of the research institution and the goals of the study.When comparing the video format to the written, several participants expressed a preference for the video format but for various reasons. Several pointed to the overwhelming amount of received information after the birth of the infant and the piles of leaflets and pamphlets that accumulate. They found it easier to watch a video with the relevant information. Again, they highlighted the accessibility in the comparison: “If you just leaf through [the pamphlet], then you may skip some things – here you get all the information in two minutes – everyone can do that. If you get a pamphlet you can easily just leave it” [mother 6]. The short and accessible format of the videos appealed to many of the participants. A few participants preferred to receive important information about a trial in written form. The majority of mothers agreed that the video should be a supplement to a written or printed PIS. Only one mother said that she would prefer seeing the video and not getting an information leaflet at all—especially if the video included clips with written information.We asked all the mothers about their thoughts and concerns about participating in a randomized trial and their motivation for participating. It was clear from the interviews that several mothers from both studies did not remember that they had received the information leaflet when they were originally recruited for the study. We do not know whether they did not receive the information leaflet or if they do not remember receiving it. The interviews further showed that not all the participants had fully understood what the trials involved when they were recruited. One mother for instance did not understand that it was a research project: “We were not told directly that it was a research project – we were told it was to get some help for our daughter” [mother 14].In both trials, SFI randomized families to either intervention or care as usual. The randomization was clearly described in the information leaflet and the front personnel who recruited the families were instructed to inform all families about the randomization. Several mothers said that they were not aware that they had been randomized or did not feel that they had been informed about this: When the interviewer asked one of the mothers if she had any concerns about the fact that it was a random allocation she responded “I did not know” [mother 6]. One mother even said that she did not know if she would have agreed to participate if she had understood that it was the researchers who by random allocation decided whether the family would receive the intervention or not. When she was asked if she would have responded differently if she had understood that she would be randomized, she responded: “Then I wouldn’t have joined. And I know others that wouldn’t have either. But I did not think about it at that time, and I’m also happy [that I joined]” [mother 15]. Even though she did not fully understand the consequences of participating, she was happy that she did join the study. When asked if the video would have made it clearer for her, she said that it would. The participants agreed that the video was clear about the randomization. One mother said: “You are not in doubt that something will be chosen for you and the different possibilities there are” [mother 6].When asked about why they joined the study, most mothers expressed that they did it to contribute to the research and to help improve the conditions for parents in the future. The altruistic motivation is evident in this quotation: “If my answers and other participants’ answers could help make it better for the municipalities finding the right interventions [for new parents], find out what works and doesn’t work, then I’m happy to do that. That was actually my only thought; if it can help other [families]” [mother 9]. The mothers were generally positive about contributing to research and thereby improving circumstances for future parents in a similar situation. For many mothers, the fact that it was a research project was important. One mother said: “I think you should always support such projects” [mother 12]. Several mothers also said that they were interested in the results and wanted to learn from the study themselves. Answering questionnaires and being followed by researchers was for many mothers a positive experience. One of the mothers framed it like this when asked why she wanted to participate: “To be a part of a research project where you can learn about yourself and your children and what is happening in the new life” [mother 13]. We find the altruistic motivation to participate and the positive attitude toward being part of a research project in both the parents with infants (IYPB) and the parents with older children with behaviour problems (PMTO). Some mothers, however, did also see the intervention as a much-needed help for their own family and an opportunity to develop as a parent and were therefore motivated to participate.Most of the participants agreed that seeing a recruitment video would not be critical for their motivation to participate in the trial. As they had decided to participate in the trial at the time they were interviewed for this study, they were motivated before watching it. Some mothers, however, expressed that a video could make them more willing to participate. They felt that the video created a feeling of connectedness with the researchers from the beginning of the study. One mother expressed it this way: “It is harder to say no face to face, even though it is through a screen” [mother 8]. The mothers felt that the researcher was there in the room with them even though it was through a video on a screen. Mother 10 expresses this contradiction—the researcher being present while simultaneously at a distance—in this quotation: “[the video] works well in that way that it is personal, but without it being face-to-face and that you feel that you need to make a decision right away”.The participants generally expressed comfort in the visual aspect of seeing the person behind the project. They liked that the person in the video was “a real human being that wants to help you and future parents” [mother 11]. Participants also expressed that they found it “trustworthy” that the researchers were seen in a location that appears to be their office. Some of the mothers commented that they had seen and read the name of the PI several times on emails etc. and liked to see how she looked. One mother said that it was “nice to get a face on the person that has been behind the project” [mother 8]. Other participants said that they “felt safe” after watching the video and that it was comforting to know who processes your personal data. Some mothers mentioned that as a new parent, they felt sensitive about their children and about disclosing private information as expressed by mother 7: “[the information] is something personal and it is a sensitive situation you are in when you need help like this”.Several of the participants commented that they found the researcher in the video trustworthy and sincere. They appreciated the time and resources that the researchers spent producing the video. They felt that this sent a signal to the participants about the seriousness of the study. Mother 4 expressed it this way: “I get a nice gut feeling that she [the researcher] is actually presenting her own material”. Many of the participants also stated that it signalled dedication and engagement that the researcher responsible for the project presented the project in the video. They felt that this signalled dedication and engagement because it showed that the study was important to the researcher and something that the researcher was proud of doing. One mother expressed it this way: “It says; ‘I want to take responsibility for this, and be the face of this – I am actually proud of what I am doing.’ It gives a positive effect that you want to stand forward with what you have done” [mother 8]. Although mothers generally found the researcher in the video serious, a few did find the researcher a bit ‘boring’. A few of the participants were not aware that the person in the video was the researcher who was responsible for the project. They encouraged the research team to make this aspect clearer in the video.We asked the participants if it made a difference to them who appeared in the video: a trial researcher or an actor. A few participants felt that this would not make a difference but the vast majority found that it made the study more personal. This was expressed by mother 7 in this quotation: “I feel that she is talking directly to me, and I personally like that better than when you sometimes use animations or cartoons”. A few of the mothers said that it did not make any difference that it was the researcher, but they still appreciated that it was a real person related to the project. Many of the participants thought that seeing the researcher made the project less abstract. Mother 12 said: “I actually like that there is someone behind, that it is not a system that speaks and writes, but a person, who then represents a system”. The participants experience that the researcher appearing in the video explaining the study personifies the study in the minds of the participants and becomes the ‘face’ of the study. This is comforting for the participants and makes the study more trustworthy. Mother 11 expressed it in the following way: “It is not just some big organization where it all ends up in. There are actually some people behind it. I think that often you get a survey […] and you don’t really know where it all ends up”.Participants expressed that seeing the researcher behind the study in the video creates a familiarity with the researchers and a feeling of connectedness. Mother 8 formulated it this way: “As soon as you see the faces and you establish a relationship, you quickly get a sense of belonging and attachment to the project”. The participants also felt that it adds consistency when they recognize the name of the researcher in e.g. info leaflets, newsletters, and questionnaires. Some of the participants felt that seeing the video created a relationship with the researcher that may enhance the chance of the participants staying in the project over time. Mother 13 expressed this in this quotation: “It will maybe create some kind of relationship […] that you want to continue in the project rather than drop out”.This study aimed to explore attitudes towards the use of informational ‘talking head’ videos to explain the background, aims, and processes of a trial from the perspectives of parents who participated in two trials of parenting interventions (PMTO and IYPB). Based on a thematic analysis of 24 semi-structured interviews, we identified three overarching themes: (1) general impression of the video, (2) thoughts on participation in research, and (3) recruitment and retention. We found that the participants were positive about using a video for recruitment and that it can contribute to ensuring that all participants understand what they are consenting to. Furthermore, we find that use of videos may not improve recruitment but could potentially improve retention due to the perceived formation of a relationship with the research team.Using an informational video when recruiting for a trial is an easy and accessible way to convey information to the participants. People acquire information in different ways, and it is therefore important to implement a variety of strategies to support recruitment and informed consent procedures, thus ideally combining oral, written, and video information about a trial. Previous research has found that one-size-fits-all traditional PIS can be a challenge especially for participants with a low education level or poor literacy or numeracy abilities , 22. DigUsing a video in the recruitment process can be an advantage specifically for these vulnerable groups of participants that are important to include in trials but may prefer video material to the written material. Low literacy affects around 750 million adults worldwide and can limit a person’s ability to acquire key information and process and recall complex information . A recenWhen using videos, there is a fine balance between keeping an appropriate length of the video while simultaneously providing enough information. If more information than what can be contained in a short video needs to be provided, it may be necessary to create e.g. a website with additional information. Mattock et al. suggest that several shorter videos (e.g. 30 s each) addressing different topics such as assessment, consent, and randomization may be optimal . This isTo ensure that participants get the best impression of the research project that they are invited to participate in, the video must be of high quality. It is relatively easy to produce a video but if it does not look professional, it may send the wrong signals to the participants. Technology has changed markedly since 2012 when we recorded the videos and they would probably look different if we made them today. One thing that for example has become very common is adding subtitles to videos so they can be accessed without the sound on. Many research projects apply a participatory design where participants are included in a qualitative preliminary phase to explore the needs and preferences of the potential participants and the best possible way of targeting them , 38. StuApproximately half of the trial participants do not read the consent document carefully . EthicalAlthough it is common for trial participants to forget or not understand the information within PIS –20, it iCombining text, audio, and graphic material is increasingly used in recruitment materials. Combining more than one mode (such as text and graphic) and giving information across more than one cognitive channel  can contribute to increased comprehension and a deeper understanding as it provides potential participants with the possibility of acquiring information more than once using different modalities . Adding Our participants were mainly motivated by altruism, but some also wanted to access help. This is in line with several other studies finding that the engagement of the participants most often can be characterized as either banal altruism (where participants participate to contribute positively to society) or conditional altruism  –46. To fWhen recruiting vulnerable groups for trials, it is common that ethics committees or frontline staff act as gatekeepers who want to protect participants from participating in trials . HoweverHaving the researchers behind the trial perform in the video provides a medium for ‘humanizing’ the trial , 49. By Using a video for recruitment seems to be beneficial in enhancing the understanding of what participation in trials means for the participant. However, it may not necessarily translate into increased recruitment . Indeed,A limitation of this study is that the participants were asked to comment retrospectively, and in many cases hypothetically, about the informational ‘talking head’ video that was available to them at the time they were recruited to each trial. Although this study includes both a clinical and a universal sample, the participants for this study constitute a convenience sample and there may be an element of selection bias in the views represented. The participants who chose to take part in the interviews after completing the trials may be extraordinarily engaged in research and might not be able to provide information about why others would not want to participate in a study that they actively chose to participate in. Another limitation of the study is the lack of co-design (or participatory design) methods in the production of the video, i.e. that parents were not asked what they would like to see or the information they would need to make an informed decision before the development of the video. An example of best practice with regard to co-design can be observed in the TRials Engagement in Children and Adolescents (TRECA) trial , 53; theFurther robust research is needed with larger samples on the effectiveness of different recruitment strategies including videos and multimedia information resources (MMIs). As outlined by Treweek et al. , a rigorThe use of video for recruitment in trials is acceptable for the participants and is a useful supplement to written PIS as the different formats address different needs. For trials aimed at vulnerable groups characterized by e.g. low literacy, children with learning disabilities, or parents with mental health problems, adding a video to the recruitment may be critical. It is possible that an informational video may not improve recruitment, but our results indicate that a professionally produced video featuring a key member of the study team produced a feeling of commitment to the study that could impact retention rates. Key recommendations are to use a participatory design when developing the video, to ensure a ‘professional’ look to the video, to supplement videos with paper-based information, to keep the length to < 3 min, and for the ‘talking head’ part to be played by a key member of the study team. We believe that this knowledge can be transferred to recruitment in a non-trial context to support face-to-face recruitment in usual services.The use of videos may be complicated if they are not compatible with the expectations of ethics committees, research funders, or gatekeepers of secondary datasets. As more evidence is generated about the potential effectiveness of videos and other forms of multimedia information resources, researchers will need to ensure dissemination efforts reach these key audiences. As evidenced by increasing demands for trial registration and open access publications, there has been a significant shift in recent years towards making research transparent and more accessible to the public . The proAdditional file 1: Interview guide


Clinical notes within EMRs were then independently screened by blinded researchers. The accuracy of the EMR score was assessed against the bedside score using area under the receiver operating curve (AUC), sensitivity, and specificity. Participants were 62% female and 32% had conditions associated with malnutrition, with a mean age of 70.6 years (SD 14.9). The EMR score had moderate diagnostic accuracy relative to PG-SGA bedside screen, AUC 0.74 (95% CI: 0.59–0.89). The accuracy, specificity and sensitivity of the EMR score was highest for patients with a score of 7, indicating EMR screen is more likely to detect patients at risk of malnutrition. This exploratory study showed that applying the PG-SGA screening tool to EMRs had enough sensitivity and specificity for identifying patients at risk of malnutrition to warrant further exploration in low-resource settings.This study aimed to explore the diagnostic accuracy of the Patient-Generated Subjective Global Assessment (PG-SGA) malnutrition risk screening tool when used to score patients based on their electronic medical records (EMR), compared to bedside screening interviews. In-patients at a rural health service were screened at the bedside ( Malnutrition has been estimated to affect 20–60% of in-patients on acute hospital wards globally ,5,6,7,8.There are multiple validated tools to identify malnutrition risk at the patient’s bedside ,9,10,11.Electronic medical records (EMRs) are steadily replacing paper-based medical records in developed countries . Since tPrevious malnutrition risk screening research has utilised clinical dietitians to undertake paper-based record audits to extract data and make clinical judgements on the level of nutrition risk within an in-patient population ,12,15,16In Australia, rural populations experience poorer health relative to metropolitan counterparts ,19,20 wiThe PG-SGA, a validated malnutrition screening tool which guides the triage of nutrition intervention, when used as a bed-side screening tool, it has been validated and shown to have high reliability . It can The aim of this exploratory study is to investigate the accuracy of a malnutrition risk score obtained by applying the PG-SGA screening instrument to the clinical text in EMRs, relative to the PG-SGA instrument applied at the bedside, in identifying rural in-patients at an increased risk of malnutrition.Ethics approval was granted by the Deakin University ethics committee and a letter of confirmation was received from the Barwon Health ethics committee. This pilot exploratory study was undertaken among in-patients on the acute admissions ward, at a rural hospital in Victoria, Australia. Over a 12-week period, a sample of eligible patients were screened for malnutrition risk at the bedside by a member of the research team, following standard protocols for the PG-SGA . EligiblThe PG-SGA malnutrition screening tool used in this study , is typiThe researchers scoring the EMR only considered that an item was “present” if EMR text indicated the patient had relevant symptoms with 100% certainty. No assumptions were made for symptoms that were not clearly described in the clinical notes . A 10% sample of the EMR scores were cross-checked by a third researcher (LA) with 100% agreement. Demographic information as collected at admission was recorded, including sex, age (in years) and whether the patient lived in the larger rural township or smaller surrounding rural communities. Length of stay (LoS) in days was also collected.The sample size was determined pragmatically within the resource limitations of this exploratory pilot study. Statistical analysis was performed with Stata SE Version 15  . The accFifty in-patients that met the eligibility criteria were recruited in a rural hospital setting over a 12-week period (25% of eligible admissions in this service during the study timeframe). The EMR score showed a moderate accuracy compared to the usual bedside scoring method; indicated by an Area Under the Curve (AUC) of 0.74 (95% CI: 0.59–0.89; This exploratory study aimed to understand whether the PG-SGA malnutrition screening tool when applied to EMRs, can accurately identify patients at risk of malnutrition, compared to screening methods at the patient bedside. This tool was chosen by the research team due to the the high scoring range which enabled enough data to be collected from the EMR to assess accuracy. As this study is one of the first to explore the accuracy of a bed-side tool when applied to the EMR, we acknowledge that research into other tools is also needed. This analysis showed that screening of clinical notes in the EMR had a good sensitivity and specificity for patients who are at risk of malnutrition. This suggests that EMR screening may be a promising approach for resource limited settings, where uptake of mandatory screening is low and where it is essential at risk patients are identified, prioritised, and assessed by a clinical dietitian. Our sample, commensurate with the rural hospital where the study was conducted, was 25% of all admissions over the timeframe, generating a representative sample in this context. For example, in data from all annual admissions, from the same setting, we identified a similar rate of patients at risk of malnutrition being 80% in this sample, compared to 77% in the larger sample from more than 500 admissions . The larHealth systems are increasingly transitioning to electronic record keeping due to the opportunities for technology to improve the care and coordination of patients, especially those with chronic and complex conditions . This isThe use of EMRs has previously been shown to improve dietetic care . For exaThe translation of clinical data to clinician knowledge to improve care is one of the current gaps of the transition to EMRs, and across the settings where an individual may receive care over any given time-frame . For exaA strength of this study is that one trained researcher undertook the bed-side screening therefore ensuring diagnostic consistency and avoiding suspicion bias possibly caused by different interviewers, noted in other similar studies comparing specificity and sensitivity and clinical tools . A limitThis exploratory study shows that applying the PG-SGA screening tool to the text in EMRs has moderate sensitivity and specificity for identifying patients at a risk of malnutrition. This provides evidence that the EMR screen has moderate accuracy in identifying patients at risk of malnutrition and that there is justification for further exploration into EMR screening to assist with identifying and triaging patients for dietetics referrals especially in rural settings where resources may be limited. This also warrants further exploration into how applying traditional bed-side screening tools perhaps through technology, to an EMR, could enable faster identification of high-risk patients. This could be an important strategy to address the low uptake of mandatory screening in hospitals, in Australia and around the world.


Perioperative malnutrition is common and is associated with increased mortality, complications and healthcare costs. Patients having surgery for cancer and gastro-intestinal disease are at particular risk. It is a modifiable pre-operative risk factor and perioperative clinicians are well placed to identify those at risk and instigate interventions shown to improve outcome. Thus, we conducted a survey of Perioperative Medicine Leads with the aim of assessing the current provision of nutritional screening and intervention pathways in the UK.Perioperative Medicine Leads registered with the Royal College of Anaesthetists were asked to complete an online survey exploring current practice in screening, assessment and management of malnutrition in the perioperative period. The survey included a mixture of open and closed questions, graded response questions and options for free text. Where a response was not received, departments were phoned directly and e-mails sent to non-responders.We received 121 completed questionnaires from 167 Perioperative Medicine Leads (response rate of 72.5%). Seventy respondents (57.9%) reported using the Malnutrition Universal Screening Tool to screen patients; however, only 61 (50.4%) referred patients at nutritional risk onto a dietitian. Sixty (49.6%) lacked confidence in local ability to identify and manage malnutrition perioperatively, with 28 (23.1%) reporting having a structured pathway for managing malnourished patients. One hundred eleven respondents (91.7%) agreed that malnutrition impacts on quality of life after surgery and 105 (86.8%) felt adopting a standard protocol would improve outcomes for patients. Those reporting a lack of confidence in dealing with malnutrition perioperatively cited a lack of organisational support, patients being seen too close to surgery and lack of clarity around responsibility as key reasons for difficulties in managing this group of patients.Malnutrition in the perioperative period is a modifiable risk factor which is common and results in increased morbidity for patients and increased cost to healthcare systems. This survey highlights areas of practice where perioperative clinicians can improve the assessment and management of patients at nutritional risk prior to elective surgery.The online version contains supplementary material available at 10.1186/s13741-021-00196-2. They were asked to complete an online survey . The survey had been reviewed internally by the RCoA College Council prior to dissemination. If a response was not received, departments were phoned directly and e-mails sent to non-responders on up to three occasions. Children’s hospitals were excluded from the final analysis, leaving a denominator of 167 hospital trusts distributed across the UK.Respondents were explicitly asked to discuss the survey with dietetic, nursing and surgical colleagues if necessary. We identified five areas of practice that we wanted to assess as part of the survey: (i) nutritional screening, (ii) assessment of malnutrition, (iii) management of patients identified as malnourished or at risk of undernourishment, (iv) attitudes around malnutrition in the perioperative period and (v) local barriers to implementing care.The survey included a mixture of open and closed questions, graded response questions and options for free text. Respondents were also asked to use free-text comments to identify areas of good local practice .The survey data were exported from Google Forms  to Microsoft Excel  for further analysis.We received 121 completed questionnaires from 167 Perioperative Medicine Leads in hospital trusts across the UK (response rate of 72.5%) between December 2018 and July 2019.Over 75% of respondents  indicated that pre-operative malnutrition screening was performed by nursing staff in their hospital. Other groups of healthcare professionals reported as performing screening were surgeons , anaesthetists  and dietitians . Fifteen respondents (12.4%) did not know who was responsible for screening, four (3.3%) stated that no one was responsible for screening and one respondent reported that a junior doctor was dedicated to collecting this information in their hospital.The most widely reported approaches to screening for risk of malnutrition were BMI , MUST  and percentage weight loss 24, 19.8%). A variety of other tools were used less frequently or the respondent did not know which tools were used . Alternative anthropometric assessments included arm muscle circumference , skin-fold thickness  and hand-grip strength . Ten respondents (8.3%) stated that no anthropometric testing was undertaken and 10 (8.3%) did not know what local practice was.Over a third of respondents  reported that no specific biochemical assessments were performed and 11 (9.1%) did not know what local practice was. One respondent stated that the use of biochemical assessment was “surgery dependent” and one used a “specific malnutrition screen”. As a marker of disease severity and inflammation, serum albumin was the most common biochemical assessment, reported by 74 respondents (61.2%). Other biochemical tests included total protein , CRP , transferrin  and lipid studies .An assessment of body composition, such as bioelectrical impedance analysis or CT analysis, was only performed in two hospitals (1.7%). Ninety respondents (74.4%) stated that no body composition assessment was undertaken and 29 (24.0%) did not know what local practice was. One respondent stated that this was “patient dependent”.Functional testing was undertaken by 57 respondents (47.1%), most frequently using a self-reported questionnaire , timed get-up-and-go  or stair climb . Four trusts (3.3%) assessed functional status using cardio-pulmonary exercise testing. Forty-nine respondents (40.5%) stated that no functional testing was undertaken and 15 (12.4%) did not know what local practice was.Half of the respondents (50.4%) reported that their hospital had no perioperative pathway for managing malnourished patients. Twenty-eight respondents 23.1%) reported that their hospital did include a perioperative pathway for malnourished patients and 17 (14.1%) reported that their hospital was in the process of developing a pathway; 15 (12.4%) did not know whether or not a formal pathway existed  reported that the patient would be referred to a dietitian. The remainder were referred on to other specialties, no one at all, or the respondent did not know whether an onward referral took place. Table Table 2ONearly half of respondents 47 (38.8%) reported that oral nutritional supplements were prescribed to malnourished patients in their hospital; 46 (38.0%) did not and 28 (23.1%) respondents were unsure of local practice.Nearly all of the respondents  either “agreed” or “strongly agreed” that malnutrition had an impact on quality of life following surgery; eight (6.6%) “strongly disagreed” and two (1.7%) neither “agreed” nor “disagreed”.The majority of respondents  either “agreed” or “strongly agreed” that adopting a standard protocol for managing perioperative malnutrition would improve patient outcomes. Three “strongly disagreed” (2.5%) and 13 (10.7%) neither “agreed” nor “disagreed”.The majority of respondents  either “agreed” or “strongly agreed” that perioperative clinicians had a role in the identification and management of malnutrition in the pre-operative period; eight (6.6%) either “disagreed” or “strongly disagreed” and 10 (8.3%) neither “agreed” nor “disagreed”.Approximately, half of the respondents  either “disagreed” or “strongly disagreed” with the statement that “they were confident their hospital was able to identify and manage patients with malnutrition perioperatively”; 37 (30.6%) neither “agreed” nor “disagreed” and 24 (19.8%) either “agreed” or “strongly agreed”.Those respondents who either “disagreed” or “strongly disagreed” with the statement that “they were confident their hospital was able to identify and manage patients with malnutrition perioperatively” (n = 60) were asked to detail their reasons for their disagreement. The main reasons given were: (i) lack of organisational support , (ii) patients seen too close to surgery , (iii) lack of clarity around responsibility , (iv) lack of training and education  and (v) time constraints .This is the first survey of Perioperative Medicine Leads in the UK to evaluate the structured screening, assessment and management of malnutrition in patients undergoing elective surgery. The response rate of 72.5% suggests the survey is sufficiently representative of current practice.Perioperative medicine is defined as the patient-centred, multidisciplinary and integrated medical care from the contemplation of surgery until full recovery. Consequently, an important part of the Perioperative Medicine Lead role should be to evaluate the pathways supporting nutritional screening and optimisation. Malnutrition is a modifiable risk factor and all patients’ nutritional status should be optimised before elective surgery  and aetiological  criteria  may be the best biochemical marker currently available and was used by nearly two-thirds of those surveyed. It is important that the perioperative clinician is aware that albumin reflects disease severity and related catabolism, and is not a direct measure of malnutrition. However, it is prognostic for complications and recommended by ESPEN for use in surgical patients , enteral tube feeding and/or parenteral nutrition). We did not examine enteral tube feeding or parenteral nutrition but did explore ONS as this is a simple intervention that can be actioned pre-operatively. NICE recommends considering ONS in those who are malnourished or at risk of malnutrition (National Institute for Health and Care Excellence So how can we improve the care we provide for this group of patients? Screening, assessing and managing these patients is important because malnutrition is one of the few modifiable pre-operative risk factors that, if addressed early and treated appropriately, can affect post-operative outcomes (Stratton and Elia There are numerous issues highlighted by this survey, some easier to remedy than others. It is noteworthy that many are common to previous work undertaken in Europe and North America, adding to the evidence that this is a key area for improvement (Grass et al. Looking to the future, technology and advances in therapies should be embraced to improve the way we assess and manage perioperative malnutrition. Examples include using bioelectrical impedance analysis, cross-sectional imaging or ultrasound to assess muscle mass (Williams et al. One of the main strengths of this study is the high response rate, implying it is representative of current practice. We focused on the areas of nutritional evaluation that are clearly within the domain of Perioperative Medicine Leads, namely standardised screening, pathway management and barriers to care rather than focusing on areas of specific dietetic expertise. As such, our findings are most relevant to the perioperative clinician seeing patients prior to elective surgery in the pre-assessment clinic. However, our study has weaknesses. We relied on Perioperative Medicine Leads being able to discuss questions with other members of the multi-disciplinary team, which may not have occurred. Furthermore, whilst we believe that Perioperative Medicine Leads should be aware of local polices and nutritional services available in their hospital, this may not always be the case.In conclusion, we report that there are deficiencies in the screening, assessment and optimisation of nutritional status prior to elective surgery in the UK. There is an urgent need to implement standardised pathways to ensure the optimisation of a risk factor that we know is amenable to intervention in a realistic pre-operative time frame and that has important impact on surgical outcomes.Additional file 1:. POM Leads Perioperative Nutrition Survey


Watching online videos (including short-form videos) has become the most popular leisure activity in China. However, a few studies have reported the potential negative effects of online video watching behaviors  among a minority of individuals. The present study investigated online video watching behaviors, motivational factors for watching online videos, and potentially addictive indicators of watching online videos. Semi-structured interviews were conducted among 20 young Chinese adults. Qualitative data were analyzed using thematic analysis. Eight themes were identified comprising: (i) content is key; (ii) types of online video watching; (iii) platform function hooks; (iv) personal interests; (v) watching becoming habitual; (vi) social interaction needs; (vii) reassurance needs; and (viii) addiction-like symptoms. Specific video content , platform-driven continuous watching, and short-form videos were perceived by some participants as being potentially addictive. Specific features or content on Chinese online video platforms  need further investigation. Future studies should explore users’ addictive-like behaviors in relation to specific types of online video content and their social interaction on these platforms. The number of online video watchers in China reached 927 million by the end of 2020, an increase of 76.33 million since March 2020, and accounting for 93.7% of the total number of Chinese internet users . Among vN = 6929) was approximately 13% , and the content is also vulgar and even unnatural”.In addition to the content of the video itself, the content of Danmu (scrolling bullet comments) and regular comments were mentioned as an important focus during online video watching by 15 participants. A few participants (3 out of 15) said they loved to see Danmu and comments while watching videos. For example:“I must watch Danmu while watching videos. I think Danmu is extraordinarily interesting. It is less funny when you watch video without Danmu”.“There is no soul without comment. Sometimes it is the comments rather than the content itself that makes a video interesting”.However, some participants (6 out of 15) reported that they preferred to watch videos without Danmu unless they need to see the others’ ideas at some point in the video. This appears to indicate the social purpose of viewing Danmu comments.“I usually turn off Danmu while watching video unless I want to know what the others are thinking…I get rid of Danmu because it affects my watching experience”.Overall, online video watchers not only pay attention to the content of the video, but also to the content of Danmu or comments presented together with the video. This shows the social function of online video watching .Theme 2. Types of online video watching.Online videos were differentiated by the participants as being short or regular, and livestream or recorded. This theme also concerns the motivations for online video watching behaviors. Some described short videos as being less than one minute. They preferred to watch short videos because they could watch them in their spare time.“I prefer short videos to regular videos. Short videos are often less than one minute, sometime about ten seconds, which meets my needs of watching videos in small time windows. And short videos are often more entertaining than other types of videos”.One participant explained that short videos were becoming more popular because the pace of life is speeding up.“I think the rise of short video is inevitable. Nowadays, the pace of society is getting faster and faster. People are more willing to spend fragmented time on short videos. For example, I’m following an online news channel on Bilibili. Their videos often last for only several minutes, which saves my time a lot”.Most participants talked about recorded online videos only, although 7 out of 20 noted that they watched livestream selling  , live gaming (Participant 14), and personal livestream shows  .Theme 3. Platform function hooks.Online video watching behaviors were greatly affected by the functional and technological hooks of online video platforms, including push notifications, recommendations, and auto scrolling. This theme concerns the research aim for the antecedents for online video watching. Participants (9 out of 20) were clearly aware of data mining technology when they received push notifications or recommendations accurately adapting to their interests.“I am aware that the recommendations from the video platforms are based on algorithms. For example, when I watched several mukbang videos, the platform recommended more mukbang videos to me until I intentionally changed to another video type”.“If I haven’t used this app today, it may then push some notifications to me that attracts me to use it. And the apps often recommend something similar to what I searched or said before. Now many apps have these functions”.Another important function was the auto-scrolling function, which allows continuous watching by automatically skipping to the next video.“After I finished a video clip, the platform will play the next video automatically, and then I may find that video is also interesting and continue to watch videos”.Theme 4. Personal interest.All 20 participants reported that the main reason for watching online videos was their personal interest and/or their need for information. This theme concerns the antecedents and motivations for online video watching. They watched videos because they were interested in specific content or topics as noted above. Some participants wanted to seek help from the internet for specific skills, learning sources, and gaming skills. Some reported that they watched videos because of ‘idol worship’. For example:“I watch online videos mainly because of my favorite female pop group”.Once they acquired knowledge and skills, or specific information , they received content gratification. This gratification motivated further watching behaviors. For example:“I usually watch mukbang when doing exercise. When watching the others eating on camera, I feel as if I am also eating the delicious food. That makes me psychologically gratified and motivates me to watch more mukbang videos”.Theme 5: Watching becoming habitual.Watching online videos can be motivated by existing habits, but, at the same time, one could develop new habits. This theme concerns the motivations, antecedents, and consequences of online video watching. Three participants’ narratives suggest that online video watching behaviors can become life habits, similar to watching television in their childhood. This was not seen as harmful to their lives.“When I was a child, I always watched cartoons after dinner every day at around 5 pm. Now I watch online videos instead. I usually check if some of my following uploaders have updated their channels at 7 or 8 pm. It is more like a habit, and I don’t think it is harmful to my life”.However, only participant 20 compared online video watching with cartoon watching experiences from his childhood. It does not appear that different individuals might have different emotional feelings on typical television watching and online videos.One participant said she developed a habit of watching online mukbang videos during gym exercise:“I think watching mukbang videos on Bilibili has become a habit, which meets my needs while exercising”.Participant 13 noted that watching or listening to livestream leisure talk or chatting with fans hosted by favorite idols was a daily practice.“Watching live stream, usually chatting with fans, by my idol has become a daily activity for me. Sometimes I just put my phone down and listen to it while doing the other things”.One participant believed that her online video watching was a habit rather than an addiction:“I have a habit of watching mukbang, but I am not addicted to it. I usually watch four or five mukbang videos each day, and it won’t take more than half an hour”.Theme 6: Social interaction needs.Some participants mentioned social interaction issues when talking about both the antecedents and consequences of online video watching. First, many participants watched the videos because of their social needs , peer influences (five participants), and parasocial relationship with uploaders (five participants)). Similar to other social media, online video watching was motivated by social needs, especially the need for peer interaction, and to be able to speak to friends about the same things they had watched.“Some of my friends may talk about a popular video or a TV show. If I haven’t watched them yet, I can’t understand their topics or join them. That made me frustrated”.Five online video watchers established their own social codes or signals that are described as ‘memes’ (“Geng” in Chinese). Only when all the interlocutors know the memes can they jointly understand a joke. This again showed the social nature of watching online videos. For example:“The memes are the ways of communication with the others. Many people around you are talking about the memes. If you know the memes, you will know what they are talking about. It is a necessity for social interaction”.Some participants (5 out of 20) established parasocial relationships with the video uploaders they were following. They felt a need to constantly check the uploaders’ updates, just like keeping in touch with friends. For example:“I frequently check if some of my following uploaders have updated new videos. If not, I may feel disappointed and lost”.“Some video uploaders or live stream hosts have become my virtual friends. Just like my old friends, I will check their lives when I think of them”.Moreover, watching online videos can have positive and negative social impacts. Positively, some participants (7 out of 20) gained social rewards because they felt pleased and gratified in social interaction during watching.“I think watching live stream is interactive and immersive. It feels like you are communicating with the live stream host closely, and the host is talking to you. Although I know it is not real, I get much gratification. I often watch live stream at midnight”.“Some video platforms have their own ‘Danmu culture’. Thousands of people chat on Danmu. It makes you feel like that you are watching the recorded video together with a lot of people simultaneously. Danmu definitely makes the video more enjoyable”.Negative impacts included social conflicts with family, friends, and strangers in public when watching online videos was too much or too loud.“One of my roommates often plays videos too loudly, which makes me uncomfortable and even disgusted”.internet trolls” who always initiated social conflicts. Participant 2 witnessed that some users quarreled on Danmu. Participant 10 reported her experience of cyberbullying:Sometimes, social conflicts and even cyberbullying occurred in comments and Danmu when online video watchers disagreed with each other. Participants 3, 11, and 20 all described some users as ““Once I commented on a video, a stranger refuted me with ten more comments…There must be something wrong with him!”.Theme 7: Reassurance needs.This theme, like that of social interaction, includes both antecedents and consequences of online video watching. For some participants, watching online videos was motivated by reassurance needs and could cause mood changes. Some participants (7 out of 20) watched online videos because of their reassurance need for recreation and escapism. For example, Participant 10 watched mukbang videos and said:“I usually do gym exercise in the evening. It is always a little bit boring and I’m often hungry so I watch mukbang videos. Watching the others eating makes me feel like I have taken their food too, which provides me with reassurance and satisfaction”.Participant 2 tried to escape from tasks at hand by watching online videos:“Watching online videos makes me procrastinate more. Sometimes I plan to finish my tasks after watching the video, but I always put it off to the next day. I may escape from my tasks by watching videos”.Second, there were positive or negative mood changes that were facilitated by online video watching. Some participants reported feelings of relaxation, encouragement, and being virtually accompanied after watching the online videos. For example:“Watching online videos is an effective way to positively change my mood especially when encountering difficulties or disappointments”.“Many uploaders share daily lives with their pets. My cat is not with me and I always miss it. Watching these videos makes me feel reassured and compensated”.“If the online video is not played, the task at hand might be paused or stopped, [The video] gives me a feeling of being accompanied by others”.However, there were negative mood changes, such as when their favorite gaming team lost:“When my supported gaming team lost, I felt disappointed and frustrated in the following two or three days. That’s the negative emotional impact of the videos”.Participant 7 watched videos because of boredom, but gained more boredom and feelings of hollowness after watching. She appeared to be trapped in a vicious circle:“I usually watch online videos when I’m bored. But after watching for a while, I may feel even more bored and empty”.Theme 8: Addiction-like symptoms.Addiction or addiction-like symptoms were mentioned by 18 participants in relation to specific video content , short videos , platform push notifications, social conflicts, time wasting, and physical issues. This theme can be categorized as concerning the potential of addictive watching. Specific content, pornography for example, was described as addictive:“One of my friends is addicted to online pornography. She watches porn almost every day, sometimes even excessively. Then she always feels exhausted and easily distracted because of watching too much porn”.Television series, movie series, reality shows, and uploaders’ video series were perceived as addictive because some participants watched the episodes continuously and uncontrollably. Since the complete content was split into different clips, Participant 4 stayed up to finish the series.“Sometimes I stay up late to watch online series, I just can’t stop it. Because the series often have suspense at the end of one episode, it motivates me to watch the following episode continuously. That leads to poorer sleep quality and makes me tired all day”.As discussed previously, platform push notifications were the key reason for continuous online video watching:“You can always receive push [notifications] and you enjoy watching the recommended videos. The platform knows your interests and favorites”.“The platform’s push [notifications] related video comes to you automatically and then you would find this video also interesting. I used to watch short videos all day until I ran out my phone’s power. That was horrible! I uninstalled that short video app”.In addition to content, one participant also highlighted the convenience of watching continuously, which is brought by specific functions of short-form videos:“With my phone in hand, I feel too easy for me to scroll down to the next video. It won’t be that easy when I rotate my phone 90 degrees and watch videos horizontally”.“longer than expected”, Participant 2) especially watching short online videos. Addiction-like symptoms, such as regrets and social conflicts, were also mentioned by some. For example:Time wasting was frequently reported by some as a negative consequence of online video watching. Participants admitted they wasted too much time Physical issues were also reported by a few participants as a negative effect of online video watching:“Watching videos excessively has bad effects on my vision, and sometimes my neck hurts”.The present study identified eight themes in relation to online video watching: (i) content is key; (ii) types of online video watching; (iii) platform function hooks; (iv) personal interests; (v) watching becoming habitual; (vi) social interaction needs; (vii) reassurance needs; and (viii) addiction-like symptoms. In relation to the research questions: (i) online video watchers’ key focus was on both the video content and the associated comments (including simultaneous Danmu comment); (ii) the antecedents for watching online videos included platform hooks, such as push notifications, personal interests, established watching habits, social interaction needs, and reassurance needs; (iii) the consequences of watching online videos included habit development, social rewards or effects, and positive or negative reassurance; and (iv) addiction-like symptoms were self-reported by some participants.Participants watched online videos for social interaction, educational content, and relaxation and it was the positive effects on online video watching that were most mentioned. Only very specific online video content was perceived as addictive . Additionally, short-form videos  were reported as addictive and time wasting due to continuous scrolling functions on smartphones. Push notifications from the online video platforms were reported as the key drivers for potential addictive watching. Physical issues were also mentioned by a few participants as addiction-like symptoms. However, participants’ perceived ‘addiction-like’ symptoms in the present study do not indicate addiction or disorder as this cannot be confirmed unless there is a clinical diagnosis and clear evidence of daily functional impairment (of which there was little).In line with previous theoretical models and empirical studies, the present study’s findings concur that social interaction plays an important contributory role in online video watching ,20,25. PSimilar to previous studies ,29,30), ,30, 29,3Besides addictions to specific content, concepts, such as short-form video addiction , remainsIn line with findings in the extant literature ,37, the fashionable lifestyle” or keep up-to-date with peers. This has also been reported in previous qualitative studies on problematic smartphone use where individuals reported the importance of social pressure and peer pressure in their continued smartphone use [Similar to a qualitative study on TikTok , the prehone use . Moreovehone use , the catThe present study identified a number of types of online video watching that have not been sufficiently investigated in previous studies, including: videos with Danmu comments , videos with auto-tune remix-themed content , and rustic videos . Danmu comments have previously been studied from a linguistics perspective , but werThere are some limitations in the present study. First, the participants might have given socially desirable answers in the interviews. They might have exaggerated or concealed some behaviors or feelings concerning their online video watching. This issue needs to be addressed, even though the interviewer in the present study was experienced in conducting interviews for qualitative research. Second, surveys and psychometric instruments were not used in the present study. Future studies could combine different data collection methods to triangulate with qualitative data. For example, the items assessing YouTube addiction used by Balakrishnan and Griffiths  could beThere are also some possible directions for future studies. First, more studies should focus on addictive or problematic watching behaviors relating to specific video content . Second, future studies need to investigate whether short-form video addiction exists as a single entity or whether it simply belongs to the more generic category of social media addiction. Third, Danmu comments, as a typical function of Chinese video platforms, should be explored from other perspectives, including linguistics and communication. Fourth, future studies might use (as aforementioned) other data collection methods  to investigate problematic online video watching behaviors as a consumption problem from a social perspective. Future studies need to control and select the samples’ characteristics carefully, in order to corroborate relevant research evidence. It should also be noted that the present study mainly focused on the watching behaviors on video platforms, whereas the uploading of video content was not included. Since online video platforms, such as YouTube, Bilibili, and TikTok have both video uploading and sharing functions ,31, it iThe present study explored online video watching among Chinese young adults, using a qualitative design. In line with previous studies, in addition to information seeking and entertainment, social interaction was a key driver in online video watching. Furthermore, addiction-like symptoms were reported regarding specific video content , program types , and continuous watching driven by platform push notifications. This study contributes to the limited literature on problematic video watching behaviors on Chinese emerging platforms , which have different features from the other widely used online video platforms, such as YouTube. Further investigations are needed on problematic watching behaviors of specific online video content , new forms of online social interaction during video watching , problematic short-form video watching , and video sharing behaviors. Different research methods  can be utilized to further explore this topic. Moreover, individual differences and sociodemographic backgrounds need to be considered in future studies concerning online video watching as well as a more detailed analysis of the techniques used by streaming platforms that facilitate repeated viewing .


Short video platforms, which thrive along with the video-based consumption industry, have become a new channel adopted by an increasing number of enterprises to distribute products. Therefore, it is necessary to study the factors influencing the consumer’s intention to re-purchase on short video platforms, which is helpful for firms to maintain their competitiveness. This paper, based on the customer value theory, seeks to establish a structural model for such factors. The intermediary effect of customer loyalty on customer satisfaction and repurchase intention of customers is also analyzed. Questionnaires were distributed and collected from users of short video platforms in China. Results show that short video content, customer experience, and perceived value have positive impacts on customer satisfaction, and customer satisfaction, along with customer loyalty, exert positive impacts on repurchase intention. Notably, customer loyalty plays an intermediary role between customer satisfaction and repurchase intention. Based on the aforesaid findings, theoretical implications are discussed and managerial implications to increase repurchase rate are offered. Statistical Report on Internet Development in China published by CNNIC, by December 2020, the number of online videos (including short video) users has reached 927 million, accounting for 93.7% of all netizens. Thereinto, the number of short video users has reached 873 million, accounting for 88.3% of netizens [Pear Video, and MiaoPai. The video covers a wide range of contents from science popularization, to daily vlogs such as makeups, pets, cuisine preparation, etc. Among these platforms, “Tik Tok”, which is preferred by the young, and “Kwai”, which takes the route of “encircling cities from rural areas”, are the most popular.With the continuous development of 5G network, the mobile internet industry has undergone earth-shaking changes in the “era of short video” dominated by visual communication. As indicated in the 47th netizens . As the In addition, these platforms enable the videos to be reposted, commented, shared, and liked, which caters to the demands for today’s mobile social networking. This phenomenon can be verified by the popularity of short video platforms among contemporary youth. Specifically, when people are in quarantine during the outbreak of COVID-19, there are an increasing number of users spending more time on various network video apps, which brings an unprecedented opportunity to short video shopping in China. However, it is critical to consider whether such a platform can retain customers long enough for re-purchase. Therefore, analyzing the influencing factors of repurchase willingness on the short video platform is of great importance.In this paper, these factors are analyzed empirically based on previous studies to enrich the studies on the repurchase willingness in this industry. Finally, some suggestions are made based on the empirical analysis for related enterprises and platforms, so that they can better understand customers’ psychology in this regard so as to retain more loyal customers and achieve a higher re-purchase rate. In the meantime, new ideas are also proposed for the future development of short video platforms to strengthen their competitiveness.2020 China Research Report on Internet Audio-Visual Development, the number of short video users, which are dominated by the “post-80s” and “post-90s”, has reached 818 million, nearly accounting for 90% of all netizens. 60.4% of these users browse short videos daily. By June 2020, the users have involved more age brackets, but they are mostly the generation born in the 1980s and people with low or medium levels of education [Short videos, which is typically a few seconds long, can be shot and edited on mobile terminals, and then shared promptly on social platforms. Zhang Haitao et al. 2020) defined it as fragmented entertainment featured with a low creation threshold and high sociability 020 defin. As statducation .Due to the rapid expansion of social e-commerce, short video consumption has become a new force and channel of online shopping, and the products can be presented to the user in a more vivid and direct form. This has prompted many enterprises to promote their products via short videos on short video platforms. Wang Jianlei (2021) suggested that customers tend to have an enjoyable, innovative, fun, and immersive shopping experience when shopping on short video platforms. For these users, the purpose of short video consumption is to gain pleasure, value and feedback capabilities, which differs significantly from shopping on traditional media . Zhou XuFeng Jianying et al. (2006) defined intention as the subjective probability of specific behaviors . The strRe-purchase is also known as “repeated purchase”. Chen Mingliang (2002) proposed in his research that, re-purchase intention means that customers wish and tend to maintain a trading relationship with suppliers . HarrisoThe short video, with a huge potential market value, can stimulate customers’ purchase intention. Wei Jingqiu et al. (2020) applied the SOR Framework to their analysis and found that users like to browse the short video mainly because of its serviceability, entertainment, and usability. These factors will directly affect customers’ emotional experience and thus stimulate their purchase intention and behavior . Wang XiCustomers will measure the advantages and disadvantages of a product or service before buying it, which is known as customer values. Woodruff (1997) explained this concept from the perspective of changing customers’ values. In his opinion, customer values refer to customers’ satisfaction with a product’s attributes and auxiliary functions based on their likes and dislikes. Li Kouqing (2001) defined it as the benefit received by customers from an enterprise that participates in their consuming behavior by managing them . TherefoIn this chapter, a literature review about short video consumption and repurchase intention is presented. Although previous studies laid the theoretical basis for this paper, gaps still exist. First, those studies primarily focus on short video consumption, and only a few of them involve the influencing factors of re-purchase. Second, there are some follow-up problems faced by the short video consumption industry, that is, how to maintain a good relationship with customers after their purchases and how to improve the loyalty of existing customers. Therefore, this paper analyzes the repurchase intention and factors influencing it and studied the interrelationship among these factors. In addition, an empirical analysis is conducted to study how such intention relates to each factor in the context of the internet, so that the enterprises in this industry can work out better marketing strategies to promote customers’ repurchasing behavior.Customers’ perception or impression of a product is directly influenced by the interestingness or authenticity of short video contents. In the era of the internet, the qualities of contents vary, so short video marketers need to know how to stand out from others. Leal et al. (2014) concluded that User-generated content affects consumer decision-making through social influence factors . As shorH1: Short video contents have a positive impact on customer satisfaction.Customer experience refers to “customers’ activities to create value for a product or service through their firsthand experience, thus enhancing customer and exchange values under particular circumstances”. We defined it as customers’ perception and emotion arising from their interaction with a product or service under specific consumption conditions. Li Qigeng et al. (2011) concluded that the repurchase intention will be positively affected by the brand experience in sense, emotion, cognition and relation . Zhou ShH2: Customer experience has a positive impact on customer satisfaction.Perceived values of customers, are defined by Zaithaml as the “overall assessment made by customers on the usefulness of a product or service after weighing perceived benefits and consumption costs”. Lin et al. (2005) indicated that the reuse intention is positively affected by perceived enjoyment and usefulness, and the expected degree of confirmation [perceived values of customers and repurchase intention [n et al. 05 indicantention . TherefoH3: Perceived values of customer have a positive impact on customer satisfaction.Philip Kotler (1995) defined customer satisfaction as “a person’s feeling of pleasure or disappointment when he/she compares the perceived outcome of a product or service against his/her expectations” . The morH4a: Customer satisfaction has a positive impact on customer loyalty.H4b: Customer satisfaction has a positive impact on the repurchase intention on short video platforms.Customer loyalty refers to the mental tendency that a customer trusts an enterprise or brand after buying its products and wants to repurchase such products on an ongoing basis. Oliver (1997) optimized this definition and theoretically proposed four stages for forming customer loyalty, namely cognitive, attitudinal, emotional and behavioral loyalties . Chen MiH5: Customer loyalty has a positive impact on the repurchase intention towards short video consumption.H6: Customer loyalty plays an intermediary role between customer satisfaction and repurchase intention.Based on the literature review above and the actual situation, a model for the influencing factors of repurchase intention on short video platforms is constructed based on the customer value theory. As shown in In this research, the questionnaire includes three parts: part one focuses on the basic information of respondents and their attitude towards shopping on short video platforms; and part two, which is the core of this questionnaire, focuses on fifteen measurement items about the above five explanatory variables. Thereinto, the 5-Point Likert Scale was adopted for the survey; and the items about the influencing factors of repurchase intention towards short video consumption referred to foreign and domestic questionnaires conducted previously in this respect, but some adjustments were made in accordance with the research model in this paper. This questionnaire survey, lasting from March to May 2021, was conducted by a random sampling method. The questionnaire was posted on the website of wjx.cn through WeChat for respondents who shopped on short video platforms at least once in China. Finally, a total of 208 questionnaires were received, with 199 effective ones, and the response rate was 95.7%. SEM, as other statistical techniques, requires an appropriate sample size in order to produce reliable estimates . Harris The sample data obtained were analyzed with SPSS19.0 and AMOS 17.0.From First, the reliability of sample data was tested. According to the results shown in The structural model fit the data well based on fit statistics as can be seen in The structural model was tested to get the regression coefficients of standardized paths. As shown in As can be seen form the above data obtained from the analysis, the results of parameter estimation are ideal. The loading coefficients of latent variables and measurement indexes are higher than 0.5, which indicates that the path coefficients of such variables are significant. A multilevel regression analysis was conducted on customer satisfaction (independent variable), loyalty (intervening variable) and repurchase intention (dependent variable) to verify the loyalty’s intermediary effect between the satisfaction and such intention. The results are shown in According to In this paper, a structural model for the repurchase intention towards short video consumption is built and empirically tested. The model has five antecedent variables, including short video contents, customer experience, perceived value, satisfaction, and loyalty. One outcome variable, i.e., the repurchase intention, was included. Then, the following conclusions are drawn:Short video content, customer experience, and perceived values of customers can regulate customer satisfaction to different degrees, showing significant positive impacts. In this paper, a structural equation model is built to analyze the interrelationship of variables. Results show that the customers’ satisfaction with short video consumption is positively affected by short video content, customer experience and perceived value, which show the standardized path coefficients of 0.17, 0.25, and 0.50, respectively. Among them, the perceived values of customers are the most influential variable, which are successively followed by customer experience and short video content. To some degree, customers can shop in a more dynamic and convenient way through short video consumption. Therefore, an enterprise shall provide valuable product information while interacting with its customers by means of short videos. Besides, this enterprise can help customers solve any problem of quality and usage in the same way, thereby improving customer satisfaction and strengthening the repurchase intention.Customer satisfaction and loyalty have a significant positive impact on the repurchase intention on short video platforms. Thereinto, customer satisfaction is the most important determinant. In other words, a customer, who is satisfied with the products bought on short video platforms, will be more willing to repurchase them. Conversely, he/she may not buy them again on these platforms but resort to other shopping platforms. In addition, customer satisfaction can also positively affect customer loyalty. That is, customer loyalty will enhance when customer satisfaction reaches a certain degree. Thus, the customers, with higher loyalty, would tend to repurchase on the same platform.The intermediary effect test shows that customer loyalty plays an intermediary role between customer satisfaction and repurchase intention. Thereinto, customer satisfaction means that customers’ expectations can be met by a product or service; and customer loyalty means that they want to buy this product or service again. Therefore, customer loyalty can be enhanced by improving customer satisfaction, thus strengthening the repurchase intention of customers on short video platforms.Due to group psychology, the opinion leaders of short videos will influence customers’ consumption decisions and attitudes, thus igniting their enthusiasm for shopping. When a customer identifies with the brand image established by opinion leaders, such as stars or online celebrities, the consumption guide with high identifiability and reliability will be formed in his/her mind. In view of this, the merchants can take full advantage of such leaders’ strong influence and appeal and select them as short video publishers. When a product is “labeled” as an objective and positive one by these leaders, customers will be more confident in and faithful to this product and more willing to repurchase it.Customers will be immersed in short videos due to their visual presentation of different content. So, the content shall originate from and integrate with the elements of our daily life, such as creating some related scenes, to endow the products with cordial feeling and visual attractiveness. In this way, the content will be more real and closer to life, showing a creative point to attract customers. In addition, as customers tend to empathize with on-site and reportorial contents, the video shall present personal colors and true feelings to impress them and strengthen their purchase intention. At last, the contents shall be designed in accordance with customers’ psychological activities so as to improve their identification with products and to stimulate their shopping desire.Short videos should faithfully introduce products’ quality, performance, advantages and differences because customers tend to have a higher level of perceived values of the products with excellent qualities and reasonable prices. At the same time, all unnecessary expenses should be avoided so that customers’ actual perception is close to or even higher than their pre-purchase expectation. Besides, enterprises can provide new services to meet customers’ personalized demands, thus maintaining regular customers and attracting new ones. Only when customers’ needs are met, will the satisfaction be improved. Finally, enterprises shall post videos constantly and design content according to customers’ psychological activities. Thus, customers, with a stronger sense of identity, will satisfy with the products. Furthermore, enterprises shall establish a stable relationship with customers to strengthen their interactive perception of the video. When customers become more dependent on short video consumption, they will have a stronger desire to repurchase.Short video platforms need to be upgraded continuously based on customers’ needs. In addition, improvements in commodity browsing experience, advertising promotion, and after-sales service are needed to enhance user stickiness. Besides, the management should be reinforced to improve products’ cost performance and crack down on counterfeits so that customers have more faith in such platforms. In this way, perceived values of customers can be maximized. For platforms, other improvements can be made in aspects such as page design, functions including search and payment, simplifying the shopping process, as well as shopping experiences including the efficiency, safety, and stability of online transactions. In this way, customers will recognize and trust the platforms and have stronger repurchase intention on these short video platforms.This study has certain limitations. The influence process of short video consumption on repurchase intention is very complicated. This study only focuses on customer satisfaction and customer loyalty, and fails to conduct a comprehensive and systematic analysis of the motivation and other antecedent variables of repeat purchases. For example, there are many factors that affect the repeated purchase of short video consumption, such as conversion costs, customer trust, and so on. Future research can explore the reconstruction intention of short video consumption from more perspectives. Similarly, limited by the setting of the research model, it is not possible to disassemble and verify the mechanism of internal factors such as consumers’ gender, income, education level, and external factors such as the category of short video platforms in more detail. The research model can be supplemented in future studies.S1 Appendix(DOCX)Click here for additional data file.S1 Data(SAV)Click here for additional data file.