The global sequence diversity of HIV-1 presents a daunting challenge for vaccine development. We investigated whether a heterologous insert prime-boost regimen could expand global coverage by selectively boosting cellular immune responses to conserved epitopes. Rhesus monkeys were primed and boosted with recombinant adenovirus vectors expressing homologous or heterologous HIV-1 Gag sequences that were optimized to focus responses on highly conserved epitopes. We observed comparable responses directed to specific regions of the Gag protein in all experimental groups without evidence of improved coverage or expanded breadth in the heterologous insert group. These data suggest that antigen-independent factors contribute to the immunodominance patterns of vaccine-elicited cellular immune responses.

Vitamin A deficiency is highly prevalent in much of the developing world, where vaccination programs are of paramount importance to public health. However, the impact of vitamin A deficiency on the immunogenicity and protective efficacy of vaccines has not previously been defined. Here we show that the vitamin A metabolite retinoic acid is critical for trafficking of vaccine-elicited T-lymphocytes to the gastrointestinal mucosa and for vaccine protective efficacy in mice. Moderate vitamin A deficiency abrogated antigen-specific T-lymphocyte trafficking to the gastrointestinal tract, gastrointestinal cellular immune responses, and protection against a mucosal challenge following immunization with a recombinant adenovirus (rAd) vaccine vector. Oral vitamin A supplementation as well as retinoic acid administration fully restored the mucosal immune responses and vaccine protective efficacy. These data suggest that oral vitamin A supplementation may be important for optimizing the success of vaccines against HIV-1 and other mucosal pathogens in the developing world, highlighting a critical relationship between host nutritional status and vaccine efficacy.

Providing knowledge at the point of care offers the possibility for reducing error and improving patient outcomes. However, the vast majority of physician’s information needs are not met in a timely fashion. The research presented in this paper models an expert librarian’s search strategies as it pertains to the selection and use of various electronic information resources. The 10 searches conducted by the librarian to address physician’s information needs, varied in terms of complexity and question type. The librarian employed a total of 10 resources and used as many as 7 in a single search. The longer term objective is to model the sequential process in sufficient detail as to be able to contribute to the development of intelligent automated search agents.

Background

Consumer eHealth interventions are of a growing importance in the individual management of health and health behaviors. However, a range of access, resources, and skills barriers prevent health care consumers from fully engaging in and benefiting from the spectrum of eHealth interventions. Consumers may engage in a range of eHealth tasks, such as participating in health discussion forums and entering information into a personal health record. eHealth literacy names a set of skills and knowledge that are essential for productive interactions with technology-based health tools, such as proficiency in information retrieval strategies, and communicating health concepts effectively.

Objective

We propose a theoretical and methodological framework for characterizing complexity of eHealth tasks, which can be used to diagnose and describe literacy barriers and inform the development of solution strategies.

Methods

We adapted and integrated two existing theoretical models relevant to the analysis of eHealth literacy into a single framework to systematically categorize and describe task demands and user performance on tasks needed by health care consumers in the information age. The method derived from the framework is applied to (1) code task demands using a cognitive task analysis, and (2) code user performance on tasks. The framework and method are applied to the analysis of a Web-based consumer eHealth task with information-seeking and decision-making demands. We present the results from the in-depth analysis of the task performance of a single user as well as of 20 users on the same task to illustrate both the detailed analysis and the aggregate measures obtained and potential analyses that can be performed using this method.

Results

The analysis shows that the framework can be used to classify task demands as well as the barriers encountered in user performance of the tasks. Our approach can be used to (1) characterize the challenges confronted by participants in performing the tasks, (2) determine the extent to which application of the framework to the cognitive task analysis can predict and explain the problems encountered by participants, and (3) inform revisions to the framework to increase accuracy of predictions.

Conclusions

The results of this illustrative application suggest that the framework is useful for characterizing task complexity and for diagnosing and explaining barriers encountered in task completion. The framework and analytic approach can be a potentially powerful generative research platform to inform development of rigorous eHealth examination and design instruments, such as to assess eHealth competence, to design and evaluate consumer eHealth tools, and to develop an eHealth curriculum.

Background

Low health literacy has a detrimental effect on health outcomes, as well as ability to use online health resources. Good health literacy assessment tools must be brief to be adopted in practice; test development from the perspective of item-response theory requires pretesting on large participant populations. Our objective was to develop a novel classification method for developing brief assessment instruments that does not require pretesting on large numbers of research participants, and that would be suitable for computerized adaptive testing.

Methods

We present a new algorithm that uses principles of measurement decision theory (MDT) and Shannon's information theory. As a demonstration, we applied it to a secondary analysis of data sets from two assessment tests: a study that measured patients' familiarity with health terms (52 participants, 60 items) and a study that assessed health numeracy (165 participants, 8 items).

Results

In the familiarity data set, the method correctly classified 88.5% of the subjects, and the average length of test was reduced by about 50%. In the numeracy data set, for a two-class classification scheme, 96.9% of the subjects were correctly classified with a more modest reduction in test length of 35.7%; a three-class scheme correctly classified 93.8% with a 17.7% reduction in test length.

Conclusions

MDT-based approaches are a promising alternative to approaches based on item-response theory, and are well-suited for computerized adaptive testing in the health domain.

Health information technologies (HIT) have great potential to advance health care globally. In particular, HIT can provide innovative approaches and methodologies to overcome the range of access and resource barriers specific to developing countries. However, there is a paucity of models and empirical evidence informing the technology selection process in these settings. We propose a framework for selecting patient-oriented technologies in developing countries. The selection guidance process is structured by a set of filters that impose particular constraints and serve to narrow the space of possible decisions. The framework consists of three levels of factors: 1) situational factors, 2) the technology and its relationship with health interventions and with target patients, and 3) empirical evidence. We demonstrate the utility of the framework in the context of mobile phones for behavioral health interventions to reduce risk factors for cardiovascular disease. This framework can be applied to health interventions across health domains to explore how and whether available technologies can support delivery of the associated types of interventions and with the target populations.

Although mucosal CD8+ T-cell responses are important in combating mucosal infections, the generation of such immune responses by vaccination remains problematic. In the present study, we evaluated the ability of plasmid DNA to induce local and systemic antigen-specific CD8+ T-cell responses after pulmonary administration. We show that the pulmonary delivery of plasmid DNA formulated with polyethyleneimine (PEI-DNA) induced robust systemic CD8+ T-cell responses that were comparable in magnitude to those generated by intramuscular (i.m.) immunization. Most importantly, we observed that the pulmonary delivery of PEI-DNA elicited a 10-fold-greater antigen-specific CD8+ T-cell response in lungs and draining lymph nodes of mice than that of i.m. immunization. The functional evaluation of these pulmonary CD8+ T cells revealed that they produced type I cytokines, and pulmonary immunization with PEI-DNA induced lung-associated antigen-specific CD4+ T cells that produced higher levels of interleukin-2 than those induced by i.m. immunization. Pulmonary PEI-DNA immunization also induced CD8+ T-cell responses in the gut and vaginal mucosa. Finally, pulmonary, but not i.m., plasmid DNA vaccination protected mice from a lethal recombinant vaccinia virus challenge. These findings suggest that pulmonary PEI-DNA immunization might be a useful approach for immunizing against pulmonary pathogens and might also protect against infections initiated at other mucosal sites.

Objective

There has been a growth of home health care technology in rural areas. However, a significant limitation has been the need for costly and repetitive training in order for patients to efficiently use their home telemedicine unit (HTU). This research describes the evaluation of an architecture for remote training of patients in a telemedicine environment. This work examines the viability of a remote training architecture called REmote Patient Education in a Telemedicine Environment (REPETE). REPETE was implemented and evaluated in the context of the IDEATel project, a large-scale telemedicine project, focusing on Medicare beneficiaries with diabetes in New York State.

Methods

A number of qualitative and quantitative evaluation tools were developed and used to study the effectiveness of the remote training sessions evaluating: a) task complexity, b) changes in patient performance and c) the communication between trainer and patient. Specifically, the effectiveness of the training was evaluated using a measure of web skills competency, a user satisfaction survey, a cognitive task analysis and an interaction analysis.

Results

Patients not only reported that the training was beneficial, but also showed significant improvements in their ability to effectively perform tasks. Our qualitative evaluations scrutinizing the interaction between the trainer and patient showed that while there was a learning curve for both the patient and trainer when negotiating the shared workspace, the mutually visible pointer used in REPETE enhanced the computer-mediated instruction.

Conclusions

REPETE is an effective remote training tool for older adults in the telemedicine environment. Patients demonstrated significant improvements in their ability to perform tasks on their home telemedicine unit.

The innate immune pathways that contribute to the potent immunogenicity of recombinant adenovirus (rAd) vaccine vectors remain largely undefined. Previous studies assessing innate immunity triggered by vaccine vectors have largely focused on in vitro studies involving antigen-presenting cells and on early in vivo inflammatory responses. Here, we systematically explore the Toll-like receptor (TLR) signaling requirements for the generation of cellular immune responses by intramuscular immunization with common and alternative serotype rAd vectors in mice. Antigen-specific CD8+ T-lymphocyte responses elicited by these rAd vectors were significantly diminished in MyD88−/− mice but not in TRIF−/− or TLR3−/− mice, suggesting the importance of MyD88-dependent TLR signaling. However, the absence of each individual TLR resulted in minimal to no effect on vaccine-elicited cellular immune responses. Moreover, responses were not diminished in IL-1R−/− or IL-18R−/− mice. These data suggest that rAd vectors engage multiple MyD88-dependent signaling pathways, none of which are individually critical; rather, they are integrated to contribute to the potent immunogenicity of rAd vectors. Stimulation of multiple innate immune mechanisms may prove a generalizable property of potent vaccines, and this strategy could be harnessed in the development of next-generation vaccine vectors and adjuvants.

The Informatics for Diabetes Education and Telemedicine (IDEATel) project has demonstrated significant changes in clinical outcome measures over the past years. This report describes upgrades and innovations in the system that allow a much more rapid upload of data and thus significant system improvement.

Abstract

The objective of this evaluation was to determine the effect of redesigning the Informatics for Diabetes Education and Telemedicine (IDEATel) telemedicine architecture on the average upload delay and on the average number of glucose uploads to a central database. These two measures positively influence our ability to deliver timely and accurate patient care to the study population. The redesign was also undertaken to improve the patients' experience in using the system and thereby increase the frequency and timeliness of their self-monitoring behavior. Using the total number of glucose uploads, we compared the delay in glucose upload times according to the type of home telemedicine unit the study participants used and the region where the participants lived. The participants were Medicare beneficiaries with diabetes living in medically underserved neighborhoods in New York City and rural Upstate New York. The populations in these two regions differed considerably in terms of ethnicity, language spoken (Spanish, English), and education level. Participants who had Generation 2 (Gen 2) (mean = 10.75, SD ± 7.96) home telemedicine units had significantly shorter upload delay times (p < 0.001) as measured in days than those participants with Generation 1 (Gen 1) (mean = 22.44, SD ± 11.18) and those who were upgraded from Gen 1 (mean = 20.67, SD ± 8.85) to Gen 2 (mean = 14.93, SD ± 9.37). Additionally, the delay was significantly shorter for participants living upstate (mean = 24.14 days, SD ± 11.95 days) than downstate (mean = 15.30 days, SD ± 7.87 days), t (975) = 13.98, p < 0.01. The system redesign made a significant impact in reducing glucose upload delays of IDEATel participants. However, upload delays were significantly impacted by the region where the participants resided.

Candidate HIV-1 vaccine regimens utilizing intramuscularly (i.m.) administered recombinant adenovirus (rAd)-based vectors can induce potent mucosal cellular immunity. However, the degree to which mucosal rAd vaccine routing might alter the quality and anatomic distribution of vaccine-elicited CD8+ T lymphocytes remains unclear. We show that the route of vaccination critically impacts not only the magnitude but also the phenotype and trafficking of antigen-specific CD8+ T lymphocytes in mice. I.m. rAd immunization induced robust local transgene expression and elicited high-frequency, polyfunctional CD8+ T lymphocytes that trafficked broadly to both systemic and mucosal compartments. In contrast, intranasal (i.n.) rAd immunization led to similarly robust local transgene expression but generated low-frequency, monofunctional CD8+ T lymphocytes with restricted anatomic trafficking patterns. Respiratory rAd immunization elicited systemic and mucosal CD8+ T lymphocytes with phenotypes and trafficking properties distinct from those elicited by i.m. or i.n. rAd immunization. Our findings indicate that the anatomic microenvironment of antigen expression critically impacts the phenotype and trafficking of antigen-specific CD8+ T lymphocytes.

Objective

To identify some of the challenges that medical residents face in addressing their information needs in an inpatient setting, by examining how voice capture in natural language of clinical questions fits into workflow, and by characterizing the focus, format, and semantic content and complexity of their questions.

Design

Internal medicine residents captured information needs on a digital recorder while on a hospital inpatient service and then participated in semi-structured interviews.

Measurements

Interviews were analyzed to identify emergent themes. Recorded questions were analyzed for focus (diagnosis, treatment, or epidemiology) and format, either foreground (specific knowledge relating to an individual patient) or background (general knowledge about a condition). Semantic concepts and types were identified using MetaMap (UMLS - Unified Medical Language System) and manually.

Results

Voice recording of questions appeared to unmask residents' latent information needs. Although residents were able to record questions during workflow, there was a delay from the time questions materialized to when they were recorded. Question focus was distributed among diagnosis (32%), treatment (40%), and epidemiology (28%), and the majority of questions were background (69%). Questions were semantically complex; foreground and background questions averaged 12.6 (SD 6.0) and 9.1 (SD 6.0) UMLS concepts, respectively. MetaMap failed to recognize concepts when residents used acronyms or abbreviations or omitted key terms.

Conclusions

We found that it is feasible for residents to capture their clinical questions in natural language during workflow and that recording questions may prompt awareness of previously unrecognized information needs. However, the semantic complexity of typical questions and mapping failures due to residents' use of acronyms and abbreviations present challenges to machine-based extraction of semantic content.

A critical goal of vaccine development for a wide variety of pathogens is the induction of potent and durable mucosal immunity. However, it has been assumed that this goal would be difficult to achieve by systemic vaccination due to the anatomic and functional distinctness of the systemic and mucosal immune systems and the resultant compartmentalization of immune responses. Here we show that antigen-specific CD8+ T-lymphocytes traffic efficiently to mucosal surfaces following systemic vaccination. Intramuscular immunization with recombinant adenovirus (rAd) vector-based vaccines expressing SIV Gag resulted in potent, durable and functional CD8+ T lymphocyte responses at multiple mucosal effector sites in both mice and rhesus monkeys. In adoptive transfer studies in mice, vaccine-elicited CD8+ T-lymphocytes exhibited phenotypic plasticity, upregulated mucosal homing integrins and chemokine receptors, and trafficked rapidly to mucosal surfaces. Moreover, the migration of systemic CD8+ T-lymphocytes to mucosal compartments accounted for the vast majority of antigen-specific mucosal CD8+ T-lymphocytes induced by systemic vaccination. Thus, intramuscular vaccination can overcome immune compartmentalization and generate robust mucosal CD8+ T-lymphocyte memory. These data demonstrate that the systemic and mucosal immune systems are highly coordinated following vaccination.

Prior research has questioned the effectiveness of existing methods to identify individuals at high risk for contracting and transmitting the Human Immunodeficiency Virus (HIV) and other sexually transmitted diseases (STDs). Thus, new approaches are needed to provide these individuals with risk-reduction strategies. We review our research on young adults’ sexual decision making, using theories and methods from social and cognitive sciences. Four patterns of condom use and associated levels of risks and beliefs were identified. These patterns suggest value in targeting intervention strategies to individuals at different levels of risk. Findings also imply that the monogamous population may be at higher risk for infection than they realize. Primary-care physicians are the first line of contact for many individuals in the health care system, and may be in the best position to screen for at-risk individuals. Given time demands and other barriers, easy-to-use evidence-based guidelines for such screening are needed. We propose such guidelines for primary-care physicians to use in identifying an individual’s risk, from which custom-tailored intervention strategies can be developed.

Objective:

Clinicians often have difficulty translating information needs into effective search strategies to find appropriate answers. Information retrieval systems employing an intelligent search agent that generates adaptive search strategies based on human search expertise could be helpful in meeting clinician information needs. A prerequisite for creating such systems is an information seeking model that facilitates the representation of human search expertise. The purpose of developing such a model is to provide guidance to information seeking system development and to shape an empirical research program.

Design:

The information seeking process was modeled as a complex problem-solving activity. After considering how similarly complex activities had been modeled in other domains, we determined that modeling context-initiated information seeking across multiple problem spaces allows the abstraction of search knowledge into functionally consistent layers. The knowledge layers were identified in the information science literature and validated through our observations of searches performed by health science librarians.

Results:

A hierarchical multi-level model of context-initiated information seeking is proposed. Each level represents (1) a problem space that is traversed during the online search process, and (2) a distinct layer of knowledge that is required to execute a successful search. Grand strategy determines what information resources will be searched, for what purpose, and in what order. The strategy level represents an overall approach for searching a single resource. Tactics are individual moves made to further a strategy. Operations are mappings of abstract intentions to information resource-specific concrete input. Assessment is the basis of interaction within the strategic hierarchy, influencing the direction of the search.

Conclusion:

The described multi-level model provides a framework for future research and the foundation for development of an automated information retrieval system that uses an intelligent search agent to bridge clinician information needs and human search expertise.

Searches of bibliographic databases generate lists of articles but do little to reveal connections between authors, institutions, and grants. As a result, search results cannot be fully leveraged. To address this problem we developed Sciologer, a prototype search and visualization system. Sciologer presents the results of any PubMed query as an interactive network diagram of the above elements. We conducted a cognitive evaluation with six neuroscience and six obesity researchers. Researchers used the system effectively. They used geographic, color, and shape metaphors to describe community structure and made accurate inferences pertaining to a) collaboration among research groups; b) prominence of individual researchers; and c) differentiation of expertise. The tool confirmed certain beliefs, disconfirmed others, and extended their understanding of their own discipline. The majority indicated the system offered information of value beyond a traditional PubMed search and that they would use the tool if available.

There are a range of barriers precluding patients from fully engaging in and benefiting from the spectrum of eHealth interventions developed to support patient access to health information, disease self-management efforts, and patient-provider communication. Consumers with low eHealth literacy skills often stand to gain the greatest benefit from the use of eHealth tools. eHealth skills are comprised of reading/writing/numeracy skills, health literacy, computer literacy, information literacy, media literacy, and scientific literacy [1]. We aim to develop an approach to characterize dimensions of complexity and to reveal knowledge and skill-related barriers to eHealth engagement. We use Bloom’s Taxonomy to guide development of an eHealth literacy taxonomy that categorizes and describes each type of literacy by complexity level. Illustrative examples demonstrate the utility of the taxonomy in characterizing dimensions of complexity of eHealth skills used and associated with each step in completing an eHealth task.

Objective

Despite the proliferation of consumer health sites, lay individuals often experience difficulty finding health information online. The present study attempts to understand users' information seeking difficulties by drawing on a hypothesis testing explanatory framework. It also addresses the role of user competencies and their interaction with internet resources.

Design

Twenty participants were interviewed about their understanding of a hypothetical scenario about a family member suffering from stable angina and then searched MedlinePlus® consumer health information portal for information on the problem presented in the scenario. Participants' understanding of heart disease was analyzed via semantic analysis. Thematic coding was used to describe information seeking trajectories in terms of three key strategies: verification of the primary hypothesis, narrowing search within the general hypothesis area and bottom-up search.

Results

Compared to an expert model, participants' understanding of heart disease involved different key concepts, which were also differently grouped and defined. This understanding provided the framework for search-guiding hypotheses and results interpretation. Incorrect or imprecise domain knowledge led individuals to search for information on irrelevant sites, often seeking out data to confirm their incorrect initial hypotheses. Online search skills enhanced search efficiency, but did not eliminate these difficulties.

Conclusions

Regardless of their web experience and general search skills, lay individuals may experience difficulty with health information searches. These difficulties may be related to formulating and evaluating hypotheses that are rooted in their domain knowledge. Informatics can provide support at the levels of health information portals, individual websites, and consumer education tools.

The development of a subunit vaccine for smallpox represents a potential strategy to avoid the safety concerns associated with replication-competent vaccinia virus. Preclinical studies to date with subunit smallpox vaccine candidates, however, have been limited by incomplete information regarding protective antigens and the requirement for multiple boost immunizations to afford protective immunity. Here we explore the protective efficacy of replication-incompetent, recombinant adenovirus serotype 35 (rAd35) vectors expressing the vaccinia virus intracellular mature virion (IMV) antigens A27L and L1R and extracellular enveloped virion (EEV) antigens A33R and B5R in a murine vaccinia virus challenge model. A single immunization with the rAd35-L1R vector effectively protected mice against a lethal systemic vaccinia virus challenge. The rAd35-L1R vector also proved more efficacious than the combination of four rAd35 vectors expressing A27L, L1R, A33R, and B5R. Moreover, serum containing L1R-specific neutralizing antibodies afforded postexposure prophylaxis after systemic vaccinia virus infection. In contrast, the combination of rAd35-L1R and rAd35-B5R vectors was required to protect mice against a lethal intranasal vaccinia virus challenge, suggesting that both IMV- and EEV-specific immune responses are important following intranasal infection. Taken together, these data demonstrate that different protective antigens are required based on the route of vaccinia virus challenge. These studies also suggest that rAd vectors warrant further assessment as candidate subunit smallpox vaccines.

Clinical trials increasingly rely upon web-based Clinical Trials Management Systems (CTMS). As with clinical care systems, Human Computer Interaction (HCI) issues can greatly affect the usefulness of such systems. Evaluation of the user interface of one web-based CTMS revealed a number of potential human-computer interaction problems, in particular, increased workflow complexity associated with a web application delivery model and potential usability problems resulting from the use of ambiguous icons. Because these design features are shared by a large fraction of current CTMS, the implications extend beyond this individual system.

As the use of health information technologies continues to proliferate amongst seniors, many of whom lack computer experience, there is a need to develop effective training approaches to foster basic competencies. This paper describes the REmote Patient Education in a Telemedicine Environment (REPETE) system, a component of the IDEATel telemedicine architecture. The REPETE architecture supports simultaneous visual and audio teaching modes over low bandwidth connections. This paper presents an in-depth qualitative analysis of two patients being trained to use the IDEATel patient web portal. The results indicate that this method of instruction was useful in facilitating patients’ use of the web application. However, the observations suggest that there is learning curve for the trainer to use the resources effectively to establish common ground and foster competencies in the patient.

Mobile devices such as PDAs are increasingly used as a part of healthcare interventions. Although they can provide powerful communication and self-management tools for patients with chronic illness, relatively little is known about their usability. A methodological framework for evaluating mobile health devices is proposed. It adapts the well-known methodologies of cognitive task analysis and usability testing. The framework is illustrated in the context of an analysis of an advanced function glucose meter. The analyses documented a range of problems which highlights the need to carefully scrutinize the usability of mobile health devices.

This study investigates how CPOE system users choose data input strategies for entering clinical orders. Complex systems often allow more than one way to complete a task. However, the appropriate entry strategy in the context of a specific clinical workflow situation may not be apparent to users. We have conducted a cognitive analysis of user interaction strategies for entering IV injection orders using a commercial CPOE system. We characterized the set of available information resources in the system interface and in the users’ memory, and evaluated how effectively the application supported decision-making processes. Seven internal medicine residents participated in an experiment entering IV heparin orders to manage anticoagulation therapy. The analysis showed that efficiency was contingent upon high level of procedural and conceptual system knowledge. CPOE interface design needs to conform to decision-making and workflow processes if the technology is to become an effective clinical tool.

To create a culture of safe practices, we need to understand how and under what conditions the public makes risky decisions about their health. Because risky sexual behaviors are known to be common in young adults, we investigated their decision making regarding sexual activities that could incur a high risk of HIV infection. Sixty young urban adults maintained journals for two weeks and were interviewed regarding condom use and sexual history. We characterized four patterns of condom use behavior: consistent (35.0%), inconsistent (16.7%), consistent to inconsistent (35.0%), and inconsistent to consistent (13.3%). Directionality of reasoning was analyzed in the explanations provided for condom use decisions. The consistent and inconsistent patterns were associated with data-driven heuristic reasoning, where behavior becomes automated and is associated with a high level of confidence in one’s judgment. In the other two patterns, the shift in behavior was due to a significant event that influenced a change in directionality to explanation-based reasoning. We discuss these results within the framework of identifying potentially high-risk groups for whom customized intervention strategies (such as computer-based educational programs) can be used to reduce risk, thereby creating a culture of safer sexual practices.

We developed a training protocol for elderly participants of a home telemedicine study, grounded in prior usability research. The training aimed to reduce barriers in developing system mastery. Our findings are indicative of both the promises and challenges involved in bridging the digital divide. Sixteen participants of a diabetes study were trained to use the computer applications.