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JMIR Preprints

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Journal Description

JMIR Preprints contains pre-publication/pre-peer-review preprints intended for community review (FAQ: What are Preprints?). For a list of all preprints under public review click here. The NIH and other organizations and societies encourage investigators to use interim research products, such as preprints, to speed the dissemination and enhance the rigor of their work. JMIR Publications facilitates this by allowing its' authors to expose submitted manuscripts on its' preprint server with a simple checkbox when submitting an article, and the preprint server is also open for non-JMIR authors.

With the exception of selected submissions to the JMIR family of journals (where the submitting author opted in for open peer-review, and which are displayed here as well for open peer-review), there is no editor assigning peer-reviewers.

Submissions are open for anybody to peer-review. Once two peer-review reports of reasonable quality have been received, we will send these peer-review reports to the author, and may offer transfer to a partner journal, which has its own editor or editorial board.

The submission fee for that partner journal (if any) will be waived, and transfer of the peer-review reports may mean that the paper does not have to be re-reviewed. Authors will receive a notification when the manuscript has enough reviewers, and at that time can decide if they want to pursue publication in a partner journal.

If authors want to have the paper only considered/forwarded to specific journals, e.g. JMIR, PLOS, PEERJ, BMJ Open, Nature Communications etc) after peer-review, please specify this in the cover letter. Simply rank the journals and we will offer the peer-reviewed manuscript to these editors in the order of your ranking.

If authors do NOT wish to have the preprint considered in a partner journal (or a specific journal), this should be noted in the cover letter.

JMIR Preprints accepts manuscripts at no costs and without any formatting requirements (but if you intend the submission to be published eventually by a specific journal, it is of advantage to follow their instructions for authors). Authors may even take a WebCite snapshot of a blog post or "grey" online report. However, if the manuscript is already peer-reviewed and formally published elsewhere, please do NOT submit it here (this is a preprint server, not a postprint server!).

 

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    Peer-Review 2.0: Welcome to JMIR Preprints, an Open Peer-Review Marketplace for Scholarly Manuscripts

    Authors List:

    Abstract:

    JMIR Preprints is a preprint server and "manuscript marketplace" with manuscripts that are intended for community review. Great manuscripts may be snatched up by participating journals which will make offers for publication.There are two pathways for manuscripts to appear here: 1) a submission to a JMIR or partner journal, where the author has checked the "open peer-review" checkbox, 2) Direct submissions to the preprint server. For the latter, there is no editor assigning peer-reviewers, so authors are encouraged to nominate as many reviewers as possible, and set the setting to "open peer-review". Nominated peer-reviewers should be arms-length. It will also help to tweet about your submission or posting it on your homepage. For pathway 2, once a sufficient number of reviews has been received (and they are reasonably positive), the manuscript and peer-review reports may be transferred to a partner journal (e.g. JMIR, i-JMR, JMIR Res Protoc, or other journals from participating publishers), whose editor may offer formal publication if the peer-review reports are addressed. The submission fee for that partner journal (if any) will be waived, and transfer of the peer-review reports may mean that the paper does not have to be re-reviewed. Authors will receive a notification when the manuscript has enough reviewers, and at that time can decide if they want to pursue publication in a partner journal. For pathway 2, if authors do not wish to have the preprint considered in a partner journal (or a specific journal), this should be noted in the cover letter. Also, note if you want to have the paper only considered/forwarded to specific journals, e.g. JMIR, PLOS, PEERJ, BMJ Open, Nature Communications etc), please specify this in the cover letter. Manuscripts can be in any format. However, an abstract is required in all cases. We highly recommend to have the references in JMIR format (include a PMID) as then our system will automatically assign reviewers based on the references.

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Latest Submissions Open for Peer-Review:

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  • Treating Functional Abdominal Pain Disorders in Children through a Guided Imagery Therapy Mobile Application: Formative Research

    From: Journal of Medical Internet Research

    Date Submitted: Dec 6, 2017

    Open Peer Review Period: Dec 7, 2017 - Feb 1, 2018

    Background: Functional abdominal pain disorders (FAPDs) are a set of chronic abdominal pain conditions, which are highly prevalent in the pediatric population and are associated with significant morbi...

    Background: Functional abdominal pain disorders (FAPDs) are a set of chronic abdominal pain conditions, which are highly prevalent in the pediatric population and are associated with significant morbidity. Of the various treatment modalities, psychological therapies like guided imagery therapy are the most effective. However, access to therapists is a significant barrier to their use. Consequently, interest is increasing in providing these therapies remotely (e.g., online, telephone). Objective: Given the need for increasing access to psychological treatments for FAPDs, we conducted a mixed methods study to assess whether affected pediatric patients and their parents would be interested in utilizing guided imagery therapy sessions delivered remotely via mobile application (app) to treat abdominal pain. Methods: Children ages 7 to 12 years old with a pediatric Rome III defined FAPD and their parent were recruited from primary care ambulatory clinics. Parents completed our modified Technology Acceptance Model Questionnaire to characterize our participants’ personal factors and behavioral intention to use a guided imagery therapy mobile app for FAPDs. Parents and children also participated in separate in-person interviews to assess interest in the proposed app. Results: Fifteen mother/child dyads participated. Children were 33% Hispanic and 73% were diagnosed with irritable bowel syndrome. Dyads were from homes of diverse socioeconomic status. The TAM Questionnaire indicated that mothers had a positive attitude toward using an app designed to treat their children’s FAPD. Behavioral intention to use such an app was also high. Qualitative findings confirmed mothers’ interest in a guided imagery mobile app. Mothers advocated for an image or interactive visual component on the mobile device to keep their child’s attention while the guided imagery therapy session audio is played; liked the idea of incorporating background sounds into the therapy sessions; thought reminder notifications built within such an app would be helpful; and most thought the best time for their child to listen to the sessions would be in the evening or before bed. Qualitative findings indicated that the children were also interested in a mobile app to treat their FAPD. They identified multiple topics (e.g., sports-related activities) that would be of interest for the guided imagery therapy sessions. Conclusions: The concept of a mobile app that remotely delivers guided imagery therapy sessions to treat pediatric patients with FAPDs appears to be acceptable to parents and children.

  • Comparative Analysis of Health Information Reporting Discrepancies Between Internet Media and Scientific Articles

    From: JMIR Preprints

    Date Submitted: Sep 15, 2017

    Open Peer Review Period: Sep 17, 2017 - Sep 2, 2018

    Background: Dietary supplements are the most used complementary and alternative health modality in the U.S., and omega-3 supplements continue to be the most popularly used non-vitamin/non-mineral supp...

    Background: Dietary supplements are the most used complementary and alternative health modality in the U.S., and omega-3 supplements continue to be the most popularly used non-vitamin/non-mineral supplements by adults. Supplement users report that they obtain health guidance from internet media resources, but there is question as to whether or not these resources provide the necessary evidence to guide health decisions. Current evidence suggests that there is a mistranslation occurring somewhere between researchers and the media. Objective: We conducted a comparative cross-sectional analysis to identify areas of discordance created when science is translated from the lab to online news media. Methods: A Google news search provided our convenience sample of 40 omega-3 supplement based media reports stratified by the years 2009-2012. Media reports (n = 17) were compared to the corresponding scientific article for content. Report and article content was extracted using commonly accepted reporting guideline domains, and domains were then compared to detect underlying omissions or mistranslations in reporting. Mean scores for all of the scientific articles and media reports were assessed for each domain. Results: Scientific articles generally maintained a mean close to complete (0.85) for each reporting domain. Media reports were far more likely to report potential caveats and warnings for consumers with a mean domain for Caveat reporting of 0.88, (95%CI[0.72, 1.0]). Conclusions: There are inherent differences in the intended audience, structure, and goals in scientific and media communications. These differences should be explored further, and consumers should be made aware of them. Additional considerations for balanced reporting and reader accessibility are also necessary to take into account, and are explored further in this analysis.

  • A Review of Smartphone Diet-tracking Applications: Usability, Functionality, Coherence with Behavior Change Theory, and Consistency of Nutrient Tracking

    From: Journal of Medical Internet Research

    Date Submitted: Dec 9, 2017

    Open Peer Review Period: Dec 11, 2017 - Feb 5, 2018

    Background: Smartphone diet-tracking applications may help individuals lose weight, manage chronic conditions, and understand dietary patterns, however, the ease of use and capabilities of these apps...

    Background: Smartphone diet-tracking applications may help individuals lose weight, manage chronic conditions, and understand dietary patterns, however, the ease of use and capabilities of these apps have not been well studied. Objective: The aim of this study was to review the usability of current iOS and Android diet-tracking apps, the degree to which app features align with behavior change constructs, and to assess variations between apps in nutrient coding. Methods: The top seven diet-tracking apps were identified from the iOS iTunes and Android Play online stores, downloaded and used over a 2-week period. Each app was independently scored using the System of Usability Scale (SUS), and features were compared to the domains in an integrated behavior change theory framework: the Theoretical Domains Framework (TDF). A 3-day food diary was completed using each app to evaluate their differences in nutrient data against the USDA reference. Results: Of the apps that were reviewed, LifeSum scored the highest average SUS score of 89.2, while MyDietCoach scored the lowest of 46.7. There were some variations in features noted between Android and iOS versions of the same apps, mainly for MyDietCoach, which affected SUS scoring. App features varied considerably, yet all of the apps had features consistent with Beliefs about Capabilities, and thus have the potential to promote self-efficacy by helping individuals track their diet and progress towards goals. None of the apps allowed for tracking of emotional factors that may be associated with diet patterns. The presence of behavior change domain features tended to be weakly correlated with greater usability (R2 ranging from 0 to 0.396). The exception to this was features related to the Reinforcement domain, which were correlated with less usability. Comparing the apps to the USDA reference for a 3-day diet, the average differences was 1.4 % for calories, 1.0 % for carbohydrates, 10.4% for protein, and -6.5% for fat. Conclusions: Diet tracking apps score well in usability, utilize a variety of behavior change constructs, and accurately code calories and carbohydrates, allowing them to play a potential role in dietary intervention studies.

  • Mobile technology utilization among patients from diverse cultural and linguistic backgrounds attending cardiac rehabilitation

    From: Journal of Medical Internet Research

    Date Submitted: Nov 27, 2017

    Open Peer Review Period: Nov 27, 2017 - Jan 22, 2018

    Background: Barriers to attending cardiac rehabilitation (CR), including cultural and linguistic differences, may be addressed by recent technological developments. However, the feasibility of using t...

    Background: Barriers to attending cardiac rehabilitation (CR), including cultural and linguistic differences, may be addressed by recent technological developments. However, the feasibility of using these approaches in diverse language patients is yet to be determined. Objective: This study aims, 1) To determine the comparative use of mobile technologies and features, as well as confidence in utilization across patients speaking different languages at home(English, Mandarin, and a language other than English and Mandarin [other]), who were eligible for CR; and 2) To examine the sociodemographic correlates of mobile technology/ feature use, including language spoken at home in these three groups. Methods: This is a Descriptive, case matched, comparative study. Age and gender-matched patients speaking English, Mandarin and other languages (n = 30/group) eligible for CR were surveyed for their mobile technology and mobile feature use. Results Results: Participants were 66.7± 13 (n=90, range 46-95) years old, 53.3% (n=48) male. The majority (n=82, 91.1%) used at least one technology device, with 74.4% (n=67) using Internet accessible devices, the most common being smartphones (n=57, 63.3%), computers/laptops (n=46, 51.1%) and tablets (n=28, 31.1%). More English-speaking participants used computer than Mandarin or “other” language speaking participants (P= 0.003 and 0.017), and were more confident in doing so compared to Mandarin-speaking participants (P=0.003). More Mandarin-speaking participants used smartphones compared with “other” language speaking participants (P=0.027). Most commonly used mobile features were voice calls (n=77, 93.9%), text message (n=54, 65.9%), Internet browsing (n=39, 47.6%), email (n=36, 43.9%), Skype / Facetime (Wechat / QQ) (n=35, 42.7%). Less Mandarin-speaking participants used email (P=0.001) and social media (P=0.007) than English-speaking participants. Speaking Mandarin was independently associated with using smartphone, computer and email (OR: 7.238 P=0.027, OR: 0.12 P=0.007, and OR: 0.089 P=0.006), and speaking “other” language was independently associated with computer use (OR: 0.223 P=0.046). Conclusions: Mobile technology is highly accepted by cardiac rehabilitation patients, including non-English speaking patients and may offer a potential solution for supporting patients from diverse language backgrounds.

  • Feasibility of a digital patient-led hospital checklist to enhance safety in cataract surgery

    From: Journal of Medical Internet Research

    Date Submitted: Jan 1, 2018

    Open Peer Review Period: Jan 4, 2018 - Mar 1, 2018

    Background: Surgery is a high-risk area for iatrogenic patient harm. Correct and sufficient communication and information during the surgical process has been reported as one of the root causes of pre...

    Background: Surgery is a high-risk area for iatrogenic patient harm. Correct and sufficient communication and information during the surgical process has been reported as one of the root causes of preventing patient harm. Information technology may substantially contribute to engaging patients in this process. Objective: To determine the feasibility of a digital patient-led checklist for cataract surgery, we evaluate the experiences of patients and nurses who have used this novel tool with a focus on use, appreciation and impact. Methods: A multidisciplinary team including cataract surgeons, nursing, pharmacy and administrative representatives developed a 19-item digital patient-led checklist for cataract patients who undergo surgery in an ambulatory setting. This ‘EYEpad’ checklist was distributed to patients and their companion during their hospital visit via an application on a tablet. It contained necessary information the patient should have received before or during the surgical preparation (8 items), before anaesthesia (2 items), and before discharge (9 items). Patients and their companions were invited to actively tick on the EYEpad the information they received or was discussed. Our qualitative research design included semi-structured individual interviews with patients and a focus group with the nurses involved. The transcripts were analysed by two independent coders using both deductive and inductive coding. Results: All but one of the 17 patients included used the EYEpad, whether or not assisted by their companion (mostly their partner). In most cases, the checklist was completed by the companion. Most patients were positive about the usability of the EYEpad. Yet, for the majority of the patients it was not clear why they received the checklist. Only four of them indicated that they understood that the EYEpad meant to validate if there was sufficient and correct information discussed or checked by the nurses. Although most nurses agreed that the EYEpad was easy to use and could be a useful tool to improve patient participation in improving safety, they felt that not all elderly patients are willing or capable of using it and that it interfered with the existing surgical process. They also anticipated to spend more time explaining the purpose and use of the EYEpad. Conclusions: Our study shows that a digital patient-led checklist is a potentially valid way to increase patient participation in improving safety, even in this group of elderly patients. It also illustrates the crucial role that nurses play in the implementation diffusion of technological innovations. Increased patient participation will only improve safety when both health care workers and patients feel empowered to share responsibility and balance power. Clinical Trial: Ethical approval was obtained from the ethics committee of the University of Twente (ECT number: 13196).

  • Parent-based, Indicated Prevention for Anorexia Nervosa: Results of a Randomized Controlled Efficacy Trial

    From: Journal of Medical Internet Research

    Date Submitted: Dec 14, 2017

    Open Peer Review Period: Dec 14, 2017 - Feb 8, 2018

    Background: Web-based preventive interventions reduce risk and incidence of bulimic and binge eating disorders among young high-risk women. However, their specific effects on core symptoms of anorexia...

    Background: Web-based preventive interventions reduce risk and incidence of bulimic and binge eating disorders among young high-risk women. However, their specific effects on core symptoms of anorexia nervosa (AN) are rather weak. Objective: The primary objective of this trial was to evaluate the efficacy of an indicated, parent-based, online preventive program “E@T” in reducing risk factors and symptoms of AN. Methods: Girls, age 11-17 years, were screened by selected risk factors and early symptoms of AN. At-risk families were then randomized to E@T or an assessment-only control condition. Assessments took place at pre-, post-intervention (six weeks later), 6-, and 12-month follow-up. Results: 12,377 screens were handed out in 86 German schools and 3,941 including consent returned. 477 (12.1%) girls were identified as at-risk for AN. 66 families were randomized to the E@T or control condition, 43 participated in post-assessments, 27 in 12-month FUs. Due to low participation rates of parents, recruitment was terminated prematurely. At 12-month-FU, girls` % expected body weight (EBW) was significantly greater for intervention participants compared with control participants (XX; P = .007) No other significant effects were found on risk factors and attitudes of disturbed eating. Conclusions: Despite a significant increase in girls` %EBW, parental participation and adherence to the intervention was low. Parent-based prevention for children at risk for AN does not seem very promising but may have a place for higher motivated parents. Clinical Trial: ISRCTN18614564

  • Combining continuous smartphone native sensors data capture and unsupervised data mining techniques for behavioral changes detection: The feasibility study of the Evidence Based Behavior (eB2) platform

    From: Journal of Medical Internet Research

    Date Submitted: Jan 4, 2018

    Open Peer Review Period: Jan 7, 2018 - Mar 4, 2018

    Background: The emergence of smart homes and wearable sensor technologies allows the non-intrusive collection of activity data. Thus, health-related events such as Activities of Daily Living (ADLs, e...

    Background: The emergence of smart homes and wearable sensor technologies allows the non-intrusive collection of activity data. Thus, health-related events such as Activities of Daily Living (ADLs, e.g., feeding, sleeping) can be captured without the patient’s active participation. We designed a system able to perform continuous monitoring based on smartphone’s native sensors and advanced machine learning and signal processing techniques. Objective: The principal objective of this study was to determine the feasibility of behavioral changes identification with a preliminary study. Concretely, outpatients owning a smartphone with the eB2 mobile app installed participate in this study. Additionally, we also use this opportunity to introduce the eB2 platform, which allows not only for behavioral changes identification but for an integral monitoring of psychiatric patients. Method: Outpatients from the Psychiatry Department of the Fundación Jiménez Díaz were proposed to participate. We performed an unsupervised quantitative analysis and a qualitative analysis on a sample of outpatients recruited between April 6th, 2017 and October 8th, 2017. The eB2 app was downloaded by the patient the day of recruitment and configured with the aid of the physician (or a technician). The app remained running in the background on the patient’s smartphone during the whole participation in the study. Results: The principal outcome measure was the identification of behavioral changes based on smartphone’s native sensors data that are processed by an unsupervised technique. In particular, a total of 39 patients participate in this study. However, for the sake of space and presentation, only detailed results from 3 patients are presented (as a case series). Although the platform and the technique allow for an easy integration of multiple data: phone and messages logs, app usage, etc, and the identification of the activity shift between day and night, in this initial study, the behavioral changes detection is based on distance travelled profiles, and so in the three patients selected eB2 detected specifical patterns and behavioral changes according their activity and clinical state Discussion: We presented the preliminary results of an ongoing study based on the eB2 platform. We have developed an unsupervised method to detect behavioral changes in outpatients that is based on the smartphone’s native sensors data. Our approach may help researchers to transfer insight from existing methods in ambient ADL recognition home sensor and wearable technology.  

  • Patients’ Experiences of Accessing Their Online Electronic Health Records - Overview from a National Patient Survey in Sweden

    From: Journal of Medical Internet Research

    Date Submitted: Nov 29, 2017

    Open Peer Review Period: Nov 29, 2017 - Jan 24, 2018

    Background: In 2012, Region Uppsala was the first county council in Sweden to introduce patient accessible electronic health records (PAEHRs). By summer 2016 all but four out of 21 county councils had...

    Background: In 2012, Region Uppsala was the first county council in Sweden to introduce patient accessible electronic health records (PAEHRs). By summer 2016 all but four out of 21 county councils had given citizens the possibility to access their medical information online. Numerous studies on the effect of PAEHRs on the work environment of healthcare professionals have been carried out, but up until now no extensive studies have been carried out regarding the patient’s experiences with using PAEHRs. Objective: The aim of the study was to investigate patients’ experiences of accessing their online electronic health records through the Swedish national patient portal. In this paper, the focus is on describing user characteristics, usage, and attitudes towards the system. Methods: A national patient survey was designed, based on an earlier interview and survey studies with patients and healthcare professionals. Data was collected during a five months period, June-October 2016. The survey was made available online on the login page to the patient accessible electronic health record system (Journalen) in Sweden. Patients from all county councils in Sweden could reach the survey. Results: 2587 users answered the survey. Two participants were excluded from the analysis, since they had only received care in a county council which did not yet show any information in Journalen. The results show that the majority of the users are women (67%) and there is a clear indication that a large amount of the users work or have worked within healthcare. Most users use Journalen infrequently (72%) and the main reason for use is to get an overview of one’s health status. Furthermore, lab results was shown to be the most important type of information to have access to. The majority of the respondents (69%) want access to new information within a day. A vast majority of the users are positive towards Journalen; 87% strongly agree and 8% agree to the statement “Getting access to Journalen is good for me”. Conclusions: The respondents provide several important reasons for why they use Journalen and why it is important for them to be able to access information in this way - several relate to patient empowerment, involvement, and security. Also considering the overall positive attitude, we can conclude that Journalen - and most probably other similar systems as well - fill important needs for patients. It is clear that patients appreciate the possibilities that Journalen gives.

  • Designing a portal to patient-centered care? Let’s start with the patient. A cross-sectional survey.

    From: Journal of Medical Internet Research

    Date Submitted: Nov 26, 2017

    Open Peer Review Period: Nov 27, 2017 - Jan 22, 2018

    Background: In recent literature, Patient Portals are considered as important tools for the delivery of patient-centered care. Yet, it is not clear how patients would conceptualize a Patient Portal an...

    Background: In recent literature, Patient Portals are considered as important tools for the delivery of patient-centered care. Yet, it is not clear how patients would conceptualize a Patient Portal and which health information needs they have when doing so. Objective: 1) to investigate health information needs, expectations and attitudes towards a Patient Portal. 2) to assess if determinants such as patient characteristics, health literacy and empowerment status can predict two different variables, namely the importance people attribute to obtaining health information when using a Patient Portal and the expectations concerning personal healthcare when using a Patient Portal. Methods: A cross-sectional survey was performed in the Flemish population on what patients prefer to know about their digital health data and on their expectations and attitudes towards using a patient portal to access their Electronic Health Record. People were invited to participate in the survey through newsletters, social media and magazines. We used a validated questionnaire including demographics, health characteristics, health literacy, patient empowerment and patient portal characteristics. Results: We received 433 completed surveys. The health information needs included features such as being notified when one’s health changes (93.7%, 371/396), being notified when physical parameters rise to dangerous levels (93.7%, 370/395), to see connections between one’s symptoms/diseases/biological parameters (85.2%, 339/398), to view the evolution of one’s health in function of time (84.5%, 333/394) and to view information about the expected effect of treatment (88.4%, 349/395). Almost 90% (369/412) of respondents were interested in using a Patient Portal. Determinants of patients’ attachment to obtaining health information on a Patient Portal were 1) age between 45 and 54 years (P = .047); 2) neutral (P = .030) or interested attitude (P = .008) towards shared decision-making; 3) commitment to question the physicians’ decisions (P = .030). (R2 = .122) Determinants of patients’ expectations on improved healthcare by accessing a Patient Portal were 1) lower education level (P = .040); 2) neutral (P = .030) or interested attitude (P = .008) towards shared decision-making; 3) problems in understanding health information (P = .037). (R2 = .106) Conclusions: The interest in using a Patient Portal is considerable in Flanders. People report they would like to receive alerts or some form of communication from a Patient Portal in case they need to take action to manage their health. Determinants such as education, attached importance to shared decision-making, difficulties in finding relevant health information and the attached importance to questioning the decisions of physicians need to be taken into account in the design of a Patient Portal.

  • Identifying subtypes of a stigmatized medical condition

    From: Journal of Participatory Medicine

    Date Submitted: Jan 15, 2018

    Open Peer Review Period: Jan 19, 2018 - Mar 16, 2018

    Background: Some conditions - such as obesity, depression and functional odor disorders - come with a social stigma. Understanding the etiology of these conditions helps to avoid stereotypes and find...

    Background: Some conditions - such as obesity, depression and functional odor disorders - come with a social stigma. Understanding the etiology of these conditions helps to avoid stereotypes and find remedies. One of the major obstacles facing researchers, especially for those studying socially distressing metabolic malodor, is the difficulty in assembling biologically homogenous study cohorts. Objective: The aim of this study was to examine phenotypic variance, self-reported data and laboratory tests for the purpose of identifying clinically relevant and etiologically meaningful subtypes of idiopathic body odor and the “People are Allergic To Me” (PATM) syndrome. Methods: Participants with undiagnosed body odor conditions enrolled to participate in several studies initiated by a healthcare charity MEBO Research. Primary outcomes were differences in metabolite concentrations measured in urine, blood and breath of test and control groups. Principal component analyses and other statistical tests were carried out for these measurements. Results: While neither of existing laboratory tests could reliably predict chronic malodor symptoms, several measurements distinguished phenotypes at a significance level less than 5%. Types of malodor can be differentiated by self-reported consumption of (or sensitivity to) added sugars (p<0.01), blood alcohols after glucose challenge (especially ethanol: p<0.0005), urinary excretion of phenylalanine, putrescine, and combinations of blood or urine metabolites. In addition, participants with bad breath (but no body odor) and body odor (with or without bad breath) significantly differed in intestinal permeability to PEG286-418. Conclusions: Our preliminary results suggest that malodor heterogeneity can be addressed by analyses of phenotypes based on patients' dietary and olfactory observations. Our studies highlight the need for more trials. Future research focused on comprehensive metabolomics and microbiome sequencing will play an important role in the diagnosis and treatment of malodor. Clinical Trial: Two of the studies discussed in the manuscript were registered as NCT02692495 and NCT02683876 at clinicaltrials.gov

  • The prevention of musculoskeletal injuries in field hockey: the systematic development of an intervention and its feasibility

    From: Journal of Medical Internet Research

    Date Submitted: Nov 27, 2017

    Open Peer Review Period: Nov 28, 2017 - Jan 23, 2018

    Background: Field hockey is associated with a risk for musculoskeletal injuries, especially in the lower extremities. At present time, no measures focussing on the prevention of lower extremity injuri...

    Background: Field hockey is associated with a risk for musculoskeletal injuries, especially in the lower extremities. At present time, no measures focussing on the prevention of lower extremity injuries exist in the Netherlands. Consequently, a scientific research project has been initiated in the Netherlands aimed at developing and implementing an evidence-based intervention to prevent the occurrence of lower extremity injuries among young and adult recreational field hockey players. Objective: This article describes: (i) the systematic development of the intervention; and (ii) the assessment of its feasibility in terms of relevancy, suitability, satisfaction and usability. Methods: The intervention was developed according to the first four steps of the Intervention Mapping and Knowledge Transfer Scheme processes, namely: needs assessment; objective and target groups; content selection; development. Subsequently, a quasi-experimental research (one-group post-test design) was conducted among 35 young field hockey players and seven coaches. Participants were asked to use the intervention for three weeks and the degrees of relevancy, suitability, satisfaction and usability of the intervention were assessed by means of a questionnaire and a group interview. Results: First, the needs assessment conducted among the main actors within recreational field hockey revealed that an injury prevention intervention was needed, ideally delivered through videos via an application for smartphone/tablet or website. Second, the objective and target groups of the intervention were defined, namely to prevent or reduce the occurrence of lower extremity injuries among both young and adult recreational field hockey players. Third, preventive measures and strategies (e.g. core stability, strength, coordination) were selected in order to accomplish a decrease in injury incidence. Last, the ‘Warming-Up Hockey’ intervention ‘was developed, consisting of a warm-up programme (16 minutes) delivered by coaches including more than 50 unique exercises. The relevancy, satisfaction and usability of ‘Warming-Up Hockey’ were positively evaluated. Group interviews revealed especially that the warm-up programme in its current form was not suitable as a pre-match warm-up. Conclusions: The feasibility of ‘Warming-Up Hockey’ was positively assessed by players and coaches. In accordance with the feasibility study, the duration of the intervention was reduced to 12 minutes, while a match-specific warm-up was developed. ‘Warming-Up Hockey’ was made available through an application for smartphone/tablet and a website. Prior to its nationwide implementation, the effectiveness of the intervention on injury reduction among field hockey players should be conducted.

  • The value of RFID in Quality Management of the Blood Transfusion Chain in an Academic Hospital Setting

    From: Journal of Medical Internet Research

    Date Submitted: Nov 27, 2017

    Open Peer Review Period: Nov 28, 2017 - Jan 23, 2018

    Background: A complex process like the blood transfusion chain could benefit from modern technologies like RFID. RFID could for example play an important role in generating logistic and temperature da...

    Background: A complex process like the blood transfusion chain could benefit from modern technologies like RFID. RFID could for example play an important role in generating logistic and temperature data of blood products, which are important in assessing the quality of the logistic process of blood transfusions and the product itself. Objective: The aim of this study is to evaluate whether location, time-stamp and temperature data generated in real-time by an active RFID system containing temperature sensors attached to Red Blood Cell products (RBCs), can be used to assess the compliance of the management of RBCs to 4intra-hospital European and Dutch guidelines prescribing logistic and temperature constraints in an academic hospital setting. Methods: A RFID infrastructure supported the tracking and tracing of 243 tagged RBCs in a clinical setting inside the hospital at the Blood Transfusion Laboratory (BTL), the Operating Room (OR) complex and the Intensive Care Unit (ICU) within the Academic Medical Center (AMC), a large academic hospital in Amsterdam, The Netherlands. The compliance of the management of 182 out of the 243 tagged RBCs could be assessed on their adherence to the following guidelines on intra-hospital storage, transport and distribution: (1) RBCs must be preserved within an environment with a temperature between 2°C and 6°C; (2) RBCs have to be transfused within 1 hour after they have left a validated cooling system; (3) RBCs that have reached a temperature above 10°C must not be restored or must be transfused within 24 hours, or else be destroyed; (4) Unused RBCs are to be returned to the blood transfusion laboratory within 24 hours after they left the transfusion laboratory. Results: In total 4 blood products (4 in 182 compliant; 2%) complied to all applicable guidelines. Fifteen blood products (15 in 182 not compliant to 1 out of several guidelines; 8%) were not compliant to one of the guidelines of either 2 or 3 relevant guidelines; Finally 148 blood products (in 182 not compliant to 2 guidelines; 81%) were not compliant to 2 out of 3 relevant guidelines. Conclusions: The results point out the possibilities of using RFID technology to assess the quality of the blood transfusion chain itself inside a hospital setting in reference to intra-hospital guidelines concerning the storage, transport and distribution conditions of RBCs. This study shows the potentials of RFID in identifying potential bottlenecks in hospital organizations’ processes by use of objective data which are to be tackled in process redesign efforts. The effect of these efforts can subsequently be evaluated by the use of RFID again. As such, RFID can play a significant role in optimization of the quality of the blood transfusion chain

  • Engaging Men in Prenatal Health via eHealth: Findings from a National Survey

    From: Journal of Medical Internet Research

    Date Submitted: Nov 29, 2017

    Open Peer Review Period: Nov 29, 2017 - Jan 24, 2018

    Background: Pregnancy outcomes in the U.S. rank among the worst of countries with a developed healthcare system. While traditional prenatal health primarily focuses on women, promising findings have e...

    Background: Pregnancy outcomes in the U.S. rank among the worst of countries with a developed healthcare system. While traditional prenatal health primarily focuses on women, promising findings have emerged in international research that suggest the potential of including men in prenatal health interventions in the U.S. eHealth applications present a promising avenue to reach new and expectant fathers with crucial parenting knowledge and healthy, supportive behaviors. Objective: To explore the perceived role of men in prenatal health, the potential use of e-health promotion, and participant-suggested ways of improving a prenatal health application designed for new and expectant fathers. Methods: A nationally-representative sample of adult males (N=962) was recruited through an online panel. The sample had an average age of 30.2 (SD=6.3) and included both fathers (413/962, 42.9%) and non-fathers (549/962, 57.1%). Nearly 12% (115/962) of participants had a partner who was pregnant at the time of the survey. Results: Despite perceived barriers such as time constraints, financial burdens, and an unclear role, men believe it is important to be involved in pregnancy health. The majority of participants (770/944, 81.6%) found the site to contain useful and interesting information. Most substantially, results indicate that more than three quarters (738/962, 76.7%) of the sample said they would share the site with others who would benefit from the information. Participants recommended the addition of interactive modules, such as a financial planning tool and videos, to make the site stronger. Conclusions: We explored the use of targeted eHealth to introduce men to prenatal education. Results indicate men are favorable to this intervention. Additional refinement should include interactive tools further engage men in this important issue. Reaching men at the prenatal phase is an early ‘teachable moment’ – where new/expectant fathers are open to information on how to help their partners have a healthy pregnancy and promote the health of their unborn children. Findings will further inform best practices for engaging men in pregnancy, which is crucial for improving maternal and child health outcomes in the U.S.

  • Development of an eHealth system to capture and analyze patient sensor and self-report data: Potential applications to improve cancer care delivery

    From: JMIR Medical Informatics

    Date Submitted: Nov 29, 2017

    Open Peer Review Period: Nov 30, 2017 - Jan 25, 2018

    Background: “COMPASS” (“Capturing and Analyzing Sensor and Self-Report Data for Clinicians and Researchers) is an eHealth platform designed to improve cancer care delivery through passive monito...

    Background: “COMPASS” (“Capturing and Analyzing Sensor and Self-Report Data for Clinicians and Researchers) is an eHealth platform designed to improve cancer care delivery through passive monitoring of patients’ health status and delivering customizable reports to clinicians. Based on data from sensors and context-driven administration of patient-reported outcome (PRO) measures, key indices of patients’ functional status can be collected between regular clinic visits, supporting clinicians in the delivery of patient care. Objective: The aim of the first phase of this project was to systematically collect input from oncology providers and patients on potential clinical applications for COMPASS in order to refine the system. Methods: Ten clinicians representing various oncology specialties and disciplines completed semi-structured interviews designed to solicit clinician input on how COMPASS can best support clinical care delivery. Three cancer patients tested a prototype of COMPASS for 7 days and provided feedback. Interview data was tabulated using thematic content analysis (TCA) to identify the most clinically relevant objective and PRO domains. Results: TCA revealed that clinicians were most interested in monitoring vital statistics, symptoms and functional status, including physical activity level (n=9), weight (n=5), fatigue (n=9), sleep quality (n=8) and anxiety. Patients (2 in active treatment, 1 in remission) reported that they would use such a device, were enthusiastic about their clinicians monitoring their health status, especially the tracking of symptoms, and felt knowing their clinicians were monitoring and reviewing their health status provided valuable reassurance. Patients would however like to provide some context to their data. Conclusions: Clinicians and patients both articulated potential benefits of the COMPASS system in improving cancer care. From a clinician standpoint, data needs to be easily interpretable and actionable. The fact that patients and clinicians both see potential value in eHealth systems suggests wider adoption and utilization could prove to be a useful tool for improving care delivery.

  • Identifying and Understanding Communities Using Twitter to Connect About Depression

    From: JMIR Mental Health

    Date Submitted: Nov 29, 2017

    Open Peer Review Period: Nov 30, 2017 - Jan 25, 2018

    Background: Depression is a leading cause of disease globally and is often characterized by a lack of social connection. With the rise of social media comes reports that Twitter users are seeking conn...

    Background: Depression is a leading cause of disease globally and is often characterized by a lack of social connection. With the rise of social media comes reports that Twitter users are seeking connections about depression online. Objective: This study aimed to identify communities where Twitter users tweeted using the hashtag #MyDepressionLooksLike to connect about depression. Once identified, we wanted to understand which community characteristics correlated to Twitter-users turning to a virtual community to connect about depression. Methods: Tweets were collected using NCapture software from May 25th to June 1st, 2016 during Mental Health Awareness month (n=104) in the northeastern United States and Washington D.C. After mapping tweets, we used a Poisson multi-level regression model to predict tweets per community (county) offset by the population aged 15-44 years old, and adjusted for percent female, white, below poverty, and single-person households. We then compared predicted versus observed counts and calculated Tweeting Index Values (TIVs) based on the residuals. Last, we examined trends in community characteristics by TIV using Pearson’s correlation. Results: We found significant associations between tweet counts and area-level proportions of females, single-person households, and population aged 15-44 years. Tweeting Index Values (TIVs) were higher than expected (TIV 5) in western, inland areas of the study region. There were lower than expected tweets in the eastern, seaboard areas (TIV 1). When examining community characteristics and over- and under-tweeting by county, we observed a clear upward linear gradient in vacant housing and over-tweeting (r= 0.31, P< .001). However, we observed U-shaped relationships for most other community factors, suggesting that the same characteristics were correlated with both over- and under-tweeting. Conclusions: Lack of connection-building amenities in physical communities may lead to both the over- and under-tweeting by Twitter users seeking connections about depression. Higher rates of vacant housing are especially linked to higher levels of tweeting than expected. Future research could expand the spatiotemporal scope.

  • Perceptions of existing wearable robotic devices for upper extremity: Findings from therapists and people with stroke

    From: JMIR Rehabilitation and Assistive Technologies

    Date Submitted: Nov 29, 2017

    Open Peer Review Period: Nov 30, 2017 - Jan 25, 2018

    Background: Advances in wearable robotic technologies have increased the potential of these devices for rehabilitation and as assistive devices. However, the utilization of these devices is still limi...

    Background: Advances in wearable robotic technologies have increased the potential of these devices for rehabilitation and as assistive devices. However, the utilization of these devices is still limited. There are also questions regarding how well these devices address users’ (therapists and patients) needs. Objective: this study was conducted with three main objectives: 1. To describe users’ perceptions about existing wearable robotic devices for upper extremity. 2. To identify if there is a need to develop new devices for upper extremity and the desired features. 3. To explore the obstacles that would influence the utilization of these new devices (if needed). Methods: Focus groups were the primary means of data collection. Data were analyzed thematically. Results: Sixteen participants took part in the focus group discussions. Our analysis identified three main themes: “They exist, but?” described participants’ perceptions about existing devices for upper extremity. “Indeed, we need more, Can we have it all?” reflected participants’ desire to have new devices for upper extremity, but also revealed heterogeneity among different participants. “Bumps on the road” identified challenges that the participants felt needed to be taken into consideration during the development of these devices. Conclusions: This study supported previous research efforts that highlighted the importance to involve the end users’ in the design process. The study suggested that having a single solution for stroke rehabilitation/assistance could be challenging or even impossible, and thus, engineers should clearly identify the targeted stroke population needs prior to the design of any device for upper extremity.

  • An Account of how Attention to Usability and Lifestyle Issues may Contribute to Protocols for Clinical Trials of Medical Devices

    From: Journal of Medical Internet Research

    Date Submitted: Nov 30, 2017

    Open Peer Review Period: Nov 30, 2017 - Jan 25, 2018

    Objectives: Within the field of medicine attempts have been made to establish the efficacy of new treatments with medical devises by double blind randomized clinical trials. Very precise protocols hav...

    Objectives: Within the field of medicine attempts have been made to establish the efficacy of new treatments with medical devises by double blind randomized clinical trials. Very precise protocols have been developed for this purpose. However, experience has shown that conducting clinical trials on medical devices may be fraught with trouble often because of the difficulty of establishing a valid sham procedure. This paper makes a contribution by showing how one may formulate protocols for clinical trials of medical devices that rely on a pragmatic approach, which includes an interest in usability and lifestyle issues, rather than a sham procedure. Our case in point is a protocol for a clinical trial, conducted by the authors, of a new kind of treatment of epilepsy with a medical device. Methods: This paper makes a methodological contribution relevant for the formulation of protocols for clinical trials of medical devises in cases where a sham devise is not practical. Results: In the paper, we make three major points: (1) abandoning basing a clinical trial of a medical device on a sham procedure, involves making choices as to the formulation of a pragmatic alternative, (2) shifting to a pragmatic evaluation based on data on for example continued use, may involve generating data on usability and lifestyle issues. Understanding to what degree noncompliance is due to usability or lifestyle issues requires attention to the design of suitable instruments for data generation, and (3) the successful formulation of a protocol for a clinical trial of a medical device (where sham is not an option) relies on a case report form (CRF) that facilitates the separation of data on the (somatic) efficacy of the treatment from data on usability and lifestyle issues. Conclusion: Digital devices play an important role in medicine today and in the future. This paper makes a contribution by showing how one may formulate protocols for clinical trials of medical devices that do not rely on a sham procedure. The approach is based on a pragmatic approach, the generating data on usability and lifestyle issues connected to the use of the devise, and the separation of these issues from the evaluation of the efficacy of the active component of the treatment.

  • The feasibility of using an electronic platform to collect health and exposure data in Australian Olympic combat sports

    From: Journal of Medical Internet Research

    Date Submitted: Nov 30, 2017

    Open Peer Review Period: Dec 2, 2017 - Jan 27, 2018

    Background: Electronic methods are increasingly being used to manage health-related data amongst general and sporting populations. Collection of such data permits analysis of injury and illness trends...

    Background: Electronic methods are increasingly being used to manage health-related data amongst general and sporting populations. Collection of such data permits analysis of injury and illness trends, improves early detection of health problems and provides evidence to inform prevention strategies. Athlete self-report monitoring (ASRM) via online systems have been successfully employed across a range of team sports to monitor health. Australian combat athletes train across the country without dedicated national medical/sports science teams to monitor and advocate for their health. Employing an internet-based ASRM system may provide an avenue to increase visibility of health problems experienced by combat athletes, and deliver key information to stakeholders about where prevention programs can be targeted. Objective: The objectives of this study were to: 1) Investigate the uptake and engagement with two online ASRM tools across a cohort of Australian combat athletes, 2) Document the type and severity of injuries/illnesses sustained by these athletes, and 3) Compare the strengths/limitations of two different injuries/illness definitions. Methods: Twenty-six athletes from four Olympic combat sports (boxing, judo, taekwondo and wrestling) were approached to complete two online ASRM tools, one daily and one weekly. Engagement with the ASRM tools was measured and health problems (injuries and illnesses) collected by the tools were coded using OSICS version 10.1 and ICP 2. Multilevel mixed effects Poisson regression was utilised to assess engagement across the study period and the effect of personal contact made on the reporting. Results: Despite over 160 contacts, athlete engagement with online tools was poor with only 13% compliance across the 12 week period. No taekwondo or wrestling athletes were compliant. Communication with athletes did not influence their long term behaviour and those that were compliant at the beginning of the study were more likely to be compliant throughout. Despite low engagement, high numbers of injuries/illness were recorded across 11 athletes: 22 unique injuries, 8 unique illnesses, 30 recurrent injuries and two recurrent illnesses. The most frequent injuries were to the knee in boxing (n=41) and thigh in judo (n=9). Judo players experienced more severe, but less frequent, injuries than did boxers yet sustained more illnesses. Athletes were continued to train irrespective of health problems in 97% of cases. Conclusions: Amongst athletes who reported injuries, many reported multiple conditions. Athletes were not highly engaged with the online ASRM tools despite ample feedback and reminders. Contact was beneficial athletes who had previously entered data but did not change the behaviour of non-compliant athletes. Results indicate that there may be a need for staff within the sports organisations drive implementation. By utilising the information gathered from online monitoring to inform daily training, engagement and subsequent data quality can be enhanced all whilst increasing coach/staff oversight of combat athlete health.

  • Investigating the relationship between media coverage and vaccination uptake in Denmark

    From: Journal of Medical Internet Research

    Date Submitted: Dec 1, 2017

    Open Peer Review Period: Dec 2, 2017 - Jan 27, 2018

    Background: Understanding the influence of media coverage upon vaccination activity is a potential resource for timely vaccination surveillance and similarly, might be an important factor when designi...

    Background: Understanding the influence of media coverage upon vaccination activity is a potential resource for timely vaccination surveillance and similarly, might be an important factor when designing outreach campaigns. The necessity and safety of the measles, mumps and rubella (MMR) vaccine has been debated for many years, making it a suitable candidate for studying the interplay between media and vaccinations. Objective: Study the relationship between media coverage, incidence of measles, and vaccination activity of the MMR vaccine in Denmark. Methods: The cross-correlations between media coverage (1,622 articles), vaccination activity (2 million individual registrations), and incidence of measles are analyzed for the period 1997-2014. All 1,622 news media articles are annotated as being pro-vaccination, anti-vaccination, or of neutral stance. Results: The majority of anti-vaccination media coverage (65% of total anti-vaccination coverage) is observed in the period 1997-2004, immediately prior to and following the 1998 publication of the falsely claimed link between autism and the MMR vaccine. For the period 1998-2004 we observe a statistically significant positive correlation between the first MMR vaccine (targeting children aged 15 months), and pro-vaccination coverage (r=.49, P=.004), and between the first MMR vaccine and neutral media coverage (r=.45, P=.003). For the first MMR vaccine during the full period 1997-2014, we observe a statistically significant positive correlation with the measles incidence (r=.31, P=.005) with a lag of one month, indicating an increase in vaccinations following measles outbreaks. Looking at the whole period, 1997-2014, we observe no significant correlations between vaccination activity and media coverage. Conclusions: While there is no correlation between vaccination uptake and media coverage for the full period 1997-2014, there is a statistically significant positive correlation between pro-vaccination and neutral media coverage and vaccination activity for the period following the falsely claimed link between autism and the MMR vaccine, in 1998-2004. The fact that a correlation was only observed during a period of controversy suggests that people are more susceptible to media influence when presented with diverging opinions. Additionally, this correlation was only observed for the first MMR vaccine, indicating that the influence of media is stronger on parents when they are deciding on the first vaccine of their children, than on the subsequent vaccines.

  • A Thematic Analysis of U.S. Hospitals’ Posts on Facebook

    From: Journal of Medical Internet Research

    Date Submitted: Dec 1, 2017

    Open Peer Review Period: Dec 3, 2017 - Jan 28, 2018

    Background: While healthcare organizations such as hospitals and clinics have widely embraced social media as a means to educate the community on health topics and increase patient loyalty and satisfa...

    Background: While healthcare organizations such as hospitals and clinics have widely embraced social media as a means to educate the community on health topics and increase patient loyalty and satisfaction, little is known about the content that these organizations actually share when using social media channels. Objective: This study aimed to explore the types of content that U.S. hospitals post on their Facebook pages and how hospitals’ Facebook activities differ with regard to content types. Methods: We collected and thematically analyzed more than 1,700 Facebook posts made over a three-month period by seventeen U.S. hospitals. During the first phase, the two researchers coded a set of 159 posts and created an initial thematic web of content. During the second phase, the researchers coded the remaining posts and then revised, refined, and validated the initial web of content accordingly. Coding consensus was achieved on 1184 of the 1548 analyzable sampled posts (76.49%). Results: We identified a list of thirteen unique health social media post themes and classified those themes into three thematic groups that included announcing, sharing, and recognizing activities. The most frequently used theme was sharing health information, which appeared in more than 35% of the posts analyzed. Such posts sought to provide health tips and advice to community members. Recognizing special days and recognizing employees were the second and third most frequently used themes, respectively, with 14.95% and 11.82% of the posts containing those themes. The frequency of these themes were surprising in that the content was geared more toward stakeholders internal to the organization, while most prior literature has focused on social media as a tool to connect with external stakeholders. In addition, we found that many of the posts involved more than one theme and selected sets of themes co-occurred frequently. For example, 25% of the posts recognizing special days also included content to share health information and nearly 38% of the posts announcing research activities also included content to share health information. Finally, we found that hospitals were in some ways similar and in some other ways different in terms of the themes that they predominantly used in their Facebook posts. Conclusions: Using Facebook is an inexpensive, yet effective way for healthcare organizations to educate people on health and wellness topics and to communicate different types of information and news to the public audience. Hospitals and clinics that are expanding their social media activities or are starting to embark on social media strategies can use the results of this study to better formulate their activities on Facebook.

  • Characteristic of Adults’ Use of Facebook and the Potential Impact on Health Behavior

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 1, 2017

    Open Peer Review Period: Dec 2, 2017 - Jan 27, 2018

    Background: Social influences are a primary factor in the adoption of health behaviors. Social media platforms, namely, Facebook provide information dissemination, raise awareness, and provide motivat...

    Background: Social influences are a primary factor in the adoption of health behaviors. Social media platforms, namely, Facebook provide information dissemination, raise awareness, and provide motivation and support for positive health behaviors. Facebook has evolved rapidly and is now a part of most individual’s daily routine. The high degree of engagement and minimal attrition of this platform necessitates consideration for integration in healthcare. Objective: To investigate the use of Facebook by adults. Knowledge is limited of the unique characteristics of Facebook use, including time spent on Facebook by adults of various age groups, necessitating this investigation. Characteristics of Facebook users are important to understand to direct efforts to engage adults in future health behavior interventions. Methods: Institutional Review Board approval was obtained for this exempt secondary analysis of existing de-identified survey data collected for the Pew Research Center. The sample included adults age 18-66 years. Binomial logistic regression was performed for the model of age group and Facebook use, controlling for other demographics. A multinomial logistic regression model was used for the variable of time spent on Facebook. Based on the regression models, we computed and reported the marginal effects on Facebook use and time spent of adults at age 18-29, 30-49, 50-64, and 65 and over. We discuss these findings in the context of the implications for health behavior change. Results: The demographics of the final sample (N=730) included adults age 18-66 years and above (mean 48.2 yrs; SD 18.3 yrs). The majority of the participants were female (372; 51%), White (591; 81%) and non-Hispanic (671; 92%). Bivariate analysis indicated that Facebook users and non-users differed significantly by age group (χ2=76.71, P = <.001), and sex (χ2=9.04, P = .003). Among subjects aged 50 and above, the predicted probability was 66% for spending the same amount of time, 10% with increased time, and 24% with decreased time. Older subjects were more likely to spend the same amount of time and less likely to decrease time on Facebook. Younger participants were more likely to decrease time on Facebook. Conclusions: The key findings of this study were Facebook use among older adults was more likely to stay the same over time, compared to the other age groups. Interestingly, the young adult age group 18-29 years was more likely to decrease their time on Facebook over time. Specifically, younger females were most likely to decrease time spent on Facebook. In general, male participants were most likely to spend the same amount of time on Facebook. These findings have implications for future prospective health intervention research, and ultimately, for translation to the clinic setting to improve health outcomes.

  • Do web-based tailored smoking cessation interventions help the quitting process, and for whom? A secondary analysis of the randomized Project Quit trial

    From: Journal of Medical Internet Research

    Date Submitted: Dec 2, 2017

    Open Peer Review Period: Dec 3, 2017 - Jan 28, 2018

    Background: Project Quit was a randomized web-based smoking cessation trial conducted by researchers from the University of Michigan, and was designed with the seven-day point prevalence as the primar...

    Background: Project Quit was a randomized web-based smoking cessation trial conducted by researchers from the University of Michigan, and was designed with the seven-day point prevalence as the primary outcome. One drawback of the point prevalence outcome is that it only focuses on the smoking behavior in a very short time window, rather than looking at the quitting process over the entire study period. Objective: In the current article, we consider an alternative outcome, namely, the number of quit attempts during the 6-month study period, that better reflects the quitting process. We aim to find out if tailored interventions are better suited to specific subgroups of smokers, in terms of the number of quit attempts outcome. Methods: We employ Poisson regression to analyze the number of quit attempts data, in order to identify interactions between the smoking cessation intervention components and individual smoker characteristics, thereby allowing us to find out data-driven, personalized interventions. Results: Among the baseline covariates, a negative effect of the number of cigarretes smoked per day (P=0.029) and a positive effect of education (P=0.026) are detected. Thus, for every 10 extra cigarettes smoked per day, there is a 5.84% decrease in the expected number of quit attempts; and 15.49% increase in the expected number of quit attempts for highly-educated participants as compared to low-educated participants. More interestingly, a negative interaction between the intervention component story and smoker’s education is detected (P=0.034), suggesting that giving a highly-tailored story to a highly educated person results in a 13.50% decrease in the number of quit attempts compared to a low-tailored story. Conclusions: We conclude that highly individually tailored level of story is significantly more effective for smokers with low level of education. This is consistent with prior analysis of the Project Quit data with the point prevalence outcome.

  • Patient factors affecting the use of Twitter for psychiatric consultation in Saudi Arabia

    From: Journal of Medical Internet Research

    Date Submitted: Dec 9, 2017

    Open Peer Review Period: Dec 11, 2017 - Feb 5, 2018

    Background: Despite the increasing prevalence of mental disorders in the Kingdom of Saudi Arabia, discussing the issue of psychiatric conditions are still avoided. In recent studies, it is indicated t...

    Background: Despite the increasing prevalence of mental disorders in the Kingdom of Saudi Arabia, discussing the issue of psychiatric conditions are still avoided. In recent studies, it is indicated that social media is increasingly being used clinically for various purposes such as consultation, solicitation of expert opinions, and social support. Objective: The purpose of this study is to explore how demographic variables, satisfaction, and e-health literacy affect Twitter usage with respect to psychiatric consultation. Methods: This study included a quantitative cross-sectional analysis conducted in Saudi Arabia between February 9 and March 2, 2015. The study population, recruited using convenience sampling, consisted of Twitter users who had sought psychiatric consultation through Twitter. The study included users that had received at least one psychiatric consultation on Twitter, were living in Saudi Arabia, and possessed the ability to speak and understand Arabic. An online questionnaire was posted on the Twitter accounts of psychiatrists who practice in Saudi Arabia. Measurements of interest were user socio-demographic factors, satisfaction, e-health literacy, Twitter usage for health purposes or psychiatric consultation, and whether the specific Twitter consultation solved their problem. Results: Among all participants, (88/155; 56.8%) used Twitter to seek medical or health advice, in general, while (52/155; 33.5%) reported using Twitter to seek psychiatric advice specifically. The Twitter users who reported psychiatric consultation were predominately female (45/53; 86.5%), with a low financial income level (35/52, 69.2%). E-health literacy did not differ between those who were using Twitter for psychiatric consultation and those who were using it for other purposes. The majority of participants reported that Twitter consultation solved their problem and that they were satisfied with the consultation. Conclusions: Being female was a significant factor for Twitter-based psychiatric consultation in Saudi Arabia, whereas other demographic factors such as age, marital status, education level, income, and nationality were not as significant.

  • A Mobile Game for Patients with Breast Cancer: Randomized Controlled Trial

    From: Journal of Medical Internet Research

    Date Submitted: Dec 4, 2017

    Open Peer Review Period: Dec 4, 2017 - Jan 29, 2018

    Background: Although video gaming has been associated with many negative health consequences, it was hypothesized that a mobile online game would help to increase compliance with cytotoxic chemotherap...

    Background: Although video gaming has been associated with many negative health consequences, it was hypothesized that a mobile online game would help to increase compliance with cytotoxic chemotherapy and decrease the incidence of chemotherapy side effects in patients with breast cancer. Objective: The potential efficiency of video games to help side effects and improve life quality and life span for metastatic breast cancer patients needs to be demonstrated. Methods: A total of 76 patients with metastatic breast cancer agreed to participate in an education-controlled trial of mobile game healthcare management. All participants were randomly assigned to a chemotherapy+mobile game play group (mobile game group) or a chemotherapy+education group (education group) at a 1:1 ratio. This study was designed as a 3-week prospective trial. Results: The mobile game group showed increased drug adherence scores and game playing time compared to the education group. The mobile game group also reported decreased personal total physical side effects (χ2=8.87, p<0.01), including fatigue (χ2=6.26, p=0.02), numbness of hand or foot (χ2<1.0, p<0.01), stomatitis (χ2<1.0, p<0.01), and hair loss (χ2<1.0, p<0.01) compared to the education group. In addition, the mobile game group also reported decreased severity of physical side effects including (F=12.37, p<0.01), decreased appetite (F=9.33, p<0.01), numbness in the hand or foot (F<1.0, p<0.01), stomatitis (F<1.0, p<0.01), and hair loss (F<1.0, p<0.01) compared to the patients in the education group. Over the course of 3 weeks, the education group showed greater decreases in scores for quality of life (QoL) compared to the mobile game group. Conclusions: Our findings indicate improved drug compliance, QoL and decreased prevalence rates for physical side effects when using a mobile game for breast cancer patients. These results suggest that the mobile game, ILOVEBREAST, may be helpful in the management of breast cancer. Clinical Trial: Clinicaltrials.gov Identifier NCT03205969

  • A Tablet-Based Mobile Hearing Screening System for Preschoolers; Design and Validation

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 3, 2017

    Open Peer Review Period: Dec 4, 2017 - Jan 29, 2018

    Background: Hearing ability is important for children to develop speech and language skills as they grow. After a mandatory newborn hearing screening, group or mass screening of children at later age...

    Background: Hearing ability is important for children to develop speech and language skills as they grow. After a mandatory newborn hearing screening, group or mass screening of children at later age such as preschoolers are usually practiced. In order for this to be effective and accessible in low-resource countries such as Thailand, novel and innovative enabling tools that make use of pervasive mobile and smartphone technology should be considered. Objective: To develop a cost effective, tablet-based hearing screening system that can perform a rapid minimal speech recognition level test. Methods: An android-based screening application was developed. The screening protocol involved asking the child to pick pictures corresponding to the set of predefined words heard at different sound levels offered in a specifically designed sequence. For the application, the set of words were validated, with their corresponding speech power levels calibrated. 63 Children were screened for their hearing abilities using the application. Results in terms of sensitivity and specificity are compared to those measured using conventional audiometric equipment. Results: For screening purposes, the developed screening system was 100% sensitive (95% CI = 83.18% to 100%) for children with speech reception threshold (SRT) or pure tone average threshold > 25 dBHL, with a specificity 0f 79.44% (95% CI = 70.83% to 86.01%). The time taken for screening of each child was less than 2 minutes on average, compared to 12 minutes required in normal procedure. Conclusions: We have shown the potential use of a tablet-based system for rapid and mobile hearing screening. The system was shown to have good overall sensitivity and specificity. Overall, the ideal can also be easily adopted for systems based on other languages.

  • A Feasibility and Satisfaction Study of Computerized Cognitive Training in Children with Autism and Intellectual Disabilities

    From: JMIR Mental Health

    Date Submitted: Dec 3, 2017

    Open Peer Review Period: Dec 26, 2017 - Feb 20, 2018

    Background: Researchers are increasingly interested in testing and developing computerized cognitive training interventions for individuals with autism spectrum disorder (ASD) due to the limited acces...

    Background: Researchers are increasingly interested in testing and developing computerized cognitive training interventions for individuals with autism spectrum disorder (ASD) due to the limited accessibility of treatments for this disorder. Understanding the feasibility of testing cognitive interventions for this population is critical especially for individuals with ASD who have low to moderate intellectual ability. Objective: To evaluate the feasibility of computerized cognitive training as measured by attrition rate and parent satisfaction survey with an open-ended questionnaire. Methods: Twenty-five participants aged 8-17 years old with an ASD diagnosis and significant intellectual impairment were recruited (Mean age = 11.2). They were instructed to complete twenty-five sessions of Cogmed Working Memory Training in five to six weeks with coach assistance. Attrition rate and parent satisfaction surveys were measured after the completion of training. Results: Most participants (96%) completed the training and indicated high satisfaction (> 88%). However, among the participants that completed the training, five participants (20%) were unable to finish in six weeks, the recommended training period by Cogmed. Conclusions: It is feasible to assess the effect of computerized, cognitive training interventions in children with ASD, with intellectual impairments, however, some may require additional weeks to complete the training. The overall completion rate, with extended time to complete the training was high. Developers of cognitive training programs for this population should take into account potential issues regarding the noise level of stimuli and characteristics of the visual graphics. Clinical Trial: N/A

  • Multi-Stakeholder Perspectives on a Maternal Text Messaging Intervention in Uganda: A Qualitative Study

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 3, 2017

    Open Peer Review Period: Dec 4, 2017 - Jan 29, 2018

    Background: Despite continued interest in the use of mHealth for maternal health there have been limited attempts to identify relevant programme theories. Objective: This paper aims to analyze the fit...

    Background: Despite continued interest in the use of mHealth for maternal health there have been limited attempts to identify relevant programme theories. Objective: This paper aims to analyze the fit between the program theory (assumptions) of m-Health designers and the realities of program beneficiaries’ experiences and perceptions of the program. Methods: To that end, we conducted a retrospective qualitative study of an SMS platform geared at improving individual maternal health outcomes in Uganda. Through interviews with program designers (n=3) we elicited three main designers assumptions and explored these against data from qualitative interviews with primary beneficiaries (n=26; 15 women and 11 men) and health service providers (n=6), and 6 focus group discussions with Village Health Team members (VHTs) (n=50), who were all involved in the program. Results: Our study results highlighted that while the program designers’ assumptions were appropriate, additional mechanisms and contextual factors, such as the importance of incentives for VHTs, mobile phone ownership and health system factors should have been considered. Conclusions: Our results indicate that text messages could be an effective part of a more comprehensive maternal health program when context and system barriers are identified and addressed in the program theories. Clinical Trial: n/a

  • Potential for Information Technology in the Workplace: Investigating the Perceptions of Primary Care Dietitians

    From: Journal of Medical Internet Research

    Date Submitted: Dec 4, 2017

    Open Peer Review Period: Dec 4, 2017 - Jan 29, 2018

    Background: Chronic disease is the leading cause of morbidity and mortality worldwide. The primary health care setting is an effective avenue for the management and prevention of chronic disease, and...

    Background: Chronic disease is the leading cause of morbidity and mortality worldwide. The primary health care setting is an effective avenue for the management and prevention of chronic disease, and dietitians working in this setting assist the management of chronic disease modifiable risk factors. However, healthcare professionals report challenges in providing care in this setting, due to time and financial constraints. Information technology offers the potential to improve health care quality, safety, efficiency and cost-efficiency, but there is limited understanding of dietitians’ application of technology in this setting. Objective: This study explored the perceptions of primary care dietitians about using information technology in their workplace. Methods: Twenty Australian primary care dietitians were recruited for semi-structured telephone interviews. Interview questions aimed to gain an understanding of dietitians’ perceptions about sharing patient outcomes through a national database, and the benefits, disadvantages, feasibility and barriers of using information technology. Interviews were audio-recorded, transcribed verbatim and thematically analysed for emerging themes and sub-themes. The technologies used by participants were collated by name and researched for their key attributes. Results: Four distinct themes emerged from the data (i) information technology improving efficiency of practice tasks, (ii) experiencing barriers to using information technology in practice, (iii) information technology enhancing outcomes through education and monitoring, and (iv) information technology for sharing information with others. Participants identified several advantages and disadvantages with using technology, and expressed a willingness to share patient outcomes using an online database. Conclusions: This study suggests that information technology is perceived to have benefits to dietitians and patients in primary health care. However, to achieve the optimal benefit, support is required to overcome barriers to better integrate information technology into practice. Further development of patient management systems and standardized online data collection systems is needed to support better usage by dietitians.

  • Design Sprint and Usability Testing of a Patient-facing, Diabetes Dashboard Embedded in a Patient Web Portal

    From: Journal of Medical Internet Research

    Date Submitted: Dec 4, 2017

    Open Peer Review Period: Dec 4, 2017 - Jan 29, 2018

    Background: Health apps and web-based interventions designed for patients with diabetes offer novel and scalable approaches to engaging patients and improving outcomes. However, careful attention to...

    Background: Health apps and web-based interventions designed for patients with diabetes offer novel and scalable approaches to engaging patients and improving outcomes. However, careful attention to the design and usability of these apps and web-based interventions is essential to reduce barriers to engagement and maximize use. Objective: We aimed to design a patient-facing, diabetes dashboard that addresses users’ needs, incorporates recommended strategies for increasing user engagement, and is satisfying to use. Methods: We applied the 5-day Design Sprint methodology developed by GV (Alphabet Inc., Mountain View, CA) to create our initial dashboard prototype. We identified recommended strategies from the literature for using patient-facing technologies to activate patients and designed dashboard functionality to match each strategy. We then conducted a mixed-methods, task-based usability assessment of dashboard prototypes with individual patients. Measures included validated metrics of task performance on five common and standardized tasks, semi-structured interviews, and a validated usability satisfaction questionnaire. After each round of usability testing, the dashboard prototype was revised in response to usability findings prior to the next round of testing until the majority of participants successfully completed tasks, expressed high satisfaction, and identified no new usability concerns (i.e., stop criterion met). Results: The sample (N=14) was composed of five patients in round 1, three patients in round 2, and six patients in round 3 at which point we reached our stop criterion. Participants’ mean age was 63 (range: 45 - 78), 57% were female, and 50% were Caucasian. Our Design Sprint yielded an initial patient-facing diabetes dashboard prototype that displayed and summarized five measures of patients’ diabetes health status (e.g., Hgb A1C). The dashboard used graphics to visualize and summarize health data and reinforce understanding, incorporated motivational strategies (e.g., social comparisons and gamification), and provided educational resources and secure-messaging capability. Greater than 80% of participants were able to successfully complete all five tasks using the final prototype. Interviews revealed usability concerns with design, efficiency of use, content and terminology which led to improvements. Overall satisfaction (0=worst, 7=best) significantly improved from the initial to the final prototype (mean±SD, 5.8±0.4 vs. 6.7±0.5, P=0.02). Conclusions: Our results demonstrate the utility of Design Sprint methodology paired with mixed-methods, task-based usability testing to efficiently and effectively design of a patient-facing, web-based diabetes dashboard that is satisfying for patients to use.

  • Innovative Tele-mentoring in Addiction Management for Remote Primary Care Physicians: A Feasibility Study

    From: Iproceedings

    Date Submitted: Dec 4, 2017

    Open Peer Review Period: Dec 5, 2017 - Jan 30, 2018

    Objective: Addiction or Substance Use Disorder (SUD) is a growing public health problem which affects the person, the whole family and society. The primary care physician is often the first point of c...

    Objective: Addiction or Substance Use Disorder (SUD) is a growing public health problem which affects the person, the whole family and society. The primary care physician is often the first point of contact in health care and can play a significant role in early detection and intervention. It is well established that early intervention is associated with better outcome, however in their formal medical training; primary care physicians receive no formal training on drug addiction management. In this pilot study we developed an innovative tele-mentoring model for drug addiction management and looked at feasibility as well acceptability among remote primary care physicians (PCPs). Methods: The tele-mentoring model consists of both synchronous and asynchronous components. The synchronous component (which includes the National Institute of Mental Health And Neuro Sciences (NIMHANS) academic centre Hub and remote district level primary care Spoke), is implemented by use of low-cost multipoint videoconference based tele-ECHO clinics. During the tele-ECHO clinics, held fortnightly, the remote PCPs used internet enabled smartphones to connect as well as present the patient case summaries to the multidisciplinary expert team of NIMHANS HUB. The asynchronous component consists of mobile based ubiquitous e-learning integrated to a course completion certificate. We evaluated this innovative tele-mentoring Programme on participant engagement, learning, competence and satisfaction. A pre-post design and e-learning assignments were used to measure the outcomes. Results: Of the proposed 21 tele-ECHO clinics, 11 were held till the end of August 2017. All the primary care physicians were able to virtually join at least one drug tele-ECHO clinic. Out of 38 participants, two participated in all the tele-ECHO clinics and 47.36% (n=18) attended more than six (>60% of total) tele-ECHO clinics. 76.31% (n=29) of the PCPs presented 41 patient case summaries. Among 38 PCPs, a cumulative of 89.47% has completed three E-Learning assignments. Majority of participants (80%) used smartphone with 4G connections to join the tele-ECHO clinics. There was a significant increase in the score on knowledge gained over the time duration of 1 month (3.00±0.86, p < 0.001) and 3 months (3.16±0.90, p < 0.001) assessments compared to the baseline (1.77±1.02). 32.25% (n=10) reported improved confidence level in managing a case of SUD on 10 point scale. Discussion: It has been feasible to connect an academic hub i.e. NIMHANS to the PCPs of 36 remote districts of Bihar and conduct multipoint videoconference based tele-ECHO clinics. The results indicate high-participant retention. The learners are comfortable in adapting new technology based learning as evidenced by higher rate of e-learning assignment completion. These findings suggest this new innovative learning model using technology can be an important way for effective training to address addiction management.

  • Physical Wellness Among Gaming Adults: A Cross-Sectional Study

    From: JMIR Serious Games

    Date Submitted: Dec 4, 2017

    Open Peer Review Period: Dec 4, 2017 - Jan 29, 2018

    Background: Video and hobby gaming are immensely popular among adults, but associations between gaming and health have primarily been studied in children and adolescents. Furthermore, most research fo...

    Background: Video and hobby gaming are immensely popular among adults, but associations between gaming and health have primarily been studied in children and adolescents. Furthermore, most research focuses on electronic gaming despite traditional hobby gaming becoming more prominent Objective: To determine whether the number of platforms played, platform preference, and gaming time are associated with obesity, physical activity, sedentary behavior, and cardiovascular risk factors Methods: We conducted a cross-sectional analysis using data obtained from 292 participants attending a large Midwestern gaming convention. Data were collected using a computer-based questionnaire that included questions on gaming behavior, demographics, physical activity (using the International Physical Activity Questionnaire), and health characteristics. Multivariable-adjusted linear and logistic regression were used to model health outcomes as a function of number of platforms played, platform preference, and weekday and weekend gaming time quartile. Results: After adjusting for covariates, a significant linear trend was seen for increasing odds of being obese and greater weekend sitting time by number of platforms played (P = 0.03 for both). Platform preference and weekend gaming time quartile showed significant associations with odds of meeting physical activity recommendations (P = 0.047 and P = 0.03 respectively). Greater odds of being obese were seen for those reporting that they sat most or all of the time while gaming (2.69 (1.14-6.31) and 2.71 (1.06-6.93) respectively). Conclusions: In adult gamers the number of platforms they play, which platforms they prefer to play on, and the amount of time spent gaming on the weekends could have important implications for their odds of being obese and meeting physical activity recommendations.

  • Home to hospital live streaming with virtual reality goggles: a qualitative study exploring the experiences of hospitalized children.

    From: Interactive Journal of Medical Research

    Date Submitted: Dec 5, 2017

    Open Peer Review Period: Dec 5, 2017 - Jan 30, 2018

    Background: Being separated from home and relatives is a major stressor for children and adolescents when hospitalized. Children long for a manner to be distracted, pleasured and socially connected du...

    Background: Being separated from home and relatives is a major stressor for children and adolescents when hospitalized. Children long for a manner to be distracted, pleasured and socially connected during hospitalization. Different technological devices have been applied in healthcare to answer those needs. Both Virtual Reality (VR) and videoconferencing have proven their value at hospital wards and in pediatrics. VisitU® combines these two technologies in an innovative way. VisitU® is a recently launched VR technology enabling the user to be virtually at home during hospitalization. Objective: Our objective was to explore the experiences of hospitalized patients with the VR intervention of VisitU® in addition to standard care. Methods: Over a 3-month period a purposive sample of 10 patients hospitalized in the Radboudumc Amalia Children’s Hospital was included in this qualitative study. Semi-structured interviews were performed, one before and one after the use of the VR device. Patients were asked open questions concerning the experiences with VisitU® on practical, cognitive, emotional and social domains. The interviews were audio recorded and transcribed verbatim. Atlas.ti was used to support qualitative analysis. Inductive thematic analysis was done according to the six-step procedure described by Braun and Clarke. Results: Six main themes were the result of qualitative analysis; “Being hospitalized”, “Expectations of VisitU®”,“VisitU® in use”, “VisitU®, the benefits”, “The impact of VisitU®” and “Barriers when using VisitU®”. The way VisitU® was used by patients varied. The main benefits of VisitU® were being somewhere else, being at home and facilitating social connection. Limitations were experienced on the technical abilities, physical side effects and complexity of use. Despite that, patients were positive about VisitU® and the patients were unanimous in the view that they would like to use it again and advise other patients to use it. Conclusions: This study shows positive experiences of children and adolescents with VR live stream enabling the user to be virtually at home during hospitalization. VisitU® brings together the needs of patients and possibilities of VR and videoconferencing; it offers patients a virtual way out of the hospital. Practical and technical obstacles must be overcome and side effects are an area of further research.

  • Economic impact of digital consulting on young people with long-term conditions: a mixed -methods approach

    From: Journal of Medical Internet Research

    Date Submitted: Jan 9, 2018

    Open Peer Review Period: Jan 10, 2018 - Mar 7, 2018

    Background: Since 2000, health professionals are starting to use email, text and other digital methods to consult with their patients in a timely manner. There is lack of evidence regarding the econom...

    Background: Since 2000, health professionals are starting to use email, text and other digital methods to consult with their patients in a timely manner. There is lack of evidence regarding the economic impact of digital consulting in the UK National Healthcare System (NHS). Objective: This study aims to estimate the direct costs associated with digital consulting as an adjunct to routine care at 18 clinics serving young people with longterm conditions. Methods: This study uses both quantitative and qualitative approaches. Semi-structured Interviews were conducted with 173 clinical team members on the impacts of digital consulting. A structured questionnaire was developed and used for health professionals across 18 sites in the UK to collect data on time and other resources used for Digital consulting. A follow-up semi-structured interview was conducted with a single senior clinician at each site to clarify the mechanisms through which Digital consulting use might lead to outcomes relevant to economic evaluation. We used the 2 part model to see the association between the time spent on Digital consulting and the job role of staff, type of clinic, and the average length of the working hours using digital consulting. Results: Staff time is the key driver of digital consulting related costs and consultant status was a significant negative predictor of time spent on this activity. Staff time spent per day digitally consulting varied widely (median 45 minutes, IQR 0-120 minutes). Time spent by consultants, nurses, physiotherapist and psychologists were 28, 120, 120, 34 minutes, respectively. Nurses, physiotherapists, and psychologists consulted digitally more than consultants by 95, 55, and 32 minutes per day, respectively. The highest total clinic cost per month was £9560 and lowest was £161. Four potential economic benefits for the NHS were identified qualitatively by health professionals: serious adverse events, patient wellbeing, waiting list length and staff workload. We did not find evidence to suggest that the clinical condition was associated with digital consulting use. Conclusions: Nurses were the greatest users of digital consulting with the greatest costs associated with their time. Teams appear to use an efficient triage system with the most expensive members digitally consulting less than lower paid team members. Staff report concerns regarding time spent digitally consulting which implies that direct costs increase. There remain considerable gaps in evidence related to cost-effectiveness of digital consulting but this study has highlighted important cost-related outcomes for assessment in future cost-effectiveness trials of digital consulting.

  • False Information and online health communication: an observational study on Italian web pages about Complementary & Alternative Medicine for cancer patients

    From: Journal of Medical Internet Research

    Date Submitted: Dec 6, 2017

    Open Peer Review Period: Dec 7, 2017 - Feb 1, 2018

    Background: Poor online health information can easily turn into misinformation, reinforcing pre-existing inaccurate beliefs in people and leading them to dangerous behaviors, especially in controversi...

    Background: Poor online health information can easily turn into misinformation, reinforcing pre-existing inaccurate beliefs in people and leading them to dangerous behaviors, especially in controversial topics such as Complementary and Alternative Medicine (CAM). Objective: In this study, we analyze a sample of web pages about CAM issues to: identify and categorize the different kinds of falsehoods, explore the relationships between the various types of falsehood, estimate the risk of running into deceptive information, and observe the differences among the experts’ and layperson’s information assessment. Methods: We performed a cross-sectional observational study to assess the quality of the sample with respect to falsehood types. We investigated the possible association between unfounded statements and correct information. Expert scholars and a layperson evaluated sentences with scientific content and results of the formers and the latter were compared too. Results: We analyzed 16 web pages and 1356 sentences. 714 (82%) were unfounded statements. There were 260 (71%) incorrect scientific statements overall, and they directly related to the risk of “unfounded” information (OR=13.90 for “incorrect” versus “correct” scientific statements; 95%CI:1.81-107.02; P=.01). In the 73 statements considered “incorrect” by experts, the layperson responded properly 43 times (59%). Conclusions: Health misinformation can severely affect people’s behavior. This study can help professionals to interpret deceptive online information about controversial issues and improve their health information and communication services.

  • Design and baseline characteristics of the GP Prompt study - A cluster randomised trial to reduce cardiovascular and renal complications in patients with Type 2 Diabetes and Microalbuminuria

    From: Journal of Medical Internet Research

    Date Submitted: Dec 7, 2017

    Open Peer Review Period: Dec 8, 2017 - Feb 2, 2018

    Background: People with Type 2 Diabetes (T2DM) and Microalbuminuria are at significantly increased risk of Cardiovascular (CV) mortality and morbidity. Recent audit data shows that most of these patie...

    Background: People with Type 2 Diabetes (T2DM) and Microalbuminuria are at significantly increased risk of Cardiovascular (CV) mortality and morbidity. Recent audit data shows that most of these patients do not achieve evidence based treatment targets for CV risk factors including blood pressure, cholesterol and HbA1c. Individualised interventions have shown success at reducing mortality and morbidity but implementation has been hampered by scarce resources available within primary care. The GP Prompt study is testing a healthcare professional technology driven intervention aiming to improve the management of patients of T2DM and MA Objective: To describe the trial design and baseline characteristics of individuals participating in a targeted, multifactorial intervention in a high risk, multi-ethnic population with type 2 diabetes (T2DM) and microalbuminuria (MA) delivered by health care professionals in a community based setting Methods: A complex, multifaceted intervention comprising a software ‘prompt’ with an evidence based treatment algorithm installed on GP computer systems alerting healthcare professionals to eligible study individuals not meeting tight CV risk factor targets, healthcare professional education, clinician email support, three monthly feedback and dissemination of performance data illustrating proportion of individuals meeting risk factor targets, practice based mean CV risk factor targets and prescribing patterns. Primary outcome is proportion of eligible participants meeting tight CV risk factor targets including systolic and diastolic blood pressure (<130/80mmHg) and total cholesterol (<3.5mmol/l) at 24 months. Secondary outcomes include proportion of individuals with HbA1c <58mmol/mol(7.5%), change in medication prescribing, changes in MA and renal function (eGFR), incidence of major adverse CV events and mortality, and coding for microalbuminuria in patient records. Cost-effectiveness of the intervention will be assessed Results: Among 2721 eligible study individuals, mean (SD) age was 62.9 (10.0), duration of diabetes 10.46 (7.22) years. Mean (SD) HbA1c was 59.3 (17.4) mmol/mol, systolic and diastolic BP (mmHg) was 134.3 (14.6) and 76.1 (9.5) mmHg, respectively and total cholesterol was 4.1 (0.98) mmol/l. Overall, 131 (4.8%) of study individuals achieved all three ‘tight’ CV risk factor targets. CV risk factor burden increased two-fold in those with GFR < 60 compared to those with GFR ≥ 60 ml/min/1.73m2. Prevalence of MA was 22.8%. In total, 1076 (39.5%) individuals were coded for microalbuminuria or proteinuria on their primary care medical record. Conclusions: The GP Prompt study is the largest UK primary care-based, technology driven, randomised controlled trial to support intensive intervention in high risk group of multi-ethnic individuals with T2DM and MA. This paper provides contemporary estimates for prevalent cardiovascular disease and adherence to evidence based cardiovascular risk factor targets at baseline in a population with T2DM and MA. The main trial results, including cost effectiveness data will be submitted for publication in early 2018 Clinical Trial: Trial registration: ISRCTN number: 14918517 Registration Date: 9/5/15

  • Emerging Technology and Data Analytics for Behavioral Health

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 6, 2017

    Open Peer Review Period: Dec 7, 2017 - Feb 1, 2018

    Wearable and portable digital devices can support self-monitoring for patients with chronic medical conditions, individuals seeking to reduce stress, and people seeking to modify mental health-related...

    Wearable and portable digital devices can support self-monitoring for patients with chronic medical conditions, individuals seeking to reduce stress, and people seeking to modify mental health-related behaviors such as substance use or mood. The resulting data may be used directly by a consumer, or shared with a clinician for treatment, a caregiver for assistance, or a health coach for support. The data can also be used by researchers to develop and evaluate just-in-time interventions that leverage mobile technology to help individuals manage their symptoms and behavior in real time and as needed. Such wearable systems have huge potential for promoting delivery of anywhere/anytime healthcare, improving public health, and enhancing the quality of life for many people. The Center for Technology and Behavioral Health at Dartmouth College, a P30 “Center of Excellence” supported by the National Institute on Drug Abuse at the National Institutes of Health, recently conducted a workshop on innovations in emerging technology, user-centered design, and data analytics for behavioral health, with presentations by a diverse range of experts in the field. The workshop focused on wearable and mobile technologies being used in clinical and research contexts, with an emphasis on applications in mental health, addiction, and health behavior change. In this paper, we summarize the workshop panels on mobile sensing, user experience design, statistics and machine learning, and privacy and security, and conclude with suggested research directions for this important and emerging field of applying digital health approaches to behavioral health.

  • The degree of correspondence in activity levels measured by ecological momentary assessment and waist-worn accelerometers differs by demographic factors

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 6, 2017

    Open Peer Review Period: Dec 7, 2017 - Feb 1, 2018

    Background: In order to address the limitations of accelerometry, such as its inability to collect contextual data, researchers have shifted towards collecting activity data on mobile devices via ecol...

    Background: In order to address the limitations of accelerometry, such as its inability to collect contextual data, researchers have shifted towards collecting activity data on mobile devices via ecological momentary assessment (EMA). Although EMA is becoming increasingly common, it is not known how EMA self-reports of physical activity and sedentary behaviors relate to objective measures of activity, or if there are factors that may influence the degree of correspondence between these two measures. Understanding the relationship between EMA and accelerometry can inform future instrument selection in studies assessing activity and health outcomes. Objective: To examine the association EMA-reported leisure time physical activities (sports/exercise) and sedentary screen behaviors (TV/videos/video games) with accelerometer-measured moderate-to-vigorous physical activity (MVPA) and sedentary time (ST), respectively, in children during matched two-hour windows, and test potential moderators. Methods: Children (N=192; mean age=9.6 years, 49% male, 54% Hispanic, and 38% overweight/obese) wore an accelerometer and completed up to 7 EMA prompts per day for 8 days during non-school time, reporting on past two-hour sports/exercise and TV/videos/video games. Multilevel models assessed the relationship between accelerometer-measured ST and EMA-reported TV/videos/video games. Given the zero-inflated distribution of MVPA, two-part models assessed the relationship between accelerometer-measured MVPA and EMA-reported sports/exercise. Results: EMA-reported TV/videos/video games were associated with greater accelerometer-measured ST (β=7.25, P<.0001). This relationship was stronger in boys (β=9.93, P<.0001) compared to girls (β=4.88, P=<.0001). EMA-reported sports/exercise were associated with greater accelerometer-measured MVPA (zero portion P<.0001; positive portion P<.0001). This relationship was stronger on weekends, in older children, and in non-Hispanic children (zero portion P’s all <.0001; positive portion P’s all <.0001). Conclusions: Conclusions: EMA reports highly correspond to accelerometer measures. However, differences in the degree of correspondence depending on various demographic characteristics suggests that future research should include both activity measures.

  • Adapting a Behavioral Weight Loss Intervention for Facebook Delivery: A Pilot Series among Low-Income Postpartum Women

    From: Journal of Medical Internet Research

    Date Submitted: Dec 7, 2017

    Open Peer Review Period: Dec 8, 2017 - Feb 2, 2018

    Background: Efforts to translate evidence-based weight loss interventions, such as the Diabetes Prevention Program (DPP), to low-income, postpartum women are limited by poor intervention attendance an...

    Background: Efforts to translate evidence-based weight loss interventions, such as the Diabetes Prevention Program (DPP), to low-income, postpartum women are limited by poor intervention attendance and high attrition rates. Strategies that improve engagement and retention in this population are needed to maximize the reach of evidence-based weight loss interventions Objective: To adapt a DPP-based weight loss intervention (Fresh Start) for Facebook delivery and to evaluate its feasibility among low-income postpartum women. Methods: This study comprised of three single group pilot studies where feasibility outcomes iteratively informed changes from one pilot to the next. We paralleled the in-person program to Facebook delivery by translating the protocol to a content library to be delivered in a Facebook feed with additional input from lifestyle coaches. Low-income postpartum women were recruited from Women, Infants, and Children (WIC) clinics in Worcester, MA. Participants were enrolled into a 16-week weight loss intervention delivered via Facebook. During the first eight weeks, Facebook intervention posts were delivered two times per day with additional posts from coaches. For the following 8 weeks, posts were delivered once per day without additional coaching. Outcome measures were collected at baseline and 16-week follow-up and included changes in weight as well as feasibility outcomes including retention, engagement (defined by likes, comments, and posts), and acceptability. Results: Pilot 1 (n = 27) had a retention rate of 89% and 62% engaged in the group during the 8-week coached phase. Mean weight loss was 2.6 pounds (SD = 8.64) and 75% reported being satisfied with the program. Pilot 2 (n = 24) had a retention rate of 83% and 55.2% engaged in the group during the 8-week coached phase. Mean weight loss was 2.5 pounds (SD = 9.23) and 80% were satisfied with the program. Pilot 3 (n = 16) had a retention rate of 88% and 67% engaged in the group during the 8-week coached phased. Mean weight loss was 7.0 pounds (SD = 11.6) and 64.3% were satisfied with the program. Conclusions: Findings demonstrated that a Facebook-delivered intervention was acceptable and could be feasibly delivered to the low-income, postpartum women. Future research is needed to evaluate the efficacy of a Facebook-delivered weight loss intervention.

  • The Social Media Landscape of China’s Tertiary Referral Hospitals: An Observation of the Best 705 Hospitals

    From: Journal of Medical Internet Research

    Date Submitted: Dec 8, 2017

    Open Peer Review Period: Dec 9, 2017 - Feb 3, 2018

    Background: Social media has penetrated all walks of life. Chinese Healthcare Institutions are increasingly utilizing social media to connect with their patients for better health service delivery. Cu...

    Background: Social media has penetrated all walks of life. Chinese Healthcare Institutions are increasingly utilizing social media to connect with their patients for better health service delivery. Current research has focused heavily on the use of social media in developed countries, with few exploring its usage in the context of developing countries, such as China. This study examines China’s best hospitals, as recognized by The National Health and Family Planning Commission (NHFPC) of the People’s Republic of China, mapping out the landscape of current social media usage by hospitals when engaging with patients. Objective: This study aims to examine China’s best hospitals, as recognized by The National Health and Family Planning Commission (NHFPC) of the People’s Republic of China, and to map out the landscape of current social media usage by hospitals when engaging with patients. Methods: We examined the best 705 hospitals in China, collecting and analyzing their usage of popular Chinese social media applications, Sina Weibo and WeChat. Specific data included: (1) hospital characteristics (i.e. established time, number of beds, hospital type, regions/localities) and (2) status of social media usage on two of the most popular local social media platforms in China (i.e. initiated time, number of followers and number of tweets or posts). We further used a logistic regression model to test the association between hospital characteristics and social media adoption. Results: A total of 537 (76.17%) tertiary-referral hospitals have created official accounts on either Sina Weibo or WeChat. Of these, WeChat is more popular than Sina Weibo. In addition, our study suggests that larger and newer hospitals with greater resources are more likely to adopt social media, while hospital type and affiliation to universities are not significant predictors of social media adoption among hospitals. Conclusions: Our study demonstrated that hospitals are more inclined to use WeChat. The move by hospitals from Sina Weibo to WeChat means that patients are seen to be not satisfied by mere communication and now place more value on health services delivery. For the future, a long journey still lies ahead for hospitals in running their official social media accounts.

  • Feasibility of a proactive text messaging intervention for smokers in community health centers

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 8, 2017

    Open Peer Review Period: Dec 9, 2017 - Feb 3, 2018

    Background: Few smokers receive evidence-based cessation services during primary care visits. Objective: We aimed to assess the feasibility of a proactive text messaging program for primary care patie...

    Background: Few smokers receive evidence-based cessation services during primary care visits. Objective: We aimed to assess the feasibility of a proactive text messaging program for primary care patients who smoke. Methods: We used electronic health records (EHRs) to identify smokers from two Massachusetts community health centers who had a mobile phone number listed. In March 2014-June 2015 patients were screened by their primary care physician then sent a proactive text message inviting them to enroll by texting back. Patients who opted-in were asked about their readiness to quit. The text message program included messages from the QuitNowTXT library and novel content for smokers who were not ready to quit. Results: Among 949 eligible smokers, 88 (9%) enrolled after receiving a single proactive text message. Compared with those who did not enroll, enrollees were more often female (61% vs. 48%, p=0.02) but otherwise did not differ in age, race, insurance status, or comorbidities. Twenty-eight percent of enrollees were not ready to quit in the next 30 days. The median time in the program was 9 days (interquartile range 2-32). Twenty-five percent of current smokers sent one or more keyword requests to the server. These did not differ by readiness to quit. Conclusions: A proactively delivered text messaging program targeting primary care patients who smoke was feasible and engaged both smokers ready to quit and those not ready to quit. This method shows promise as part of a population health model for addressing tobacco use outside of the primary care office. Clinical Trial: NA

  • The impact of web-based-only platforms on weight loss and lifestyle habits changes in overweight and obese adults: a systematic review and meta-analysis

    From: Journal of Medical Internet Research

    Date Submitted: Dec 8, 2017

    Open Peer Review Period: Dec 9, 2017 - Feb 3, 2018

    Background: Background: Obesity is a high prevalent condition with important health implications throughout the world. Face-to-face interventions to treat obesity demand a large number of human resour...

    Background: Background: Obesity is a high prevalent condition with important health implications throughout the world. Face-to-face interventions to treat obesity demand a large number of human resources and time both by the health system and for patients. In this context, the internet is an attractive tool for delivering weight loss programs. Users´ anonymity, 24 hour-access and the possibility of reaching a large number of patients and also remote areas are reasons for this. Objective: Objectives: We aimed to investigate the effectiveness of web-based-only (no hybrid or mixed) interventions on weight loss and lifestyle habits changes in individuals with overweight/obesity. Methods: Methods: We searched Pubmed/Medline, SciELO, Lilacs, PsychNet, Web of Science up to February, 2017, and references of previous reviews for randomized trials that compared web-based-only to offline interventions for weight and lifestyle habits changes in adults with overweight/obesity. Random effects meta-analysis and meta-regression were performed for mean weight changes. We rated the quality of evidence using GRADE. Results: Results: Among the 3811 articles retrieved, nine were selected. Mean weight and BMI changes were not different between web-based and offline interventions (-1.06 kg; 95% CI -2.75 to 0.63, and -0.04 kg/m2; 95% CI -0.73 to 0.04, respectively). Compared to offline interventions, web-based-only interventions led to a greater (<6 months follow-up) weight loss in the short-term (-2.14 kg; 95% CI -2.71 to -1.56), but not in the long-term (-0.70 kg; 95% CI -4.47 to 3.07). Web-based interventions were also superior to no specific interventions (-3.03 kg; 95% CI -3.55 to -2.51). We rated the quality of evidence as moderate due to high attrition rates and heterogeneity, mainly (79%) attributable to control group differences. Conclusions: Conclusion: Moderate quality evidence showed that web-based interventions lead to greater short-term weight loss than offline interventions in overweight/obese adults. There was not any difference in weight loss between these two types of intervention in the long-term. High attrition rates suggest that engagement is a major issue in web interventions.

  • PIVET: A Scaled Phenotype Evidence Generation Framework using Online Medical Literature

    From: Journal of Medical Internet Research

    Date Submitted: Dec 14, 2017

    Open Peer Review Period: Dec 14, 2017 - Feb 8, 2018

    Background: Researchers are developing methods to automatically extract clinically relevant and useful patient characteristics from raw healthcare datasets. These characteristics, often capturing esse...

    Background: Researchers are developing methods to automatically extract clinically relevant and useful patient characteristics from raw healthcare datasets. These characteristics, often capturing essential properties of patients with common medical conditions, are called computational phenotypes. Being generated by (semi)-automated, data-driven methods, such potential phenotypes need to be validated as clinically meaningful (or not) before they are acceptable for use in decision making. Objective: We present Phenotype Instance Verification and Evaluation Tool (PIVET), a framework that uses co-occurrence analysis on an online corpus of publically available medical journal articles to build clinical relevance evidence sets for user-supplied phenotypes. PIVET adopts a conceptual framework similar to the pioneering prototype tool, PheKnow-Cloud, which was developed for the phenotype validation task. PIVET completely re-factors each part of the PheKnow-Cloud pipeline to deliver vast improvements in speed without sacrificing the quality of the insights PheKnow-Cloud achieved. Methods: PIVET leverages indexing in NoSQL databases to efficiently generate evidence sets. Specifically, PIVET uses a succinct representation of the phenotypes that corresponds to the index on the corpus database and an optimized co-occurrence algorithm inspired by the Aho-Corasick algorithm. We compare PIVET’s phenotype representation to PheKnow-Cloud’s by using PheKnow-Cloud’s experimental set-up. We also introduce a statistical model trained on domain-expert verified phenotypes to automatically classify phenotypes as clinically relevant or not. Additionally, we show how the classification model can be used to examine user-supplied phenotypes in an online, rather than batch, manner. Results: PIVET maintains the discriminative power of PheKnow-Cloud in terms of identifying clinically relevant phenotypes for the same corpus with which PheKnow-Cloud was originally developed, but PIVET’s analysis is an order of magnitude faster than that of PheKnow-Cloud. Not only is PIVET much faster, it can be scaled to a larger corpus and still retain speed. We evaluated multiple classification models on top of the PIVET framework and found ridge regression to perform best, realizing an average F1 score of 0.91 when predicting clinically relevant phenotypes. Conclusions: We show PIVET improves on the most notable existing computational tool for phenotype validation in terms of speed and automation, and is comparable in terms of accuracy.

  • Patients’ experiences of blended Group Therapy for Depression: Fit and Implications for the Group Setting.

    From: Journal of Medical Internet Research

    Date Submitted: Dec 9, 2017

    Open Peer Review Period: Dec 11, 2017 - Feb 5, 2018

    Background: Blended group therapy (bGT) combines group sessions with internet- and app-based treatment modules. Consequently, bGT widens the choice of interventional strategies within Internet Interve...

    Background: Blended group therapy (bGT) combines group sessions with internet- and app-based treatment modules. Consequently, bGT widens the choice of interventional strategies within Internet Interventions at reasonable costs. This is the first qualitative study on bGT. Objective: This study investigates the user-centred feasibility of bGT, with special emphasis on the fit and dynamic interplay between face-to-face and internet-based components of group therapy. Methods: A total of 22 patients, with a variety of experiences from two different bGT interventions, were interviewed following a semi-structured interview guide. In-depth interviews were analysed by three trained psychologists, using thematic analysis and a rule-guided online program (QCAmap). The transcript of the interviews (113 555 words) was condensed to 1081 coded units, with subsequent extraction of 16 themes. Results: Technology was described as a treatment facilitator and motivator, increasing the salience and consolidation of cognitive behavioural therapy materials, and resulting in in- and intersession alignment to the treatment. Additionally, patients value the option of intimate online self-disclosure (via lateral patient-to-therapist communication) and therapists are provided with tools for between-session monitoring and reinforcement of exercising. In this context, group phenomena seem to back up therapists’ efforts to increase treatment engagement. Negative effects regarded the possible dissonance due to non-compliance with online tasks and the constriction of in-session group interaction. Lastly, issues of tailoring and structure seem to meet different preconditions compared to individual therapy. Conclusions: bGT constitutes a structured and proactive approach to work with depression and the integration of both modalities initiates a beneficial interplay. Results confirm the user-centred value of bGT and provide a first insight into bGT’s role in fostering relevant active treatment factors. However, potential negative effects should be considered carefully. Clinical Trial: DRKS00010894; DRKS00010888

  • Neurosurgery - More Eminence than Evidence: Results of an International Survey

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 10, 2017

    Open Peer Review Period: Dec 11, 2017 - Feb 5, 2018

    Background: The publication rate of neurosurgical guidelines has increased tremendously over the past decade. However, only a small proportion of clinical decisions appears to be based on high-quality...

    Background: The publication rate of neurosurgical guidelines has increased tremendously over the past decade. However, only a small proportion of clinical decisions appears to be based on high-quality evidence. Objective: To evaluate the available evidence within neurosurgery and its value within clinical practice according to neurosurgeons. Methods: A web-based survey was sent to 2552 neurosurgeons, who were members of the European Association of Neurosurgical Societies. Results: The response rate to the survey was 7% (173 respondents). According to 49% of the respondents, neurosurgery is based on less evidence compared with other medical specialties, and not enough high-quality evidence is available on which to base clinical practice. However, 84% of the respondents believed neurosurgery is amenable to evidence. Of the respondents, 59% considered the neurosurgical guidelines in their hospital to be based on high-quality evidence. Responders that did consider the neurosurgical guidelines in their hospital to be based on high-quality evidence did consider their own treatments more often as based on Level I and/or Level II (84% resp. 55%) (P < .001). Also, neurosurgeons with formal training believed they could understand, criticize and interpret statistical outcomes presented in journals better than those without formal training (93% resp. 68%) (P < .001). Conclusions: According to the respondents, neurosurgery is based less often on high-quality evidence than other medical specialties. When looking at the results of the survey, formal training in EBM is desirable, so neurosurgeons can better understand, criticize and interpret statistical outcomes presented in journals.

  • Assessing Mobile Phone Access and Willingness for Text-Based mHealth Intervention to Improve Prenatal Care at Primary Care Centers in North West Ethiopia: a Cross-sectional Study

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 10, 2017

    Open Peer Review Period: Dec 11, 2017 - Feb 5, 2018

    Background: Maternal mortality remains high in many low- and middle-income countries (LMIC) where limited access to health services is linked to low antenatal care (ANC) utilization. Effective communi...

    Background: Maternal mortality remains high in many low- and middle-income countries (LMIC) where limited access to health services is linked to low antenatal care (ANC) utilization. Effective communication and engagement with care providers is vital for the delivery and receipt of sufficient health care services. There is strong evidence to show that simple text-based interventions can improve prenatal care utilization but most mHealth interventions doesn’t go to scale because of lack of context. Objective: The aim of this study was to determine access to mobile phones by pregnant women attending ANC, willingness to receive an SMS-based mHealth intervention for ANC services and to identify its associated factors among pregnant women attending ANC clinic in Gondar Town administration, North West Ethiopia. Methods: A cross sectional quantitative study was conducted among 422 pregnant women attending ANC from March 27- April 28, 2017. Data were collected using structured interviewer-administered questionnaires. Data entry and analysis were done using Epi-Info version 7 and SPSS version 20 respectively. Descriptive statistics, bivariable and multivariable logistic regression analysis was done. Odds ratio with 95% confidence interval was used to identify factors associated with willingness to receive SMS based mHealth intervention. Results: A total of 416 (98.6 % response rate) respondents were included in the analysis. About 76.7% (319/416) of respondents owned a mobile phone, and 71.2% (296/416) were willing to receive SMS. Factors associated with willingness were: Youth age group (AOR = 2.869, 95 % CI: [1.451-5.651], having Secondary and above education level (AOR = 4.995, 95 % CI: [1.489-14.773] and frequency of mobile phone use (AOR = 0.319, 95 % CI: [0.141-0.718]). Conclusions: A high proportion of pregnant women in an ANC clinic in this remote setting have mobile phone and are willing to receive SMS based mHealth intervention. Age, educational status and frequency of mobile phone use are significantly associated with willingness to receive SMS based mHealth interventions.

  • Computerized Cognitive-Behavioral Therapy (cCBT) for Social Anxiety Disorder (SAD): Systematic Review, Meta-analysis, Trial Sequential Analysis (TSA)

    From: Journal of Medical Internet Research

    Date Submitted: Dec 11, 2017

    Open Peer Review Period: Dec 12, 2017 - Feb 6, 2018

    Background: Computerized cognitive-behavioral therapy (cCBT) was developed to make treatment for Social anxiety disorder (SAD) patients more easily available. Objective: The present article aims to ev...

    Background: Computerized cognitive-behavioral therapy (cCBT) was developed to make treatment for Social anxiety disorder (SAD) patients more easily available. Objective: The present article aims to evaluate the efficacy of cCBT on SAD and investigate the important features of cCBT for effective and safe self-guided interventions. Methods: The present study employs a systematic review and meta-analysis to measure the efficacy of computerized interventions for SAD. Results: Based on 30 studies, we systematically reviewed and described computerized cognitive-behavioral therapy (cCBT) studies on SAD, with attention to the literature characteristics, therapists’ support, intervention modules, drop-out rates, satisfaction rates, and limitations. Furthermore, the current research used a meta-analysis of RCTs to assess the efficacy of cCBT for SAD. For this purpose, 18 articles were included. Random-effects model showed that cCBT treatments for SAD had a greater effect size than waiting-list conditions (g = .96 [95% CI, .55 - 1.37], k = 14, z = 4.57, P < .001), but the Trial Sequential Analysis (TSA) indicated the current evidence was insufficient to be regarded as conclusive. Compared to other treatment conditions (such as traditional CBT), cCBT showed an equal efficacy (g = .17 [95% CI, -.004 - .39], k = 5, z = 1.91, P = .056). Moreover, when comparing the cCBT group with the waiting-list group, the subgroup analysis also found that the effect size of cCBT for SAD was larger in two conditions. Firstly, the treatment efficacy of cCBT on SAD with therapist support was higher than that without therapist support (Q = 7.91, P =.005). Secondly, the effect size of cCBT on SAD for the general population (recruited from mass media) was significantly larger than that for specific population (referred from therapists) (Q = 5.04, P = .025). Conclusions: cCBT is an efficacious treatment for SAD that could play a role in SAD treatment beyond traditional psychological interventions. An option could be to implement cCBT before the regular SAD treatment, which might function as an initial self-help intervention for stepped care in situations when participants need to wait for a long time to get the traditional therapy treatment.

  • Extrahepatic Autoimmune Diseases are Prevalent in Autoimmune Hepatitis Patients and their First-Degree Relatives

    From: Journal of Medical Internet Research

    Date Submitted: Dec 11, 2017

    Open Peer Review Period: Dec 12, 2017 - Feb 6, 2018

    Background: Concurrent autoimmune illnesses contribute to increased medical burden and reduced quality of life in those with autoimmune hepatitis (AIH). The frequency of coexisting autoimmune conditio...

    Background: Concurrent autoimmune illnesses contribute to increased medical burden and reduced quality of life in those with autoimmune hepatitis (AIH). The frequency of coexisting autoimmune conditions among North American AIH patients and their families remains incomplete. Challenges associated with disease capture in the electronic medical record, high study costs, and geographic spread of patients are formidable barriers to understanding the extent of concurrent autoimmune conditions in these groups. Objective: We aimed to examine the frequency of extra-hepatic autoimmune disorders (EHAD) among AIH cases and healthy controls as well as their first-degree relatives using social networking sites (SNS). Methods: We developed a 53-question survey detailing history of autoimmune diseases. A survey link was posted at routine intervals within specific online cohorts on SNS. Healthy controls, without self-reported autoimmune liver disease, were recruited from Amazon’s Mechanical Turk. Continuous variables were summarized using medians and P-values obtained with the Wilcoxon rank sum test. Categorical variables were compared using the Chi-squared test. Results: Cases (n = 306) were more likely than controls (n = 1,162) to be older (median: 49 years vs 33 years), female (93% vs 82%), and have an EHAD (42% vs 19%) (p=0.001). The most frequent EHADs among cases were thyroid disease (16%), Sjögren’s syndrome (9%), Raynaud’s (7%), and psoriasis (5%). 56% of cases and 36% of controls reported at least one first-degree relative (FDR) with history of EHAD (p=0.001). Cases had significantly higher risk of EHAD compared to controls after adjustment for age, sex, race, and BMI (OR: 2.46, CI:1.8-3.3, p=0.001). Conclusions: Patients with AIH report higher prevalence of co-existent extrahepatic autoimmune disorders compared to healthy controls, and their first-degree relatives are also more likely to have autoimmune disorders. Clinical Trial: n/a

  • Systematic development of a smartphone application (WhiteTeeth app) to promote oral-health behavior among Dutch adolescents with fixed orthodontic appliances

    From: Journal of Medical Internet Research

    Date Submitted: Dec 11, 2017

    Open Peer Review Period: Dec 12, 2017 - Feb 6, 2018

    Background: The insertion of fixed orthodontic appliances increases the risk of dental caries, particularly in adolescents. Caries can be prevented by performing good oral-health behavior. To support...

    Background: The insertion of fixed orthodontic appliances increases the risk of dental caries, particularly in adolescents. Caries can be prevented by performing good oral-health behavior. To support adolescents with fixed orthodontic appliances in promoting oral-health behavior, we therefore developed a mobile-health (mHealth) intervention, the WhiteTeeth application (app). Objective: To describe the systematic development of a theory and evidence-based mHealth intervention, WhiteTeeth app, for promoting oral-health behavior. Methods: For systematic development of the intervention, we used Intervention Mapping (IM), an intervention-planning guide. In this manuscript we present the results of the first five steps of IM: (1) problem analysis, (2) program outcomes and objectives, (3) program design, (4) program production, and (5) program implementation plan. Results: On the basis of the problem analysis (step 1), we identified fluoride use and the control of dental plaque levels (e.g., tooth brushing and proxy brush usage) as target behaviors for preventing caries. After defining specific program objectives based on these target behaviors (step 2), we translated selected theoretical methods, such as prompting self-monitoring and reinforcing implementation intentions, into practical strategies (step 3). The results of steps 1 – 3 were used to design a mHealth app, the WhiteTeeth app, which was piloted with the target group for acceptability and usability (step 4). To prepare for the adoption and implementation of the intervention, several meetings with adolescents and dental professionals were organized (step 5). Conclusions: This article is a comprehensive description of the systematic development and design of the WhiteTeeth app. It responds to recent calls for improved reporting on the process of intervention development.

  • Can simulator-based teaching improve medical students’ knowledge and competences? Results of a randomized trial using a coronary angiography simulator to learn coronary anatomy.

    From: Journal of Medical Internet Research

    Date Submitted: Dec 11, 2017

    Open Peer Review Period: Dec 12, 2017 - Feb 6, 2018

    Background: Simulator-based teaching for coronary angiography (CA) is a seductive educational tool for medical students to improve knowledge and skills. Its pedagogical impact has not been fully evalu...

    Background: Simulator-based teaching for coronary angiography (CA) is a seductive educational tool for medical students to improve knowledge and skills. Its pedagogical impact has not been fully evaluated yet. Objective: The aim of this study was to compare traditional face-to-face teaching with a simulator-based teaching. Methods: 118 students, in their 4th to 6th year of medical school, were prospectively randomized in two groups: a control teaching group (n=59, CONT group) and a simulator (Mentice AB, Sweden) group (n=59, SIM group). CONT group received a PowerPoint-based course whereas SIM group received a simulator-based course including exactly the same information in an interactive environment. After the course, students were evaluated by 40 multiple choice questions (maximum of 100 points (pts)), including questions on coronary anatomy (part1), angiographic projections (part2) and real case interpretations (part3). Results: Student characteristics were identical in both groups: 52.5% were female; age was 22.6±1.4 years. 35.6% were in their 4th year, 35.6% in 5th year and 28.8% in 6th year. SIM students scored higher than CONT students irrespective of age and year of medical school (59.5±10.8 vs. 43.7±11.3pts,p<0.00001) for all parts of the evaluation (part1: 36.9±6.6 vs. 29.6±6.9pts,p<0.00001; part2: 5.9±3.0 vs. 3.1±2.8pts,p<0.00001; and part3: 16.8±6.9 vs. 10.9±6.5pts,p<0.00001). Student satisfaction was also higher in SIM group than in CONT group (98% vs. 75% p<0.0001). Conclusions: This trial suggests that simulator-based teaching in CA significantly improves students' knowledge in coronary anatomy and angiography projections, as well as clinical and decision-making competences. These results should encourage further evaluation of simulator-based teaching in other branches of medicine.

  • Improving Internal Medicine Residents' Colo-Rectal Cancer (CRC) Screening Knowledge via Smart Phone Application: A Novel Approach

    From: JMIR Medical Education

    Date Submitted: Dec 11, 2017

    Open Peer Review Period: Dec 12, 2017 - Feb 6, 2018

    Background: Colo-Rectal cancer is the third most common type of cancer and the second leading cause of cancer death in the United States. About one in three adults in US is not getting the CRC screeni...

    Background: Colo-Rectal cancer is the third most common type of cancer and the second leading cause of cancer death in the United States. About one in three adults in US is not getting the CRC screening as recommended. Internal medicine residents are deficient in CRC screening knowledge. Objective: To improve internal medicine residents' CRC screening knowledge via novel approach of developing and publishing a smart phone application. Methods: A questionnaire was designed based on CRC screening guidelines of ACS, ACG and USPSTF. The questionnaire was emailed via SurveyMonkey link to all the residents of internal medicine department. The responses were analyzed after 4 weeks. Then a smart phone application was designed and was published on Play Store and App Store for android users and i phone users respectively. The survey was repeated, and the responses were compared with the previous one. Pearson Chi square test and the fisher exact test was applied to look for statistical significance. Results: 50 residents completed the first survey and 41 completed the second survey after publication of the application. Some of the areas of CRC screening which showed statistically significant improvement (P value < 0.05) included age to start CRC screening in African Americans, ordering preventive tests first, identification of CRC screening tests, identification of preventive and detection methods, positive tests to be followed by colonoscopy, follow up after colonoscopy findings and CRC surveillance in diseases. Conclusions: In this modern era of smart phones and gadgets, developing a smartphone based application or educational tool is a novel idea and can help in improving the knowledge of residents about colorectal cancer screening.

  • MISSION COPD: Outcomes from a Multidisciplinary, Vertically Integrated Care Clinic

    From: Journal of Medical Internet Research

    Date Submitted: Dec 13, 2017

    Open Peer Review Period: Dec 13, 2017 - Feb 7, 2018

    COPD is the second leading cause of death in the UK and accounts for 1.7% of bed days in acute hospitals. An estimated 2/3 patients with COPD remain undiagnosed. MISSION COPD aimed to proactively iden...

    COPD is the second leading cause of death in the UK and accounts for 1.7% of bed days in acute hospitals. An estimated 2/3 patients with COPD remain undiagnosed. MISSION COPD aimed to proactively identify patients from primary care who were undiagnosed or uncontrolled and deliver a comprehensive integrated multidisciplinary clinic to address the needs of this complex group to improve diagnosis, personalise therapy and empower patients to self manage. This clinic was led by a Respiratory Specialist team from Portsmouth Hospitals NHS trust working with five Primary Care surgeries in Wessex. 108 patients were seen, with 98 consenting to be followed up for research. Diagnoses were changed in 14 patients and 32 new diagnoses were made. Reductions were seen across all aspects of unscheduled care compared to each participants use in the 12 months prior: emergency GP visits (3.37-0.79 per patient, p=<0.01), exacerbations (2.64-0.56 per patient, p=0.01), out-of-hours calls (0.16-0.05 per patient, p=0.423), hospital admissions (0.49-0.12 per patient, p=0.48). Improvements were seen in quality of life and symptom scores in addition to patient activation (PAM) and patient reported confidence. This pilot has demonstrated the MISSION model may be an effective way to provide comprehensive gold-standard care that is valued by patients and promotes integration across sectors.

  • A web-based telemanagement system for patients with complex inflammatory bowel disease: development and design of a randomized controlled clinical trial

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 13, 2017

    Open Peer Review Period: Dec 14, 2017 - Feb 8, 2018

    Background: Telemedicine has been successfully used to provide inflammatory bowel disease (IBD) patients with healthcare services remotely via the implementation of information and communications tech...

    Background: Telemedicine has been successfully used to provide inflammatory bowel disease (IBD) patients with healthcare services remotely via the implementation of information and communications technology, which uses safe and feasible applications that have been well accepted by patients in remission. However, the design of telemedicine applications in this setting involve difficulties that hinder the adherence of patients to the follow-up plans and the efficacy of these systems to improve disease activity and quality of life. Objective: To evaluate the development of a web platform, TECCU (Telemonitoring of Crohn’s Disease and Ulcerative Colitis) for remote monitoring of patients with complex IBD and the design of a clinical trial involving IBD patients who received standard care (G_Control), nurse-assisted telephone care (G_NT), or care based on distance monitoring (G_TECCU). Methods: We describe the development of a remote monitoring system and the difficulties encountered in designing the platform. A 3-arm randomized controlled trial was designed to evaluate the effectiveness of this web platform in disease management compared with G_NT and G_Control. Results: According to the schedules established for the medical treatment initiated (corticosteroids, immunosuppressants or biological agents), patients from each group answered periodic questionnaires regarding disease activity, quality of life, therapeutic adherence, adverse effects, satisfaction, work productivity, and social activities. Blood and stool analyses (fecal calprotectin) were performed periodically. Based on the results of these tests in G_TECCU, alerts were generated in a web platform with adapted action plans, including changes in medication and frequency of follow-up. The main issues found were the development of an easy to use web platform, the selection of validated clinical scores and objective biomarkers for remote monitoring and the design of a clinical trial to compare the three main follow-up methods evaluated to date in IBD. Conclusions: The development of a web-based remote management program for safe and adequate control of IBD proved challenging. The results of this clinical trial will advance knowledge regarding the effectiveness of TECCU web for improvement of disease activity, quality of life, and use of health care resources in complex IBD patients. Clinical Trial: Telemedicine Crohn's Disease and Ulcerative Colitis (TECCU) NCT02943538 https://clinicaltrials.gov/ct2/show/NCT02943538

  • Effectiveness of a text messaging-based intervention targeting alcohol consumption among university students: a randomized controlled trial

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 13, 2017

    Open Peer Review Period: Dec 14, 2017 - Feb 8, 2018

    Background: Excessive drinking among university students is a global challenge leading to significant health risks. Still, heavy drinking among students is widely accepted and part of a social norm. V...

    Background: Excessive drinking among university students is a global challenge leading to significant health risks. Still, heavy drinking among students is widely accepted and part of a social norm. Various forms of mobile phone interventions have been developed in order to reach the large number of students who engage in excessive drinking. A growing number of studies suggest that text messaged based interventions potentially could reach a large proportion of students, and if effective such an intervention might make a difference concerning heavy drinking in the student community. Objective: The objective of this study was to test the effectiveness of a behaviour change theory based six-week text message intervention among university students. Methods: The study was a two-arm randomized controlled trial with an intervention group receiving a six-week text message intervention and a control group that was referred to treatment as usual at the local student health care centre. Outcome measures were collected at baseline and at three months after the initial invitation to participate in the intervention. The primary outcome was total weekly alcohol consumption. Secondary outcomes were frequency of heavy episodic drinking, highest estimated blood alcohol concentration and number of negative consequences due to excessive drinking. Results: A total of 896 students were randomized to either the intervention or control group. The primary outcome analysis included 92.0% of the participants in the intervention group and 90.1% of the control group. At follow-up, total weekly alcohol consumption decreased in both groups but no significant difference was seen. Data on the secondary outcomes included 49.1% of the participants in the intervention group and 41.3% of the control group. No significant difference between the groups was seen for any of the secondary outcomes. Conclusions: The present study did not reach a sufficient number of participants according to the initial power calculations, which could partly explain the lack of significance. Still, the intervention, although theory based, needs to be re-assessed and refined to better support the target group. Apart from establishing which content forms an effective intervention, the optimal length of an alcohol intervention targeting students also needs to be addressed in further studies. Clinical Trial: Trial registration number: ISRCTN95054707. The trial was registered on 31 August 2016. Ethical approval at the regional ethical committee in Linköping, Sweden: dnr 2016/134-31

  • Responding to Unsolicited Medical Requests from Healthcare Professionals (HCP RUR) on Pharmaceutical Industry Social Media Sites

    From: Journal of Medical Internet Research

    Date Submitted: Dec 12, 2017

    Open Peer Review Period: Dec 12, 2017 - Feb 6, 2018

    Background: The use of social media has risen tremendously over the past decade with usage rates spanning from 5% American adults in 2005 up to 69% in 2016. A 2011 survey of 4,033 clinicians found tha...

    Background: The use of social media has risen tremendously over the past decade with usage rates spanning from 5% American adults in 2005 up to 69% in 2016. A 2011 survey of 4,033 clinicians found that 65% physicians use social media for professional purposes. In order to remain relevant in today’s digital society, Medical Information departments must continue to assess new digital channels and evolve their medical information services to meet the changing needs of their customers. Objective: To evaluate the impact and feasibility of using social media as a channel to respond to unsolicited medical requests from Healthcare Professionals (HCP RUR) directed toward the pharmaceutical industry. Methods: Three pilots were conducted from November 2016 to June 2017 during three professional congresses: the 2016 American College of Rheumatology (ACR) Annual Meeting, the 2017 American Society of Clinical Oncology (ASCO) Annual Meeting, and the 2017 American Headache Society (AHS) Annual Scientific Meeting. For each social media account, an identified Community Manager (CM) monitored the incoming account feed for proper triaging of posts. When an unsolicited medical request appeared, the CM routed the question to the Tier One Medical Information Contact Center (MICC) agents to respond. The following metrics were collected: total number of unsolicited requests directed to MICC agents, total number of unsolicited requests that required escalation to Tier Two Medical Information Associates (MIAs), total number of unsolicited requests that were confirmed US HCPs, total number of unsolicited requests received after hours, and total number of unsolicited requests that were redirected to a different channel. Results: Nine unsolicited medical requests were received during the three pilots with request numbers ranging from two to four requests per pilot. One was from a confirmed US HCP that required escalation to the Tier Two MIAs. A majority of requests (seven out of nine) came in after scheduled monitoring hours with many requests appearing to be from potential consumers. Four requests were redirected to the MICC phone number. The Marketing accounts received more unsolicited medical requests than the Corporate accounts (seven versus two, respectively), and the three Twitter accounts saw more overall engagement (ie, medical requests and other general engagement) than the LinkedIn account. Conclusions: A limited number of medical questions were asked by HCPs using social media during the three pilots. New innovative MICC channels often take time to build awareness. Thus, continued channel awareness is needed to fully understand the channel’s true impact. Since consumers currently make up a majority of the engagement, companies should look into creating a combined consumer and HCP RUR strategy to provide better customer experience to all customers.

  • Online Information Infrastructure Increases Inter-Rater Reliability of Medical Coders: A Quasi-Experimental Study

    From: Journal of Medical Internet Research

    Date Submitted: Dec 13, 2017

    Open Peer Review Period: Dec 13, 2017 - Feb 7, 2018

    Background: Medical coding is essential for standardized communication and integration of clinical data. The Unified Medical Language System by the National Library of Medicine is the largest clinical...

    Background: Medical coding is essential for standardized communication and integration of clinical data. The Unified Medical Language System by the National Library of Medicine is the largest clinical terminology system for medical coders and natural language processing tools. However, abundance of ambiguous codes leads to low rates of uniform coding among different coders. Objective: To measure uniform coding among different medical experts in terms of inter-rater reliability (IR) and analyze the effect on IR by using an expert-based online code suggestion system. Methods: A quasi-experimental study was conducted. Six medical experts coded 602 medical items from structured quality assurance forms (QA) or free-text eligibility criteria (EC) of 20 different clinical trials. Medical item content was selected based on mortality-leading diseases according to WHO data. The intervention consisted of using a semi-automatic code suggestion tool that is linked to a European information infrastructure providing a large medical text corpus of more than 300,000 medical form items with expert-assigned semantic codes. Krippendorff’s alpha (Kalpha) with bootstrap analysis was used for IR analysis and coding times were measured before and after intervention. Results: The intervention improved IR in structured QA form items (from Kalpha= 0.50, 95%-CI [0.43-0.57] to Kalpha = 0.62 [0.55-0.69]) and free-text eligibility criteria (from Kalpha = 0.19 [0.14-0.24] to Kalpha = 0.43 [0.37-0.50]) while preserving or slightly reducing mean coding time per item for all six coders. Regardless of intervention, pre-coordination and structured items were associated with significant higher IR, but the proportion of items that were pre-coordinated significantly increased after intervention (EC: Odds ratio: 4.92 [2.78 - 8.72]; QA: Odds ratio: 1.96 [1.19-3.25]). Conclusions: Use of an online information infrastructure improved IR towards moderate or even substantial inter coder agreement. Pre-coordination and use of structured vs. free-text data elements are key drivers for higher IR.

  • Digital characteristics and dissemination indicators to optimize delivery of internet-supported mindfulness-based interventions for people with a chronic condition: a systematic review

    From: Journal of Medical Internet Research

    Date Submitted: Dec 14, 2017

    Open Peer Review Period: Dec 15, 2017 - Feb 9, 2018

    Background: Internet-supported mindfulness-based interventions (MBIs) are increasingly being used to support people managing a chronic condition. Characteristics of MBIs vary greatly in their mode of...

    Background: Internet-supported mindfulness-based interventions (MBIs) are increasingly being used to support people managing a chronic condition. Characteristics of MBIs vary greatly in their mode of delivery, communication patterns, level of facilitator involvement, intervention period and resource intensity, making it difficult to compare how individual digital features may optimize intervention adherence and outcomes. Objective: The aims of this review were to (1) provide a description of digital characteristics of internet-supported MBIs, and examine how these relate to evidence for efficacy and adherence to the intervention; and (2) gain insights into the type of information available to inform translation of internet-supported MBIs to applied settings. Methods: Medline Complete, PsycInfo and CINAHL databases were searched for studies assessing a MBI delivered or accessed via the internet, and engaging participants in daily mindfulness-based activities such as mindfulness meditations and/or informal mindfulness practices. Only studies using a comparison group of alternative interventions (active compactor), usual care, or wait-list were included. Given the broad definition of chronic conditions, specific conditions were not included in the original search to maximize results. The search resulted in 958 articles, from which 11 articles describing 10 interventions met the inclusion criteria. Results: Internet-supported MBIs were more effective than usual care or wait-list groups, and self-guided interventions were as effective as facilitator guided interventions. Findings were mainly informed by female participants. Adherence to interventions was inconsistently defined, and prevented robust comparison between studies. Reporting of factors associated with intervention dissemination, such as population representativeness, program adoption and maintenance, and costs was rare. Conclusions: More comprehensive descriptions of digital characteristics need to be reported to further our understanding of features that may influence engagement and behavior change, and to improve the reproducibility of MBIs. Gender differences in determinants and patterns of health behavior should be taken into account at the intervention design stage to accommodate for male and female preferences. Future research could compare MBIs with established evidence-based therapies to identify the population groups that would benefit most from internet-supported programs. Clinical Trial: PROSPERO - CRD42017078665

  • Drug Repositioning for Parkinson’s Disease Based on Adverse Drug Reactions Detected from Social Media

    From: Journal of Medical Internet Research

    Date Submitted: Dec 13, 2017

    Open Peer Review Period: Dec 14, 2017 - Feb 8, 2018

    Background: Due to the high cost and low success rate in new drug development, systematical drug repositioning methods are exploited to find new indications from existing drugs. Objective: We sought t...

    Background: Due to the high cost and low success rate in new drug development, systematical drug repositioning methods are exploited to find new indications from existing drugs. Objective: We sought to propose a new computational drug repositioning method to identify repositioning drugs for Parkinson’s disease (PD). Methods: We developed a novel heterogeneous network mining repositioning method that constructed a three-layer network of disease, drug, and adverse drug reaction (ADR), and involved user-generated data from online health communities, to identify potential candidate drugs for PD. Results: We identified 44 non-Parkinson drugs by using the proposed approach, with data collected from both pharmaceutical databases and online health communities. Based on the further literature analysis, we found literature evidence for 28 drugs. Conclusions: In summary, the proposed heterogeneous network mining repositioning approach is promising for identifying repositioning candidates for PD. It shows that adverse drug reactions (ADRs) are potential intermediaries to reveal relationships between disease and drug.

  • YouTube as an Educational Resource in Medical Education: A Scoping Review

    From: JMIR Medical Education

    Date Submitted: Dec 13, 2017

    Open Peer Review Period: Dec 14, 2017 - Feb 8, 2018

    Background: Video has been a powerful teaching and learning tool in medical education, enabling knowledge, skill and attitude formation in a variety of areas and reaching learners with various learnin...

    Background: Video has been a powerful teaching and learning tool in medical education, enabling knowledge, skill and attitude formation in a variety of areas and reaching learners with various learning and communication styles. The millennial generation has grown up with video at their fingertips at any time and any place, and social networking sites such as YouTube enable the sharing of video amongst a vast online community. YouTube has emerged as a growing educational resource for both learners and medical educators. However, the usefulness of YouTube in supporting teaching and learning across the continuum of medical education has not been explored in detail. Given the increasing usage of YouTube in medical education, a review of the literature on YouTube and its utilization in medical education could inform more effective adoption and usage by institutions, educators, practitioners and learners. Objective: To explore the use of YouTube across the medical education continuum. Methods: A scoping review of the literature was performed. PubMed, ERIC and CINAHL were searched for literature on YouTube usage for medical education purposes published between 2005 and 2017 using a combination of search terms. Articles were screened using a defined set of inclusion criteria. Key items of information from each paper were collated using a data extraction tool and common themes from the literature were identified via thematic analysis. Results: Of the 113 articles initially identified in the literature search, 31 met inclusion criteria. Results show that a large number of YouTube videos exist across a variety of medical topic areas. However, only a small number of studies have evaluated the effectiveness of YouTube as an educational intervention and these are largely limited to learner satisfaction only. YouTube does offer the opportunity for educators to share videos and for learners to access a wide array of video materials. However, a majority of studies involving the assessment of content quality suggest that YouTube videos may be an inadequate source of information for learning due to the high variability of content. A key limitation in many of these studies was that searches were mainly restricted to publicly available video content. Conclusions: There is a paucity of research and evaluative work surrounding the use of YouTube as an educational resource across the medical education continuum. The quality of the content on YouTube is highly variable due to a lack of peer-review. Further evaluation of the effective integration of YouTube in medical education would inform further understanding and future practice.

  • Most available apps for cardiopulmonary resuscitation are medically incorrect or user-unfriendly: Results from a systematic search combined with guideline-adherence and usability testing.

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 13, 2017

    Open Peer Review Period: Dec 14, 2017 - Feb 8, 2018

    Background: In case of a cardiac arrest the start of cardiopulmonary resuscitation by a bystander before the arrival of the emergency personnel, increases the probability of survival. However, the ste...

    Background: In case of a cardiac arrest the start of cardiopulmonary resuscitation by a bystander before the arrival of the emergency personnel, increases the probability of survival. However, the steps of high-quality resuscitation are not known by every bystander or might be forgotten in this complex and time-critical situation. Smartphone applications offering real-time step-by-step instructions might be a valuable source of information. Objective: This work examines the currently available smartphone applications offering real-time instructions in case of a cardiac arrest, evaluates their adherence to current resuscitation guideline and tests the usability. Methods: Our three-step-approach combined a systematic review of currently available apps guiding a layperson through a resuscitation situation, an adherence-testing to medical guidelines and a usability evaluation of the determined apps. The systematic review followed an adapted PRISMA flow diagram, the guideline-adherence was tested with aid of a conformity checklist and the usability was evaluated by a group of smartphone frequent users and emergency physicians with the SUS tool. Results: The structured search in Google Play Store and Apple App Store resulted in 3890 hits. After removing redundant ones, 2640 hits were checked for fulfilling the inclusion criteria. Thereby 34 apps meeting all inclusion criteria were identified. These included apps were checked for medical correctness as defined by the European Resuscitation Council’s guidelines. Only 5 out of 34 apps (14.7%) fulfilled all criteria checked to determine guideline-adherence All other apps gave no or wrong information on at least one relevant topic. Regarding the usability, solely one out of three apps was evaluated with a SUS score above the published average of 68. Conclusions: Implementing a systematic quality control for health-related apps should be enforced to ensure that all products provide medically correct content and sufficient usability in complex situations. This is of superior importance for apps dealing with the treatment of life-threatening events such as cardiac arrest. Clinical Trial: The study was approved by the Institutional Review Board of Universitätsmedizin Greifswald under case number BB 055/17.

  • Engaging Youth with Type 1 Diabetes as Participants in Research Design

    From: Journal of Participatory Medicine

    Date Submitted: Dec 13, 2017

    Open Peer Review Period: Dec 14, 2017 - Feb 8, 2018

    Background: Adolescents with type 1 diabetes (T1D) have difficulty achieving optimal glycemic control, partly due to competing priorities that interfere with diabetes self-care. Often, significant di...

    Background: Adolescents with type 1 diabetes (T1D) have difficulty achieving optimal glycemic control, partly due to competing priorities that interfere with diabetes self-care. Often, significant diabetes-related family conflict occurs, and adolescents’ thoughts and feelings about diabetes management may be disregarded. Patient-centered diabetes outcomes may be better when adolescents feel engaged in the decision making process. Objective: To co-design a clinic intervention utilizing shared decision making for addressing diabetes self-care with an adolescent patient and parent advisory board (PAB). Methods: The PAB consisted of six adolescents (teens) between the ages 12-18 years with T1D and their parents. Teens and parents provided informed consent and participated in one or both of two PAB sessions, lasting 3-4 hours each. Session 1 topics included: (1) patient-centered outcomes related to quality of life, parent-teen shared diabetes management, and shared family experiences; and (2) implementation and acceptability of a patient-centered diabetes care plan intervention where shared decision making was utilized. Audio recordings, notes and other materials were analyzed to identify and extract ideas relevant to the development of a patient-centered diabetes management plan. These ideas were written onto separate post-it notes and then visually coded into similar themes. The information was utilized to develop a prototype for a “Diabetes Management Plan” tool that was pilot tested during Session 2. Results: Session 1 identified five principal patient-centered quality of life measurement domains: fear/worry, mealtime struggles, assumptions and judgments, feeling “abnormal”, and conflict. Two objectives were determined to be principally important for a Diabetes Management Plan intervention: 1) focusing the intervention on conflict resolution strategies, 2) working toward a verbalized common goal. The Diabetes Management Plan tool was created according to these findings and has been implemented in a clinical trial with the aim of assisting with patient-centered goal setting. Conclusions: Patients with T1D can be effectively engaged and involved in patient-centered research design. Teens with T1D prioritize reducing family conflict and fitting into their social milieu over health outcomes at this time in their lives. It is important to acknowledge this when designing interventions to improve health outcomes in teens with T1D. Clinical Trial: NCT02115555

  • eMental Healthcare Technologies for Anxiety and Depression in Childhood and Adolescence: A Systematic Review of Studies Reporting Implementation Outcomes

    From: JMIR Mental Health

    Date Submitted: Dec 14, 2017

    Open Peer Review Period: Dec 14, 2017 - Feb 8, 2018

    Background: Anxiety and depression disorders are frequent conditions in childhood and adolescence. eMental healthcare technologies are proposed to improve availability and access to services, but thei...

    Background: Anxiety and depression disorders are frequent conditions in childhood and adolescence. eMental healthcare technologies are proposed to improve availability and access to services, but their uptake within health systems is limited. Objective: The objective of this systematic review was to examine how the implementation of eMental healthcare technologies has been studied among eMental healthcare technologies for childhood and adolescent anxiety disorders and depression. Methods: A search of 5 electronic databases and grey literature was conducted. Eligible studies assessed an eMental healthcare technology for treating or preventing anxiety and/or depression, included children and/or adolescents (< 18 years), or their parents or healthcare providers, and reported findings on technology implementation. The methodological quality of studies was evaluated using the Mixed Methods Appraisal Tool. Outcomes of interest were based on 8 implementation outcomes: acceptability (satisfaction with a technology), adoption (technology uptake and utilization), appropriateness (“fitness for purpose”), cost (financial impact of technology implementation), feasibility (extent to which a technology was successfully used), fidelity (implementation as intended), penetration (‘spread’ or ‘reach’ of the technology), and sustainability (maintenance or integration of a technology within a healthcare service). For extracted implementation outcome data, we coded statistically significant favorable ratings on measurement scales as “positive results”, and statistically significant unfavorable ratings on measurement scales as “negative results”. Those studies that reported both positive and negative findings were coded as having “mixed results”. Results: Forty-six studies met inclusion criteria the majority of which were rated as excellent to very good in methodological quality. These studies investigated eMental healthcare technologies for anxiety (n=23), depression (n=18), or both anxiety and depression (n=5). Studies of technologies for anxiety evaluated: (1) acceptability (78%) reporting high levels of satisfaction, (2) adoption (43%) commonly reporting positive results, and (3) feasibility (43%) reporting mixed results. Studies of technologies for depression evaluated: (1) appropriateness (56%) reporting moderate helpfulness, and (2) acceptability (50%) describing a mix of both positive and negative findings. Studies of technologies designed to aid anxiety and depression commonly reported mixed experiences with acceptability and adoption, and positive findings for appropriateness of the technologies for treatment. Across all studies, cost, fidelity, and penetration and sustainability were the least measured implementation outcomes. Conclusions: Acceptability of eMental healthcare technology is high among users, and the most commonly investigated implementation outcome. Perceptions of the appropriateness and adoption of eMental healthcare technology varied. Implementation research that identifies, evaluates, and reports on costs, sustainability and fidelity to clinical guidelines is crucial in making high quality eMental healthcare available to children and adolescents.

  • The Development of BackPocketDriver: A Smartphone-based Behavior Change Intervention for Youth Drivers

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 22, 2017

    Open Peer Review Period: Dec 23, 2017 - Feb 17, 2018

    Background: The over-representation of youth in road crash injury and fatality rates is a major public health problem, globally. In New Zealand, youth drivers are most vulnerable in the restricted lic...

    Background: The over-representation of youth in road crash injury and fatality rates is a major public health problem, globally. In New Zealand, youth drivers are most vulnerable in the restricted license period, when they can drive without the requirement for supervision by an experienced adult. Behavioral change interventions delivered using smartphone technology to young drivers could serve as a useful feedback mechanism for safe driving in this context, but this potential remains to be fully explored. Objective: We have applied behavioral change principles to design and develop a smartphone based intervention with the aim of helping youth drivers develop and hone safe driving skills. Methods: An iterative process was used to support the development of the smartphone intervention. We reviewed behavioral change literature, identifying fundamental principles and exploring use of behavioral change techniques in other areas of public health. We engaged with key stakeholders, including the young drivers, government agencies and relevant organizations. We also took into account technology adoption considerations when designing the application. Results: We developed BackPocketDriver, an Android smartphone app that uses in-built sensors to monitor and infer driver behavior. The application implements features that were identified during the design process and which are traceable to behavioral change techniques. Features incorporated include messaging to enhance motivation and driver education, journey feedback summaries, approaches to goal setting, social support and gamification elements (achievements and leaderboards). Conclusions: BackPocketDriver’s design rests on a sound foundation – behavioral change theory. With explicit links between the theory and app features, the app aims to be an effective intervention to change and improve youth driver behavior.The next phase of the work is to assess the intervention for effectiveness. Clinical Trial: Not applicable.

  • Agile Development to Improve Recruitment and Enrollment for mHealth Research: Lessons from the Dot™ Contraceptive Efficacy Study

    From: Journal of Medical Internet Research

    Date Submitted: Dec 14, 2017

    Open Peer Review Period: Dec 14, 2017 - Feb 8, 2018

    Background: Smartphone applications (apps) that provide women with information about their daily fertility status during their menstrual cycles have the potential to become an important addition to th...

    Background: Smartphone applications (apps) that provide women with information about their daily fertility status during their menstrual cycles have the potential to become an important addition to the contraceptive method mix. However, if these apps claim to help a user prevent pregnancy, they must undergo similar rigorous research required for other contraceptive methods. Georgetown University’s Institute for Reproductive Health (IRH) is conducting a prospective longitudinal efficacy trial on Dot, an algorithm-based fertility app designed to help women prevent pregnancy. Objective: Recruiting research participants who meet the criteria required of a contraceptive efficacy study and enrolling an adequate number to statistically assess the effectiveness of Dot is critical. Recruiting and enrolling participants for the Dot study involved making decisions based on research and analytic data, constant process modification, and close monitoring and evaluation of the effect of these modifications. The aim of this paper is to highlight decision points during the recruitment-enrollment process and the effect of modifications on enrollment numbers and demographics. Methods: Originally, the only option for women to enroll in the study was to do so over the phone with a study representative. Upon noticing low enrollment numbers, we examined the seven steps from the time a woman received the recruitment message until she completed enrollment, and made modifications accordingly. In Modification 1, we added call-back and voicemail procedures to increase the number of completed calls. Modification 2 involved employing a chat/instant message (IM) feature to facilitate study enrollment. In Modification 3, the process was fully automated to allow participants to enroll in the study without the aid of study representatives. Results: After these modifications were implemented, 719 women were enrolled in the study over a 6 month period. The majority of participants (68.7%) were enrolled during Modification 3, in which they had the option to enroll via phone, chat, or the fully automated process. Overall, 27.5% were enrolled via a phone call, 19.9% a chat/IM, and 50.9% directly through the fully automated process. With respect to the demographic profile of our study sample, we found a significant statistical difference in education level across all modifications (p<0.05) but not in age or race/ethnicity (p>0.05). Conclusions: Our findings show that agile and consistent modifications to the recruitment and enrollment process were necessary to yield an appropriate sample size. An automated process resulted in significantly higher enrollment rates than one that required phone interaction with study representatives. While there were some differences in demographic characteristics of enrollees as the process was modified, in general our study population is diverse and reflects the overall United States population in terms of race/ethnicity, age, and education. Additional research is proposed to identify how differences in mode of enrollment and demographic characteristics may affect participants’ performance in the study. Clinical Trial: ClinicalTrials.gov NCT02833922; https://clinicaltrials.gov/ct2/show/NCT02833922 (Archived be WebCite at http://www.webcitation.org/6nDkr0e76)

  • Development and evaluation methods of applications for Augmented Reality in nursing: a systematic review

    From: JMIR Medical Informatics

    Date Submitted: Dec 18, 2017

    Open Peer Review Period: Dec 19, 2017 - Feb 13, 2018

    Background: Inclusion of information technology into nursing is rising. Furthermore, technological advancements lead to an increased attention for Augmented Reality (AR). As AR is implemented on smart...

    Background: Inclusion of information technology into nursing is rising. Furthermore, technological advancements lead to an increased attention for Augmented Reality (AR). As AR is implemented on smart devices and therefore part of a pervasive system, it can highly influence the daily working process. Thus, values should be taken into account when designing and implementing an AR application for nursing. Objective: The aim of this review is to provide an overview about the current research on AR in nursing with special focus on design and evaluation methods as well as on the integration of values. This led to the following research question: “Which research according to the topic of AR in nursing exists?” With focus on the topics use cases, evaluation, devices used, and ethics. Methods: We searched eight databases of the areas of nursing and informatics including PubMed, Web of Science and ACM. We used the keywords ‘Nurs’, ‘Care’ OR ‘Caring’ in combination with the phrasings ‘Augmented Reality’, ‘AR device’, ‘AR glass’, ‘Smart device’, ‘Smart glass’, ‘Smart watch’ OR ‘Google glass’. We included studies concerning the topic of AR in nursing. Quantitative as well as qualitative and mixed methods studies were included. We conducted a critical interpretive synthesis to synthesize the results. Results: The search led to 434 articles of which 13 were then included into the final analysis. According to our research question we defined four topics deductively and identified nine subtopics inductively. The subtopics are use case identification, setting/use case description, requirements elicitation, evaluation goals, evaluation methods, evaluation outcome, technical challenges, ethical approval, and values. Whereas reviewed publications evaluated the use of AR in nursing as merely positive they identified technical challenges as well. Usage of devices varies and values are hardly considered in application design and evaluation. Conclusions: Our results show, that research according to AR in nursing exists. Methods to identify use cases and to evaluate applications differ between the studies. Furthermore, devices used vary. Examples are smart glasses, tablets, and smart watches. Reviewed studies predominantly evaluated usage of google glass. Results provided show that design and evaluation of smart devices for nursing to date is conducted without explicitly taking values into account. Furthermore, evaluation does not consider framing conditions. Our study findings are important and informative to the nurses and technicians who are included in the development of new technologies. They can use this review to reflect on their own design of use case identification, requirements elicitation and evaluation.

  • Adherence to technological elements and study design – a critical analysis of a web-based intervention for women with type 1 diabetes in pregnancy and early motherhood

    From: Journal of Medical Internet Research

    Date Submitted: Dec 15, 2017

    Open Peer Review Period: Dec 16, 2017 - Feb 10, 2018

    Background: Numerous web-based interventions have been implemented to promote health and health-related behaviors in persons with chronic conditions. Using randomized controlled trials (RCTs) to evalu...

    Background: Numerous web-based interventions have been implemented to promote health and health-related behaviors in persons with chronic conditions. Using randomized controlled trials (RCTs) to evaluate such interventions creates a range of challenges, for example, that users’ adherence can be influenced by technology and that the control group may be using other web-based support outside the intervention. This in turn can influence the study outcome. Applying a critical perspective when evaluating web-based health interventions is important, as has been done here. Objective: Further critically analyzing the challenges of doing an RCT to test web-based support offered to women with type 1 diabetes mellitus in pregnancy and up to six months after birth. Methods: The MODIAB-web study was critically examined using an exploratory case study methodology and the framework for analysis offered through the Persuasive Systems Design model (PSD model). Focus was on technology, study design and web-based support usage, with special focus on the forum for peer support. Descriptive statistics and qualitative content analysis were used. Results: The persuasive content and technological elements in the design of the RCT included all four categories of the PSD model, but not all design principles were implemented. The study duration was extended to a period of four and a half years. Of 81 active participants in the intervention group, a maximum of 36 women were simultaneously active. User adherence varied between 2 to 6 413 individual logins with a median of 91. The forum for peer support was used by 63 participants. Although only 24 participants interacted in the forum, there was a fairly rich exchange of experiences and advice between them. Thus, adherence in terms of social interactions was negatively affected by limited active participation due to prolonged recruitment process and randomization effects. Conclusions: Lessons learned from this critical analysis are that technology and study design matter and might mutually influence each other. The randomization element in a RCT design can become a barrier to achieving a critical mass of user interactions in web-based interventions, especially when social support is included. For extended study periods, the technology used may need to be adapted in line with newly available technical options to avoid the risk of becoming outdated in the user realm, which in turn might jeopardize study validity in terms of RCT designs. Theory-driven strategies enable a multifaceted repertoire in technology design. Based on the lessons learned in this RCT, we have identified recommendations to take into account when designing and evaluating web-based health interventions.

  • Theory-based digital interventions to improve asthma self-management outcomes: a systematic review

    From: Journal of Medical Internet Research

    Date Submitted: Jan 15, 2018

    Open Peer Review Period: Jan 15, 2018 - Mar 12, 2018

    Background: Asthma is a chronic disease that requires effective self-management to control it and prevent mortality. The use of theory-informed digital interventions promoting asthma self-management i...

    Background: Asthma is a chronic disease that requires effective self-management to control it and prevent mortality. The use of theory-informed digital interventions promoting asthma self-management is increasing. However, there is limited knowledge concerning how, and to what extent, theory has been applied, which theoretical models could potentially improve asthma self-management, and which components of these models are most effective. Objective: To examine the use and application of theories in the development of digital interventions to enhance asthma self-management, and to evaluate whether these interventions are effective in eliciting behaviour change and improving clinical outcomes and quality of life. Methods: Electronic databases (The Cochrane Library, MEDLINE, EMBASE and PsycINFO) were searched systematically using pre-determined terms and inclusion criteria. Additional studies were identified by scanning reference lists of relevant studies. Two researchers screened titles and abstracts and a third researcher resolved discrepancies. Full-text review was undertaken for relevant studies. Studies meeting inclusion criteria were assessed for risk of bias using The Cochrane Collaboration tool. The review was conducted in accordance with the PRISMA statement. Interventions were coded as fully or partly digital, and in terms of the type of digital platform used and the theory of model applied. The Theory Coding Scheme (TCS) was used to establish: the extent to which each intervention had applied theory, which theoretical constructs or behavioural determinants had been addressed, the involvement of the target group with the development of the intervention, if, and how, interventions were tailored, and if participants’ selection had been based on assessment of need. The impact of the interventions on behavioural and clinical outcomes and healthcare utilisation was described using narrative synthesis. Results: Sixteen studies evaluating 15 different digital interventions were selected for this review. The most commonly cited theories/models included Social Cognitive Theory, the Health Belief Model and the Common-Sense Model of Self-Regulation. The 3 studies that applied theory to an extent of ≥50% of the different uses of theory, as assessed by the TCS, showed a significant positive effect (P<0.05) of the intervention on all measured behavioural and clinical outcomes, but from those that incorporated <50% of the different uses of theory, only 2% of 13 studies showed such an effect. Conclusions: Theory-based digital interventions can be effective at improving clinical outcomes and self-management behaviour. Most studies lack detail on the theoretical constructs and how they have been applied to the design of the intervention, or selection of participants. A systematic approach to the use of theory to guide the design, selection and application of intervention techniques is needed. Clinical Trial: N/A

  • Impact of Pokémon Go on Physical Activity: A Multilevel Study in Asia

    From: Journal of Medical Internet Research

    Date Submitted: Dec 16, 2017

    Open Peer Review Period: Dec 16, 2017 - Feb 10, 2018

    Background: Physical activity has long been considered an important component of a healthy lifestyle. Although many efforts have been made to promote physical activity, there has yet to be an effectiv...

    Background: Physical activity has long been considered an important component of a healthy lifestyle. Although many efforts have been made to promote physical activity, there has yet to be an effective global intervention in physical activity promotion. Some researchers suggest that Pokémon GO, a location-based augmented reality (AR) game, effectively promotes physical activity on a global scale, but the details of the impact are far from clear. Objective: To study the impact of Pokémon GO on players’ physical activity, and how the impact varies across players with different physical activity levels. Methods: We conducted a field study to investigate Pokémon GO’s impacts on physical activity in five types of built environment in Hong Kong. Pokémon GO Players were asked to report their demographics through a survey, and their Pokémon GO behaviours and data of daily walking and running distance were collected from their mobile phones. Participants (n=210) were residents of Hong Kong, aged 13 to 65 years old and playing Pokémon GO using iPhone 5 or 6 series in five selected types of built environment. We measured the average daily walking and running distance over a period of 35 days, from 14 days before to 21 days after installation of Pokémon GO. Multilevel modelling was used to identify and examine the predictors – including Pokémon GO behaviours, weather; demographics and built environment – of Pokémon GO’s impact on daily walking and running distance. Results: Average daily walking and running distance increased 18.1% (0.96 km) in the 21 days after participants installed Pokémon GO compared with the distance over the 14 days before installation. However, this impact attenuated over time and is estimated to disappear after 26 days (P<0.001). Multilevel models indicate that Pokémon GO has a stronger and more lasting impact on less physically active players than more physically active ones (P<0.001). Playing Pokémon GO in green space has a significant positive relationship with walking and running distance (P<0.001). Moreover, results show that Pokémon GO behaviours – play Pokémon GO or not, as well as days played, weather (total rainfall, bright sunshine, mean air temperature, and mean wind speed), and demographics (age, gender, income, education, and BMI) – were associated with walking and running distance. Conclusions: Pokémon GO can efficiently activate players, especially less physically active ones, to do physical activity. Pokémon GO has the potential to build new links between humans and green space to encourage people to do physical activity. The results indicate that location-based AR games, such as Pokémon GO, have a great potential to be an effective public health intervention at the global scale.

  • M-Health solutions for hypertensive disorders in pregnancy: A scoping literature review

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 16, 2017

    Open Peer Review Period: Dec 16, 2017 - Feb 10, 2018

    Background: Hypertensive disorders are the most common complications during pregnancy with incidence rates between 5% and 11% of pregnancies, being gestational hypertension and preeclampsia the leadin...

    Background: Hypertensive disorders are the most common complications during pregnancy with incidence rates between 5% and 11% of pregnancies, being gestational hypertension and preeclampsia the leading causes of perinatal and maternal morbidity and mortality, especially in Low- and Middle-Income Countries (LMIC) where maternal and perinatal mortality ratios are still high. Pregnant women with hypertensive disorders could greatly benefit from m-Health solutions, as a novel way to identify and control early symptoms, as shown in an increasing number of publications in the field. Those digital health solutions may overcome access limiting factors and the lack of skilled medical professionals and finances commonly presented in resource-poor environments. m-Health solutions provides tools to meet the United Nations Sustainable Development Goal (SDG), particularly SDG 3: Ensure healthy lives and promoting well-being for all at all ages, which among its targets are to reduce the maternal and neonatal mortality ratios. Objective: A literature review of m-Health solutions used as support in hypertensive disorders during pregnancy has been conducted, with the objective to identify the most relevant protocols and prototypes that could influence and improve current clinical practice Methods: A methodological review following a scoping methodology was conducted. Manuscripts published in research journals reporting technical information of m-Health solutions for hypertensive disorders in pregnancy were included, categorizing articles in different groups: “Diagnosis and Monitoring”, “m-Health Decision Support System”, “Education”, and “Health Promotion”, rising 7 research questions to study the manuscripts. Results: The search in electronic research databases yielded 327 articles. After removing duplicates, 230 articles were selected for screening. Finally, 11 articles met the inclusion criteria and data were extracted from them. Very positive results in the improvement of maternal health and acceptability of solutions were found, although most of the studies involved a low number of participants and no complete clinical study has been carried out. Accordingly, none of the reported prototypes were integrated in the different healthcare systems. Only 4 studies used sensor for physiological measurements, and only 2 used blood pressure sensors, in spite of the importance of this physiological parameter in the control of hypertension. The reported m-Health solutions are found to be of great potential to improve clinical practice in areas with lack of skilled medical professionals or with low healthcare budget, of special relevance in LMIC, although again, no extensive clinical validation has been carried out in these environments Conclusions: m-Health solutions hold an enormous potential to support hypertensive disorders during pregnancy and improve current clinical practice. Even though very positive results have been reported in terms of usability and improvement of maternal health, rigorous complete clinical trials are still necessary in order to support integration in healthcare systems. There is a clear need for simple m-Health solutions specifically developed for resource-poor environments that meets the United Nations SDG, of enormous interest in LMIC

  • Challenges facing clinical research

    From: Interactive Journal of Medical Research

    Date Submitted: Dec 17, 2017

    Open Peer Review Period: Dec 17, 2017 - Feb 11, 2018

    Background: Most countries thrive to build and expand national research. A number of challenges may hinder clinical researchers and potential researchers particularly in developing countries. We aim t...

    Background: Most countries thrive to build and expand national research. A number of challenges may hinder clinical researchers and potential researchers particularly in developing countries. We aim to study these challenges in the Kingdom of Saudi Arabia (KSA). Objective: We aim to study these challenges in the Kingdom of Saudi Arabia (KSA). Methods: A questionnaire reflecting possible challenges was presented to the delegates and faculties of 5 cancer related educational scientific meetings in KSA. Results: One hundred and forty seven responders were practicing in KSA and are the subject of this report of whom 95 (64.6%) were physicians. While 122 (83%) are interested in conducting research, service commitments and inadequate time, process of research approval within one’s department and obtaining financial funding were the most frequent challenges reported by 86 (58.5%), 61 (41.5%) and 53 (36.1%) of responders. Conclusions: Major challenges may hinder clinical research development. The identified challenges need to be seriously addressed if advances in clinical research are to be expected.

  • Satisfaction Rate of "Talking Pole" by Emergency Department Patients: A Descriptive Study

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 23, 2017

    Open Peer Review Period: Dec 25, 2017 - Feb 19, 2018

    Background: Patient engagement is important, however, it can be difficult in emergency department (ED). Objective: The aim of this study was to evaluate the satisfaction of ED patients in using a pati...

    Background: Patient engagement is important, however, it can be difficult in emergency department (ED). Objective: The aim of this study was to evaluate the satisfaction of ED patients in using a patient-friendly health information technology device, “Talking Pole.” Methods: This study was conducted in May 2017 at the ED of a tertiary hospital. The “Talking Pole” is a smartphone-based device attached to a pole with sensors. It is capable of sensing patient movement and fluid dynamics. In addition, it provides clinical information from electronic medical records to patients, and is a wireless communication tool between patients and nurses. Patients and caregivers with prior history of ED admission were selected for the study. Once consent was given, participants received “Talking Pole” units which they were encouraged to use. Two hours later, each participant was given an 18-item questionnaire, with a 5-point satisfaction scale, regarding the usability and usefulness of the “Talking Pole.” Results: Fifty-two participants were recruited including 28 patients (53.8%). The remaining participants were caregivers. There were 20 (38.5%) male participants; the average age was 54.6 years (±12.9), and 33 (63.5%) participants had cancer-related visits. The overall satisfaction rate was 4.17 (±0.79). Factors associated with overall satisfaction were: “comparison to the previous visit” (0.73), “perceived benefit” (0.73), “information satisfaction” (0.70), “efficiency” (0.70) and “learnability” (0.68); Conclusions: Patient and caregiver satisfaction with the “Talking Pole” was positive in the ED environment, and highly correlated with “comparison to the previous visit”, “perceived benefit”, “information satisfaction”, “efficiency” and “learnability”. Clinical Trial: The study was approved by the Samsung Medical Center institution’s ethics committee (IRB File No: SMC 2017-03-034-002)

  • Using predictive analytics to identify children at risk of defaulting from routine immunization program

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 18, 2017

    Open Peer Review Period: Dec 19, 2017 - Feb 13, 2018

    Background: Despite the availability of free routine immunizations in low and middle-income countries (LMICs), many children are incompletely vaccinated, vaccinated late for age or drop out over the c...

    Background: Despite the availability of free routine immunizations in low and middle-income countries (LMICs), many children are incompletely vaccinated, vaccinated late for age or drop out over the course of the immunization schedule. Without the technology to model and visualize risk on large datasets, vaccinators and policy-makers are unable to identify and target groups and individuals at high risk of dropping out thus default rates remain high preventing universal immunization coverage. Predictive analytics algorithm leverages Artificial Intelligence (AI), and uses statistical modeling, machine learning and multi-dimensional data mining to accurately identify children who are most likely to delay or miss their follow-up immunization visits. Objective: To conduct feasibility testing and validation of a predictive analytics algorithm to identify which children are likely to miss the follow-up vaccines through risk profiling of clients. Methods: The algorithm was developed using 47,554 longitudinal immunization records, split into a training and validation cohort. Four machine learning models (random forest, recursive partitioning, support vector machines and C-forest) were used to generate the algorithm to predict, for each child, the likelihood of defaulting on the follow-up immunization visit. The models were encapsulated in the predictive engine, which decided the most appropriate method to apply in a given case. Each of the models was assessed on: accuracy, precision (positive predictive value), sensitivity, specificity and negative predictive value, and area under curve. Results: Out of 11,889 cases in validation dataset, the random forest model correctly predicted 8,994 cases yielding 94.9% sensitivity and 54.9% specificity. The C-Forest Model, Support Vector Machines and Recursive Partitioning Models improved prediction respectively by achieving 352, 376 and 389 visits above the predictions made by the random forest model. All models had a C-statistic of 0.750 or above while the highest statistic (AUC 0.791, 95% CI: 0.784– 0.798) was seen for the Recursive Partitioning algorithm. Conclusions: This feasibility study demonstrates predictive analytics can accurately identify children who are at higher risk for defaulting on follow-up immunization visits. Correct identification of potential defaulters opens a window for evidence-based targeted interventions in resource limited settings to achieve optimal immunization coverage and timeliness.

  • Using mobile technology to provide personalised reminiscence for people living with dementia and their carers: An appraisal of outcomes from a quasi-experimental study

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 19, 2017

    Open Peer Review Period: Dec 20, 2017 - Feb 14, 2018

    Background: Dementia is an international research priority. Reminiscence is an intervention that prompts memories, and has been widely used as a therapeutic approach for people living with dementia....

    Background: Dementia is an international research priority. Reminiscence is an intervention that prompts memories, and has been widely used as a therapeutic approach for people living with dementia. A novel iPad app was developed to support home-based personalised reminiscence. It is crucial that technology-enabled reminiscence interventions are appraised. Objective: This study sought to measure the effect of technology-enabled reminiscence on mutuality (defined as the level of ‘closeness’ between an adult living with dementia and their carer), quality of carer and patient relationship and subject wellbeing. Methods: A 19-week personalised reminiscence intervention facilitated by a programme of training and a bespoke iPad app was delivered to people living with dementia and their family carers, in their own homes. Participants (n=60) were recruited in dyads from a cognitive rehabilitation team affiliated with a large UK health care organisation. Each dyad comprised a person living with early to moderate dementia and his/her family carer. Outcome measurement data were collected at baseline, midpoint and intervention close. Results: The participants with dementia attained statistically significant increases in mutuality (p < .001), quality of carer and patient relationship (p < .001), and subjective wellbeing (p < .001) from baseline to endpoint. The carers attained non-significant increases in mutuality and quality of carer and patient relationship, and a non-significant decrease in subjective wellbeing. Conclusions: Our results show that individual specific reminiscence supported by an iPad app may have efficacy in the context of early to moderate dementia. A robust randomised controlled trial of technology enabled personalised reminiscence is warranted.

  • letter to the editor about a published article DOI: 10.2196/mhealth.8458

    From: Journal of Medical Internet Research

    Date Submitted: Dec 18, 2017

    Open Peer Review Period: Dec 23, 2017 - Feb 17, 2018

    ...

  • Health professionals’ attitudes towards and experiences with a smartphone application for women with gestational diabetes mellitus of different ethnic backgrounds in a randomised controlled trial: a qualitative study.

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 18, 2017

    Open Peer Review Period: Dec 19, 2017 - Feb 13, 2018

    Background: The increase in women with gestational diabetes mellitus (GDM) provides new challenges for health professionals. Health professionals can find it challenging to provide information about t...

    Background: The increase in women with gestational diabetes mellitus (GDM) provides new challenges for health professionals. Health professionals can find it challenging to provide information about the management of GDM to women with different ethnic backgrounds. mHealth may constitute a useful tool for blood sugar control and the care process. However, little is known about health professionals’ experiences and attitudes towards the use of mHealth for women with GDM. Objective: The aim of this study was to explore how health professionals perceived to provide care to pregnant women of different ethnic backgrounds who managed GDM with the Pregnant+ app in a Randomized Controlled Trial (RCT). Methods: Individual interviews with nine health professionals providing care for women with GDM were conducted. Analysis was guided by thematic analysis, according to Brown and Clark. Health professionals with the main responsibility for the care of participants with GDM in the Pregnant+ RCT were recruited at the five recruiting diabetes outpatient clinics (DOC) in the Oslo region, Norway. Results: Health professionals perceived mHealth, and especially the Pregnant+ app, as an appropriate tool for the care of women with GDM. Women with GDM were described as a heterogeneous, and motivated group that could be easily to reach with health-related information. Some participants reported challenges to provide advice to women with different food cultures. The advantages of the Pregnant+ app were the provision of information that women could access at home, health professionals’ trust in this information, the culture-sensitivity of the app and the convenience for women to register blood sugar levels. Technical problems, in particular automatic transfer of blood glucose measurements, were outlined as the main barrier to use the Pregnant+ app. Strict inclusion criteria and the inclusion of participants who could not speak Norwegian were the main challenges in the recruitment of the RCT. Conclusions: This study suggests that mHealth could be a useful tool to enhance health professionals care of women with GDM. Future mobile apps for the management of GDM should be developed by a trustworthy source and in cooperation with health professionals, culture-sensitive and without technical problems.

  • Truckies and Facebook: Using social media for health promotion in a ‘hard-to-reach’ group

    From: Journal of Medical Internet Research

    Date Submitted: Dec 19, 2017

    Open Peer Review Period: Dec 20, 2017 - Feb 14, 2018

    Background: Workers in the road transport industry, and particularly truck drivers, are at increased risk of chronic disease. Innovative health promotion strategies involving technologies such as soci...

    Background: Workers in the road transport industry, and particularly truck drivers, are at increased risk of chronic disease. Innovative health promotion strategies involving technologies such as social media may engage this ‘hard-to-reach’ group. There is a paucity of evidence for the efficacy of social media and related technologies for health promotion in the Australian transport industry. Objective: To use a mixed-methods framework within a Participatory Action Research approach to evaluate a social media technology health promotion intervention, the Truckin’ Healthy Facebook webpage, in selected Australian transport industry workplaces. Methods: Five workplace managers and 30 truck drivers from 6 transport industry organisations were engaged in developing workplace health promotion interventions, including a social media technology intervention. Participatory Action Research methods, including a pre and post intervention manager survey, truck driver survey, key informant semi-structured interviews, truck driver focus groups and focused observation, were used to evaluate the social media technology intervention. Questions were asked about workplace managers’ and truck drivers’ opinions, engagement and satisfaction with the intervention. Results: Workplace managers reported high rates of implementation and satisfaction with the social media technology intervention, and expressed a keen interest in learning more about social media technology and how it may be used for workplace health promotion and other purposes. Truck drivers were poorly engaged with the intervention because: 1) many believe they are the ‘wrong age’ and lack the necessary skills, 2) the cost of smart phone technology is prohibitive, 3) they confine their use of social media technology to non-work related purposes, and 4) many workplaces have ‘no Facebook’ policies Conclusions: The use of social media technology as a health promotion intervention in transport industry workplaces has potential. Much more research needs to be undertaken to better understand the effective use of social media technology to engage ‘hard-to-reach’ groups. Participatory Action Research allows interventions to be developed to fit the socio-cultural context of workplaces.

  • Correlations between objective behavioral features collected from mobile and wearable devices, and mood symptoms in affective disorders: A systematic review

    From: Journal of Medical Internet Research

    Date Submitted: Dec 19, 2017

    Open Peer Review Period: Dec 20, 2017 - Feb 14, 2018

    Background: A number of studies have recently reported on the correlation between objective behavioral features collected via mobile and wearable technologies and mood symptoms in affective disorders...

    Background: A number of studies have recently reported on the correlation between objective behavioral features collected via mobile and wearable technologies and mood symptoms in affective disorders (unipolar disorder and bipolar disorder). However, individual studies have reported on different and sometimes contradicting results and no quantitative systematic review of the correlation between objective behavioral features and mood symptoms has been published. Objective: The objectives of this systematic review were to 1) provide an overview of correlations between objective behavioral features and mood symptoms reported in the literature, and 2) investigate the strength and statistical significance of these correlations across studies. The answers to these questions could potentially help in the identification on which objective features have shown most promising results across studies. Methods: A systematic review of the scientific literature, reported according to the Preferred Reporting items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was conducted. IEEE Xplore, ACM Digital Library, Web of Sciences, PsychINFO, Pubmed, DBLP computer science bibliography, HTA, DARE, Scopus and Science Direct were searched and supplemented by hand examination of reference lists. The search was limited to studies published 2007-2017. Results: A total of 34 studies were eligible for the present review. They investigated 71 unique objective features divided into six different types covering 16 various sensor data inputs. Several objective features were found to have consistent correlation directionality with mood assessment (e.g., the amount of home stay, sleep duration, vigorous activity), while others showed directionality discrepancies across the studies (e.g., amount of SMS sent, time you spend between locations, frequency of smartphone screen activity). Conclusions: Several studies showed consistent and statistically significant correlations between objective behavioral features collected by mobile and wearable technology and mood symptoms. Hence, continuous and every-day monitoring of behavioral aspects in affective disorders could be a promising supplementary objective measure to estimate mood. However, the evidence is limited by methodological issues in individual studies and by a lack of standardization of 1) the collected objective features, 2) the mood assessment methodology, and 3) the statistical methods applied. Therefore, consistency in data collection and analysis in future studies is needed making replication studies as well as meta-analyses possible.

  • Web-based interventions for depression in individuals with diabetes: a review and discussion

    From: JMIR Diabetes

    Date Submitted: Dec 19, 2017

    Open Peer Review Period: Dec 20, 2017 - Feb 14, 2018

    Background: Depression is twice as common in people with diabetes. This comorbidity worsens the course of both pathologies. Screening and treatment of depression in patients with diabetes are highly r...

    Background: Depression is twice as common in people with diabetes. This comorbidity worsens the course of both pathologies. Screening and treatment of depression in patients with diabetes are highly recommended in clinical practice guidelines. However, depression is still both under recognized and undertreated. In response to the need to find ways to enhance reach, psychological treatments have taken advantage of the benefits of Internet and/or technological devices as delivery format, delivering interventions that require considerably less (or even none) interaction time with the therapist. These kinds of treatments hold promise for effective interventions at low costs with positive results. Objective: The aims of this review were to describe web-based interventions for depression in individuals with diabetes, and discuss the procedures and findings of these studies in the light of the evidence brought by a wider range of interventions for depression and/or diabetes. Methods: A comprehensive literature search was conducted in PsycINFO and MEDLINE electronic databases. Studies were included if they met the following selection criteria: (1) the study was published in English or Spanish language peer-reviewed journals, (2) the sample of the study was composed of individuals with diabetes, (3) the intervention targeted depression symptomatology, (4) was accessible via internet, and (5) had little to none clinician support. Results: Five research studies were identified in the review. All studies were RCTs, most studies used waitlist as control. Interventions variate in their characteristics, but most of them were clinical-assisted, had a CBT approach, used diabetes-specific topics, had a weekly modular display, used homework assignments and had some kind of adherence management strategy. These characteristics are consistent with intervention features associated with positive results in the literature. The efficacy of these studies to treat depressive symptoms supports the notion that web-based format is a suitable psychology service delivery option for diabetic individuals with depression. Conclusions: Congruently with previous research on depression treatment, web-based interventions for depression in people with diabetes have positive results. Future research should bring light to the reason why these interventions are effective and for whom, and which aspects can increase patient’s adherence. Some recommendations are: (1) to compare interventions with controls that match with nonspecific factors of the intervention (2) refine depression and diabetes distress inclusion criteria and assessment, (3) study if the need of tailoring with diabetic-specific content is associated with the presence of diabetic distress, (4) include measures of glycemic control, (5) assess other psychological outcomes, moderators, use and perception of the intervention, (6) avoid possible recruitment bias, (7) identify effective adherence management techniques and persuasive features, (8) detect which contents of the interventions are more effective, and (9) study the benefits of including peer support.

  • Developing a self-administered Decision Aid for FIT based Colorectal Cancer screening tailored to citizens with lower educational attainment: a qualitative study

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 20, 2017

    Open Peer Review Period: Dec 21, 2017 - Feb 15, 2018

    Background: Citizens with lower educational attainments take up colorectal cancer screening to a lesser degree, and more seldom read and understand conventional screening information than citizens wit...

    Background: Citizens with lower educational attainments take up colorectal cancer screening to a lesser degree, and more seldom read and understand conventional screening information than citizens with average educational attainments. The information needs of lower educational attainment citizens are diverse, however, with preferences ranging from wanting clear recommendations to seeking detailed information about screening. Decision aids have been developed supporting lower educational attainment citizens in making informed decisions about colorectal cancer screening participation, but none embracing diverse information needs. Objective: The aim of this study was to develop a self-administered decision aid for participation in FIT-based colorectal cancer screening. The decision aid should be tailored to lower educational attainment citizens and embrace diverse information needs. Methods: The decision aid was developed according to an international development framework, with specific steps for: designing, alpha testing, peer reviewing, and beta testing the decision aid. In the design phase, a prototype of the decision aid was developed based on previous studies about lower educational attainment citizens' information needs and the International Patient Decision Aid Standards (IPDAS) guidelines. Alpha testing was conducted using focus group interviews and email correspondence. Peer review was conducted using email correspondence. Both tests included both lower educational attainment citizens and healthcare professionals. The beta testing was conducted using telephone interviews with lower educational attainment citizens. Data were analyzed using thematic analysis. Results: The developed decision aid presented information in steps, allowing citizens to read as much or as little as wanted. Values clarification questions were included after each section of information and answers were summarized in a “choice-indicator” on the last page, guiding the citizens towards a decision about screening participation. Statistics were presented in both natural frequencies, absolute risk formats and graphically. The citizens easily and intuitively navigated around the final version of the decision aid, and stated that they felt encouraged to think about benefits and harms of colorectal cancer screening without being overloaded with information. They found the decision aid easy to understand and the text of suitable length. The healthcare professionals agreed with the citizens on most parts; however, concerns were raised about the length and readability of the text. Conclusions: We have developed a self-administered decision aid presenting information in steps. We involved both citizens and healthcare professionals to target the decision aid for lower educational attainment citizens. This decision aid represents a new way of communicating detailed information and may be able to enhance informed choices about colorectal cancer screening participation among lower educational attainment citizens.

  • Risk knowledge of people with relapsing-remitting multiple sclerosis – results of an international survey

    From: Journal of Medical Internet Research

    Date Submitted: Dec 23, 2017

    Open Peer Review Period: Dec 25, 2017 - Feb 19, 2018

    Background: Adequate risk knowledge of people with Multiple Sclerosis (pwMS) is a prerequisite for informed choices in medical encounters. Previous work showed that MS risk knowledge is low among pwMS...

    Background: Adequate risk knowledge of people with Multiple Sclerosis (pwMS) is a prerequisite for informed choices in medical encounters. Previous work showed that MS risk knowledge is low among pwMS and role preferences are different in Italy and Germany. Objective: We investigated the level of risk knowledge and role preferences in 8 countries and assessed putative variables associated with risk knowledge. Methods: An online-survey was performed based on the Risk knowledge questionnaire for people with relapsing-remitting MS (RIKNO 2.0), the electronic Control Preference Scale (eCPS), and other patient questionnaires. Results: Of 1939 participants from Germany, Italy, the Netherlands, Serbia, Spain and Turkey, 986 (51%) completed the RIKNO 2.0, with a mean of 41% correct answers. There were less than 50 participants in the UK and Estonia and data were not analysed. Risk knowledge differed across countries (P < .001). Variables significantly associated with higher risk knowledge were higher education (P < .001), previous experience with disease modifying drugs (P = .001), correct answer to a medical data interpretation question (P < .001), while higher fear for wheelchair dependency was negatively associated to risk knowledge (P = .001). Conclusions: MS risk knowledge was overall low and differed across participating countries. These data indicate that information is an unmet need of most pwMS. Clinical Trial: Not applicable.

  • Hot Topics and Fronts in E-health Research: A Scientometric Analysis in CiteSpace

    From: JMIR Medical Informatics

    Date Submitted: Dec 20, 2017

    Open Peer Review Period: Dec 21, 2017 - Feb 15, 2018

    Background: E-health is the use of information and communication technology to treat patients. It has many benefits like cost reduction (e.g., health delivery cost), convenience for users, and health...

    Background: E-health is the use of information and communication technology to treat patients. It has many benefits like cost reduction (e.g., health delivery cost), convenience for users, and health policy system improvement. Several literature reviews have included one part or the other of the field, but an overall review is lacking possibly due to the field’s constant evolution. An overview of E-health research is needed. Objective: To show an over view of E-health research and lay a foundation for futhers research on health IT policy. Methods: We selected the related literature on E-health downloaded from Web of Science as data source and used the visualization analysis function of CiteSpace. Literature information would be converted into precise mapping knowledge domain. Through further analysis of mappings, we explored the theoretical framework and the forefront in the field of E-health. Results: Over the past 15 years, USA, England, and Australia were the top three countries that published the largest number of papers. Researches about Internet technology, telemedicine,m-health, and healthcare lay the basis of E-health research development. Particularly, m-health, health system management, and experimental intervention have emerged and formed the new study frontier in recent 3-5 years. With the advancement of E-health projects, an increasing number of scholars have been studying the commercialization of E-health. Conclusions: We analyzed the international studies from the aspects of the references’ quantity, country, author, keywords, and co-cited references. This paper provides a reference for scholars working on this field and lays a foundation for further research on health IT policy.

  • Caregiver Involvement via Social Media can help to Prioritize Research and Resource Needs for Hirschsprung’s Disease

    From: Journal of Medical Internet Research

    Date Submitted: Jan 9, 2018

    Open Peer Review Period: Jan 10, 2018 - Mar 7, 2018

    Background: Patient and public involvement in health research is important to produce relevant and impactful results. Objective: To prioritize and summarize Hirschsprung’s Disease (HD)-related infor...

    Background: Patient and public involvement in health research is important to produce relevant and impactful results. Objective: To prioritize and summarize Hirschsprung’s Disease (HD)-related information needs among caregivers of children with HD and their pediatric surgeons through partnership with a parent-initiated social media campaign. Methods: We conducted an online survey with the two stakeholder groups to identify information needs. The caregiver survey was conducted through a global online community and the surgeon survey was distributed to members of the Canadian Association of Paediatric Surgeons (CAPS). We conducted a literature review to identify evidence on the prioritized topics. Results: Eighty-nine individuals completed the caregiver survey, and 52 pediatric surgeons completed survey distributed through CAPS. Only 20% of caregivers reported being very satisfied or satisfied with current HD-related resources. A final prioritized list of information needs included: i) bowel management, ii) nutrition and growth, iii) infection, iv) perianal irritation, v) gastrointestinal pain, vi) surgical diagnostics, and vii) surgical complications. Eighty-seven studies were included in the literature review: eight reviews, two randomized controlled trials, 74 cohort studies and three practice guidelines. Two priority issues identified by caregivers had only a single study that met inclusion criteria while one topic had none. Conclusions: With caregiver and surgeon input, we identified seven information priority areas related to HD. A review on the literature of the priorities found little evidence to support the development of high-quality guidelines. More research is necessary to meet the information needs related to HD as identified by stakeholders.

  • Using Natural Language Processing to Augment Qualitative Text Analysis

    From: Journal of Medical Internet Research

    Date Submitted: Dec 20, 2017

    Open Peer Review Period: Dec 21, 2017 - Feb 15, 2018

    Background: Qualitative research methods are increasingly being used across disciplines because of their ability to help investigators understand the perspectives of participants in their own words. H...

    Background: Qualitative research methods are increasingly being used across disciplines because of their ability to help investigators understand the perspectives of participants in their own words. However, qualitative analysis is a laborious and resource intensive process. To achieve depth, researchers are limited to smaller sample sizes when analyzing text data. One potential method to address this concern is natural language processing (NLP). Qualitative text analysis involves researchers reading data, assigning code labels, and iteratively developing findings; NLP has the potential to automate part of this process. Unfortunately, little methodological research has been done to compare automatic coding using NLP techniques and qualitative coding, which is critical to establish the viability of NLP as a useful, rigorous analysis procedure. Objective: The purpose of this article is to compare the utility of a traditional qualitative text analysis, a natural language processing analysis, and an augmented approach that combines qualitative and NLP methods. Methods: We conducted a two-arm cross-over experiment to compare qualitative and NLP approaches to analyze data generated through two text message survey questions, one about prescription drugs and one about police interactions, sent to youth aged 14-24. We randomly assigned a question to each of two experienced qualitative analysis teams for independent coding and analysis before receiving NLP results. A third team separately conducted NLP analysis of the same two questions. We conducted an analysis of our analysis to compare 1) similarity of findings derived, 2) quality of inferences generated, and 3) time spent in analysis. Results: The qualitative only analysis for the drug question (n=58) yielded four major finding while the NLP analysis yielded three findings that missed contextual elements. The qualitative and NLP augmented analysis was most comprehensive. For the police question (n=68), qualitative only analysis yielding four primary findings and NLP only analysis yielding four slightly different findings. Again, the augmented qualitative and NLP analysis was most comprehensive and produced the highest quality inferences, increasing our depth of understanding (i.e., details and frequencies). In terms of time, the NLP only approach was quicker than qualitative only for the drug (120 vs. 270 minutes) and police question (40 vs. 270 minutes). Beginning with qualitative analysis followed by the qualitative/NLP augmented analysis took longer than beginning with NLP for both the drug (450 minutes vs 240 minutes) and police question (390 minutes vs. 220 minutes). Conclusions: NLP provides both a foundation to code qualitatively more quickly and a method to validate qualitative findings. NLP methods were able to identify major themes found with traditional qualitative analysis but was not as useful at identifying nuances. Traditional qualitative text analysis added important details and context.

  • Development and feasibility of an electronic-Swallowing Intervention Package (e-SiP) to support swallowing function in patients with head and neck cancer

    From: Journal of Medical Internet Research

    Date Submitted: Jan 11, 2018

    Open Peer Review Period: Jan 11, 2018 - Mar 8, 2018

    Background: Many patients undergoing treatment for head and neck cancer (HNC) experience significant swallowing difficulties, and there is some evidence that swallowing exercises may improve outcomes,...

    Background: Many patients undergoing treatment for head and neck cancer (HNC) experience significant swallowing difficulties, and there is some evidence that swallowing exercises may improve outcomes, including quality of life. This feasibility study developed an evidence-based, practical Swallowing Intervention Package (SiP) for patients undergoing chemo-radiotherapy (CRT) for HNC. As part of the study, an electronic version of SiP (e-SiP) was concurrently developed to support patients to self-manage during treatment. This paper reports on the e-SiP component of this work. Objective: To develop and conduct preliminary evaluation of an electronic support system (e-SiP) for patients undergoing CRT for head and neck cancer. Methods: The study involved health professionals and patients who were undergoing CRT for head and neck cancer. The scoping stage of e-SiP development involved investigated the potential usefulness of e-SiP, exploring how e-SiP would look and feel and what content would be appropriate to provide. Patient and carer focus groups and a health professionals’ consensus day were used as a means of data gathering around potential e-SiP content. A repeat focus group looked at an outline version of e-SIP and informed the next stage of its development around requirements for tool. This was followed by further development and a testing stage of e-SiP involved the coding of a prototype which was then evaluated using a series of steering group meetings, semi-structured interviews with both patients and health care professionals, and analysis of e-SiP log data. Results: Feedback from focus groups and health professional interviews was very positive and it was felt e-SiP use would support and encourage patients in conducting their swallowing exercises. However, of the ten patients offered e-SIP, only two opted to use it. For these patients, aspects of the e-SIP application were considered useful, in particular the ease of keeping a diary of exercises performed. Interviews with users and non-users suggested significant barriers to its use. Most significantly the lack of flexibility of platform on which e-SiP could be accessed appeared a dominant factor in deterring e-SiP use. Conclusions: Results suggest a need for further research to be conducted around the implementation of e-SiP. This involves evaluating how e-SiP can be better integrated into usual care, and through patient training and staff engagement, can be seen as a beneficial tool to help support patients in conducting swallowing exercises.

  • Feasibility and Acceptability of a Personalized Assessment of Chronic Abdominal Pain Triggers

    From: Journal of Medical Internet Research

    Date Submitted: Dec 20, 2017

    Open Peer Review Period: Dec 21, 2017 - Feb 15, 2018

    Background: Though there is general consensus that pediatric chronic abdominal pain is likely the result of interacting biopsychosocial pathways, studies produce mixed evidence for its etiology. These...

    Background: Though there is general consensus that pediatric chronic abdominal pain is likely the result of interacting biopsychosocial pathways, studies produce mixed evidence for its etiology. These mixed results could be due to the nonstationarity of the effects over time or because there are individual differences uncaptured by current research designs. In either case, intensive longitudinal data collected from the biopsychosocial systems that dynamically influence chronic abdominal pain should add clarity. Objective: The current study aimed to determine if it was feasible and acceptable to use ecological momentary assessment (EMA) to assess biopsychosocial contributors to chronic abdominal pain with two objective sensors and a mobile application. In addition, we aimed to determine if it was possible to identify idiographic pain triggers for each patient. Methods: Participants included 30 pediatric chronic abdominal pain patients, aged 8-17, who wore a physiological monitor and accelerometer that measured sleep and physical activity and answered four surveys per day on an app over the course of a 14-day study period. Results: Results indicated that participants were 96.2% and 95.5% compliant to the wrist-worn accelerometer measuring sleep and physical activity, respectively. Participants completed 76.3% of expected surveys and were least adherent to the physiological monitor (37.9%). Additionally, it was possible to generate 24 (80%) personalized reports describing unique pain triggers for participants in the study. Conclusions: Findings support the use of EMA and longitudinal assessment to examine real-time interactions between biopsychosocial variables in this population.

  • A web-based tailored intervention to support optimal medication adherence among kidney transplant recipients: a pilot parallel-group randomized controlled trial

    From: JMIR Formative Research

    Date Submitted: Dec 21, 2017

    Open Peer Review Period: Dec 21, 2017 - Feb 15, 2018

    Background: Background: Optimal immunosuppressive medication adherence is essential to graft survival. Transplant-TAVIE is a web-based tailored intervention developed to promote this adherence. Object...

    Background: Background: Optimal immunosuppressive medication adherence is essential to graft survival. Transplant-TAVIE is a web-based tailored intervention developed to promote this adherence. Objective: Objective: To evaluate the intervention’s acceptability, feasibility and preliminary efficacy. Methods: Methods: In a pilot parallel-group randomized controlled trial, a convenience sample of 70 kidney transplant patients on immunosuppressive medication was randomly assigned either to an experimental group (Transplant-TAVIE) or to a control group (existing websites). Kidney transplant recipients had to be older than 18 years, be taking immunosuppressant medication and have access to the Internet to participate in this study. Transplant-TAVIE was composed of three interactive web-based sessions hosted by a virtual nurse. User appreciation of and exposure to intervention were documented. Medication adherence, medication self-efficacy, intake-related skills, and medication side-effects were assessed at baseline and 3 and 6 months later. ANOVAs were used to assess inter-group differences over time. Results: Results: After baseline questionnaire completion, participants were randomly assigned either to Transplant-TAVIE (n = 35) or to the websites (n = 35). Participants were transplanted, on average, since 6.8 years. Among the experimental group, users found the intervention to be acceptable (33.3% were extremely satisfied, 28.9% very satisfied, and 27.8% satisfied) and 54.3% completed the sessions of Transplant-TAVIE. At baseline and over time, both groups reported high medication adherence, high medication self-efficacy, and frequent use of skills related to medication intake. No inter-group differences emerged over time. Conclusions: Conclusions: Results support the feasibility and acceptability of Transplant-TAVIE. It could constitute an accessible adjunct in support of existing specialized services.

  • Upper Midwest Farmers and Farm Workers as Key Informants in User-Centered Occupational Health Prototype Development

    From: Journal of Medical Internet Research

    Date Submitted: Dec 22, 2017

    Open Peer Review Period: Dec 23, 2017 - Feb 17, 2018

    Background: The cost of workplace injuries and illnesses impacts significantly on overall healthcare costs and is a significant annual economic burden in the United States. Within the dangerous occupa...

    Background: The cost of workplace injuries and illnesses impacts significantly on overall healthcare costs and is a significant annual economic burden in the United States. Within the dangerous occupational sector of Agricultural, Fishing, and Forestry, injury surveillance is limited and the annual economic burden of injuries not well known. Many farm owners in the Upper Midwest have expanded operations and taken on the role of manager and employer; yet they receive little training in injury prevention, farm safety, or workers’ compensation programs and processes. Clinicians play a key role in return to work of injured and ill farmers and farm workers, though little to no formal training is offered in medical school. Objective: This project aimed to develop a prototype application designed to assist clinicians in returning to injured workers to light-duty job assignments with their current employer. Methods: Semi-structured interviews with farmers and farm workers from the Upper Midwest, coupled with English- and Spanish-speaking farm worker focus groups advised the development team from conception through an iterative design and development project. Results: A total of 35 farm workers participated in five focus groups comprising three Spanish-speaking and two English-speaking groups. The initial interviews and worker focus groups guided an iterative design and development cycle. Guidance impacted everything from workflows and button placement to output sheets that offer specific light-duty farm work recommendations for the injured worker to discuss with his/her employer. Additionally, eight farmers were interviewed in the final year of the 5-year project to further explore barriers of adoption regarding the use of mHealth (mobile health). Conclusions: Development of a complex prototype intended to impact patient care is a significant undertaking. Reinventing a paper-based process to eventually integrate with an electronic health record or a private company’s human resource system requires substantial stakeholder input from each facet including patients, employers, and clinical care teams. The prototype is available for testing, and further research is needed in the form of clinical trials to assess effectiveness of the process and the software’s impact in return-to-work of injured and ill workers. Farmers are increasingly adopting new technology from smartphone apps to autonomous, self-driving equipment capable of capturing enormous amounts of operational data. There is significant financial incentive to return injured workers to a light duty job, limiting work time loss. It is unlikely that clinicians would face barriers amongst farmers in adopting return-to-work technology. However, there is little incentive for clinicians to adopt the technology. Without seamless integration into the clinical electronic health record workflow, it is unlikely that individual physicians would consistently leverage such a system at the point-of-care. Clinical Trial: Not a clinical trial; not applicable.

  • Association between Social Media Presence and Adult and Children’s Hospitals U.S. News and World Report Reputation Score and Ranking

    From: Journal of Medical Internet Research

    Date Submitted: Dec 21, 2017

    Open Peer Review Period: Dec 21, 2017 - Feb 15, 2018

    Background: The U.S. News and World Report reputation score correlates strongly with overall rank in adult and pediatric hospital rankings. Social media affects how information is disseminated to phys...

    Background: The U.S. News and World Report reputation score correlates strongly with overall rank in adult and pediatric hospital rankings. Social media affects how information is disseminated to physicians and is used by hospitals as a marketing tool to recruit patients. It is unclear whether the reputation score for adult and children’s hospitals is affected by their social media presence. Objective: We sought to analyze the association between a hospital’s social media metrics and the U.S. News 2017-2018 Best Hospital Rankings for adult and children hospitals. Methods: A cross-sectional analysis of data from the 2017-2018 U.S. News and World Report publicly available annual rankings for adult and children hospitals was performed. Also, a cross-sectional analysis of Twitter, Facebook, and Instagram metrics of hospitals receiving at least one subspecialty ranking in U.S News was also performed. A multiple regression model was employed to analyze the correlation between social media metrics and a hospital’s total point’s (i.e. rank) and reputation score for both adult and children hospitals while controlling for bed size. Results: Number of Twitter follower’s [Adult: r = 0.796 (P < 0.001); Children: r = 0.518 (P < 0.001)] and number of tweets by an adult hospital correlation with reputation score [r = 0.516 (P < 0.001)] were found to be some of the most significant correlations when controlling for bed size. Conclusions: Multiple Twitter, Facebook and Instagram social media metrics correlated with adult and children’s hospital’s reputation score and total points (i.e. overall rank). This association may indicate that a hospital’s reputation may be influenced by its social media presence or that overall rank and high reputation score drives social media followers.

  • Using participatory design methodologies to develop a Mental Health eClinic to improve access to, and quality of, mental health care for young people.

    From: Journal of Medical Internet Research

    Date Submitted: Dec 22, 2017

    Open Peer Review Period: Dec 22, 2017 - Feb 16, 2018

    Background: The Mental Health eClinic (MHeC; including health promotion, assessment, screening, triage protocols, treatment via video conferencing, and self-directed mental health support) aims to del...

    Background: The Mental Health eClinic (MHeC; including health promotion, assessment, screening, triage protocols, treatment via video conferencing, and self-directed mental health support) aims to deliver best practice clinical services to people experiencing mental health problems by breaking down traditional barriers to care and making healthcare more personalised, accessible, affordable and available. Objective: The aim of this study was to use participatory design (PD) methodologies with end-users (young people and youth health professionals) and our research team to develop the MHeC to improve timely access to, and better quality, mental health care for young people across Australia. Methods: A research and development (R&D) cycle for the co-design and build of the MHeC included several iterative PD phases: PD workshops; knowledge translation of ideas generated during workshops to wireframes; rapid prototyping and one-on-one consultations with end-users, including assessing usability of the alpha build of the MHeC. Results: Four PD workshops with end users and our research team (n=37), four knowledge translation sessions, and one round of one-on-one end-user consultation sessions (n=6) were conducted. The iterative R&D cycle validated five main components of the MHeC for young people: home page and triage system; a comprehensive physical and mental health assessment; a detailed dashboard of results; a booking and video visit system; and, links to apps and etools recommended by youth health professionals. Conclusions: The MHeC presents a technologically-advanced and clinically-efficient system that can be adapted to suit a variety of settings in which there is an opportunity to connect with young people. This will enable many young people, and especially those currently not able or willing to connect to face-to-face services, to receive the right intervention from the right service at the right time.

  • Mobile application development for a healthy lifestyle program (mHELP) in overweight or obese multi-ethnic perinatal women using a theory-based, evidence-driven and user-centered approach

    From: Journal of Medical Internet Research

    Date Submitted: Dec 25, 2017

    Open Peer Review Period: Dec 25, 2017 - Feb 19, 2018

    Background: Mobile application (app) is becoming an increasingly ubiquitous platform for delivery of health behavior interventions among overweight and obese perinatal women. However, only a few metho...

    Background: Mobile application (app) is becoming an increasingly ubiquitous platform for delivery of health behavior interventions among overweight and obese perinatal women. However, only a few methodological guidelines on integrating theory, evidence, and qualitative research for their designs are available. Objective: This study aimed to develop a theory-based, evidence-driven, and user-centered healthy lifestyle app targeting overweight and obese multi-ethnic pregnant women. Methods: This paper illustrates how intervention development may be enriched with theoretical basis, systematic review, and qualitative study. An individual face-to-face interview was performed to incorporate the user’s involvement in the design. These interviews were audio-taped and transcribed. Thematic analysis technique was utilized for emerging themes. Results: Integrated concepts of social cognitive theory of self-regulation, self-regulation model, and strength model of self-control were selected as basis of the intervention. Evidence from our systematic review and meta-analysis provided the strongest evidence for the development of intervention. Sixteen obese or overweight pregnant women were invited to participate in a semi-structured interview. The following key themes emerged: content, platform, interactivity, format, and functionality. App is a favorable technology platform for healthy diet advice, appropriate physical exercise, and weight management because it is user-friendly and convenient. This app contains culture-specific, pregnancy-related, and credible contents, including educational, professional and peer support and self-monitoring domains. Design should include aesthetic appeal, visualized features, and interactive multimedia. Conclusions: A three-step process integrating theoretical basis, evidence from systematic review, and research finding with target users can be considered a guide for future app development. Clinical Trial: No yet

  • Delineating Mechanisms and Factors Associated with the Usability and Scalability of a Peritoneal Dialysis Virtual Care Solution

    From: Journal of Medical Internet Research

    Date Submitted: Dec 27, 2017

    Open Peer Review Period: Dec 29, 2017 - Feb 23, 2018

    Background: Early research in the area of virtual care solutions with peritoneal dialysis (PD) patients has focused on evaluating the outcomes and impact with these solutions. There has been less atte...

    Background: Early research in the area of virtual care solutions with peritoneal dialysis (PD) patients has focused on evaluating the outcomes and impact with these solutions. There has been less attention focused on understanding the mechanisms and factors associated with the usability and scalability of virtual care for chronic kidney disease (CKD) patients receiving PD at home. Objective: In this context, a study was undertaken to assess and understand the usability and scalability of a virtual care solution aimed at enhancing CKD patients’ outcomes and experiences. Methods: This study used a qualitative design with semi-structured interviews and a thematic analysis approach. Twenty-five stakeholders (six patients and three caregivers; six healthcare providers; two vendors; and eight health system decision makers) participated in this study. Results: The following three primary mechanisms emerged to influence the usability of the virtual care solution: 1) receiving hands-on training and ongoing communication from a supportive team; 2) adapting to meet user needs and embedding into workflow, and 3) being influenced by patient and caregiver characteristics. Further, two overarching recommendations were developed for considerations around scalability: 1) co-design locally, embed into the daily workflow, and deploy over time and 2) share the benefits and build the case. Conclusions: Study findings can be used by key stakeholders in their future efforts to enhance usability and scalability of virtual care solutions for chronic disease management.

  • Clients’ experiences of Internet based psychological treatments: Protocol for a meta-synthesis of qualitative studies

    From: JMIR Research Protocols

    Date Submitted: Jan 12, 2018

    Open Peer Review Period: Jan 12, 2018 - Jan 26, 2018

    Background: Given the rise of Internet based treatments (IBT´s) as an effective tool for psychological disorders, it is necessary to perform researches that examine the experience of clients with thi...

    Background: Given the rise of Internet based treatments (IBT´s) as an effective tool for psychological disorders, it is necessary to perform researches that examine the experience of clients with this type of intervention. The qualitative methodology has proved to be useful for analyzing the perceptions of the clients in terms of facilitators, barriers, acceptability, and negative effects of the IBT's. However, a lack of integration of these primary studies has hindered from applying the results in new research studies and in the clinical practice. Objective: The objective of the present paper is to describe the protocol for a metasynthesis of qualitative studies aimed at exploring the clients’ experiences that underwent an IBT. Methods: It will be used Elliot and Timulak’s meta-synthesis approach to review and synthesize qualitative studies related to the experiences in terms of perceived barriers and facilitators by clients undergoing IBT´s. For each search string, the different aspects included in the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) tool will be considered. Electronic databases (PubMed, PsycINFO and Web of Science) will be searched. Two independent reviewers will analyze the material in order to determine if eligibility criteria are fulfilled. Findings will allow creating a hierarchy of domains in terms of their relevance throughout all the primary studies. The obtained data from primary studies will be cross-analyzed by utilizing a descriptive and interpretative procedures. Findings will allow creating a hierarchy of domains in terms of their relevance throughout all the primary studies. Results: To date, the search strategy is being conducted. It is aimed to complete the study at the end of 2018. Conclusions: A conceptual framework of the barriers and facilitators perceived by the clients will be developed. Implications and recommendations for clinical practice, research and training will be suggested. In this vein, an agenda for the next generation of IBT´s upcoming years will be discussed. Clinical Trial: PROSPERO: CRD42018079894

  • Development and piloting of a highly tailored text and voice messaging intervention to support adherence to antihypertensive medications within the primary care setting

    From: Journal of Medical Internet Research

    Date Submitted: Dec 22, 2017

    Open Peer Review Period: Dec 22, 2017 - Feb 16, 2018

    Background: Tailored automated text and voice message interventions are effective ways to increase adherence to medications. Objective: This paper describes the systematic development and piloting of...

    Background: Tailored automated text and voice message interventions are effective ways to increase adherence to medications. Objective: This paper describes the systematic development and piloting of a highly tailored text and voice message intervention to increase adherence to medications within primary care. Methods: Following the MRC guidance this paper describes: a) the systematic development of the theoretical framework and tailored intervention content, based on review of theories and meta-analyses of effectiveness (n=2 meta-analyses with meta-regression); b) the systematic development of the intervention delivery mode, intervention content and implementation procedures, based on consultations with telecommunication experts (n=6 experts, including industry, academics, and university service providers), face-to-face interviews using think aloud protocols (n=19 patients and n=5 health care providers), experiential focus groups (n=12 patients), stakeholders’ consultations (n=7 stakeholders, including commissioners, health care providers, and patients), systematic reviews (n=2 reviews), and PPI input (n=100 PPI members); and c) the piloting of the intervention, based on a one-month pre-post study (n=17 patients). The mixed methods analysis combined findings from the parallel studies complementarily. The target population that informed the intervention were adults above 40 years old, with a primary diagnosis of hypertension, taking multiple medications, presumed to be non-adherent to their medications, and attending primary care settings within different areas of deprivation in the East of England. Results: Intervention development suggested the target behaviour of the intervention to be the tablets taken at a regular time of the day. It also suggested the delivery of both INA and NINA messages and their interchange during a prescription-based month, but INA messages to be less frequent than NINA messages. It also suggested that participants could be more receptive to intervention content when they initiate medication taking or they change prescription plan. Intervention piloting suggested that the intervention is acceptable and feasible. It also suggested high intervention engagement with, and fidelity of, the intervention content, which included Behaviour Change Techniques (BCTs). The final version of the intervention aims to increase adherence to daily prescribed oral medications, is delivered using text and voice messages, and includes a combination of nine BCTs (e.g., implementation intentions, information about health consequences), is highly tailored to patients’ beliefs (e.g., beliefs about medications, self-efficacy, social norms, perceived regimens complexity), and prescription plan. During the intervention, patients can select between two BCTs to maintain medication taking (e.g., habit formation or self-monitoring). Conclusions: This paper describes a theory and evidence based intervention that aims to support adherence to high blood pressure medications, as an adjunct to primary care consultations, and it is currently evaluated in a randomised controlled trial. Clinical Trial: ISRCTN10668149 DOI 10.1186/ISRCTN10668149.

  • Implementing an eHealth Technology to Address Gaps in Early Infant Diagnosis Services: A Qualitative Assessment of Kenyan Providers’ Experiences

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 3, 2018

    Open Peer Review Period: Jan 5, 2018 - Mar 2, 2018

    Background: Literature suggests that eHealth interventions can improve the efficiency and accuracy of health service delivery, improve health outcomes, and are generally well received by patients; how...

    Background: Literature suggests that eHealth interventions can improve the efficiency and accuracy of health service delivery, improve health outcomes, and are generally well received by patients; however, there is limited data on provider experiences using eHealth interventions in resource-limited settings. The HITSystem is an eHealth intervention designed to improve early infant diagnosis (EID) outcomes among HIV-exposed infants. Objective: We aimed to compare providers’ experiences with standard EID and HITSystem implementation at 6 Kenyan hospitals and 3 laboratories with the goal of highlighting the multilevel factors that may facilitate or impede the uptake of eHealth in similar settings. Methods: As part of a randomized control trial to evaluate the HITSystem, we conducted semi-structured interviews with 17 EID providers at participating intervention and control hospitals and laboratories. We used the Consolidated Framework for Implementation Research (CFIR) to guide data coding and analysis. Results: Qualitative analysis revealed salient themes falling under 11 constructs within 3 domains of the CFIR model (inner setting, outer setting, and intervention characteristics). Providers emphasized relative advantages of the HITSystem over standard EID as strong facilitators to implementation, including improved efficiency in sample tracking and patient follow up, strengthened communication networks among key stakeholders, and improved capacity to meet patient needs. These advantages were realized from an intervention that providers saw as easy to use and compatible with workflow. Supply stock outs and patient psychosocial factors (including disclosure, stigma, and poverty) provided on-going challenges to EID service provision. Furthermore, slow or sporadic access to Internet and heavy workload prevented real-time HITSystem data entry for some clinicians. Conclusions: Providers underscored the relative advantages of the HITSystem over standard EID as the primary facilitator of implementation. These results suggest that eHealth interventions can maximize implementation success by ensuring that end-users can see clear advantages of intervention use and can easily integrate it into varying workflows. Clinical Trial: clinicaltrials.gov, NCT02072603: https://clinicaltrials.gov/ct2/show/NCT02072603

  • An Exploration of Eating Disorders and Emotional States: An Infodemiological Study of Tweets Among Followers of Pro-Eating Disorder Sites

    From: JMIR Mental Health

    Date Submitted: Dec 22, 2017

    Open Peer Review Period: Dec 26, 2017 - Feb 20, 2018

    Background: Studies have shown that individuals with eating disorders (ED) often suffer from negative emotional arousal as well. Increasingly, studies have been utilizing social media as a tool to bet...

    Background: Studies have shown that individuals with eating disorders (ED) often suffer from negative emotional arousal as well. Increasingly, studies have been utilizing social media as a tool to better understanding public health issues. Objective: The aim of the study was to explore whether Twitter users who show signs of ED also show signs of negative emotional states and can be identified by their tweets. Methods: Using the Twitter API, six pro-ED Twitter accounts were identified. Twenty-percent of account followers were randomly extracted and screened for ED-related content (N=2139). Tweets from identified followers were analyzed using LIWC and MALLET to test for signs of depression. Machine learning was used to build a model to classify individuals as having an eating disorder or not based on the language used in their Tweets. Results: Twitter users with ED mentioned terms related to negative emotions, anxiety, anger, and sadness significantly more often than non-ED Twitter users; they also mentioned terms related to positive emotion less often. It was found that word clusters formed by ED users’ tweets were related to negative arousal and self-harm. It was also determined that people with eating disorders can be accurately classified using machine learning (sensitivity: 0.89, specificity: 0.94, positive predictive value: 0.94, negative predictive value: 0.88). Conclusions: Users who show signs of ED on Twitter also show signs of negative emotions on Twitter, and models induced with machine learning can accurately differentiate those with eating disorders from those without.

  • Digital Food Records: A Mixed-Methods Study to Evaluate Feasibility and Acceptability for Use in Community-Based Interventions

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 23, 2017

    Open Peer Review Period: Dec 25, 2017 - Feb 19, 2018

    Background: There is a pressing need to understand and optimize use of dietary assessment tools that can be used in community-based participatory research (CBPR) interventions. A Digital Food Record (...

    Background: There is a pressing need to understand and optimize use of dietary assessment tools that can be used in community-based participatory research (CBPR) interventions. A Digital Food Record (DFR), which uses a handheld device to capture dietary intake through text and photography, is a particularly promising mobile assessment method. Little is understood about acceptability and feasibility of DFR in CBPR, and how best to tailor dietary assessment tools to the needs of a community. Objective: To address this gap, we used a mixed methods approach to evaluate the acceptability and feasibility of DFR among church-based populations in resource-limited wards of Washington, D.C. Methods: This community-based pilot study was conducted as part of the D.C. Cardiovascular (CV) Health and Needs Assessment (NCT01927783). Participants (n=17) received a mobile device (iPod Touch) to photo-document dietary intake for a 3-day DFR using a mobile application (app), FitNinja (Vibrent Health). Acceptability of DFR was explored through thematic analysis of verbatim transcripts from a moderated focus group (n=8). Feasibility was evaluated by the percentage of participants complying with instructions (i.e., capturing both before and after meal photos for at least 2 meals/day for 3 days). Results: Qualitative themes identified were related to: 1) feasibility and acceptability of the mobile device and app, including issues in recording dietary information and difficulty with photo-documentation; 2) suggestions for additional support and training experiences; and 3) comparisons to other mobile apps. Fifteen of the 17 participants (88%) photo-documented at least one meal during the study period. Three participants (18%) fully complied with DFR instructions. Conclusions: This study demonstrates DFR as a feasible and acceptable tool in CBPR. Engaging community members in the implementation of novel assessment methods can identify barriers to their use and optimize community-based interventions. Clinical Trial: ClinicalTrials.gov NCT01927783

  • The Chinese adaptation of Smartphone Addiction Scale-Short version in Hong Kong adults: a population study

    From: Journal of Medical Internet Research

    Date Submitted: Dec 24, 2017

    Open Peer Review Period: Dec 25, 2017 - Feb 19, 2018

    Background: Problematic mobile phone use (PMPU) is an emerging but under-studied public health issue. Extremely limited is known on the pattern of PMPU at the population level. A valid and reliable me...

    Background: Problematic mobile phone use (PMPU) is an emerging but under-studied public health issue. Extremely limited is known on the pattern of PMPU at the population level. A valid and reliable measure of PMPU that permit cross-cultural comparisons is needed for further studies. Objective: To evaluate the psychometric properties of Chinese Smartphone Addiction Scale-Short version (SAS-SV) as a measure of PMPU and examined its sociodemographic and health behavior correlates in Chinese general adults in Hong Kong, where the proportion of smartphone user was the second highest globally. Methods: The psychometric properties of the Chinese SAS-SV were assessed in a territory-wide, probability-based telephone survey of 3211 Hong Kong general adults aged ≥ 18 years (mean 43.3 years, 45.3% men). The sample was randomly split into 2 subsamples for exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). One-week test-retest reliability was evaluated in a random subset of 100 subjects. SAS-SV cut-off scores of ≥ 31 for males and ≥ 33 for females were used to determine the prevalence of PMPU. Multivariable linear regression calculated the regression coefficients (b) of SAS-SV score in relation to sociodemographic factors, health behaviors and chronic disease status. Data were weighted by age, sex and education attainment distributions of the Hong Kong general population. Results: EFA revealed an unifactorial structure for the Chinese SAS-SV (92.9% variance explained), which was replicated by a CFA. Internal consistency (Cronbach’s alpha = 0.844) and one-week test-retest reliability were satisfactory (intraclass correlation = 0.76, P < .001). The prevalence of PMPU was 38.5% (95% confidence interval [CI] 36.9%-40.2%). Female sex, younger age, being married/ co-habitated or divorced/ separated (vs unmarried), and lower education level were associated with a higher SAS-SV score (all P < .05). After controlling for sociodemographic factors and mutual adjustment, higher SAS-SV scores were observed in subjects who currently smoke (vs never smoker; b = 1.48, 95% CI 0.19, 2.78), drink alcohol weekly or more (vs never drinker; b = 1.50, 95% CI 0.18, 2.83), and were physically inactive (P for trend = 0.019). Conclusions: Chinese SAS-SV is a valid and reliable psychometric for assessing PMPU, which was associated with sociodemographic and health behavioral risk factors in Hong Kong adults. Further research on the health consequences of prevalent PMPU in Chinese is warranted.

  • The Biopsychosocial-Digital Approach to Health and Disease – Call for a Paradigm Expansion

    From: Journal of Medical Internet Research

    Date Submitted: Dec 25, 2017

    Open Peer Review Period: Dec 25, 2017 - Feb 19, 2018

    Digital health is an advancing phenomenon in modern healthcare systems. Currently, numerous stakeholders in various countries are evaluating the potential benefits of digital health solutions at the i...

    Digital health is an advancing phenomenon in modern healthcare systems. Currently, numerous stakeholders in various countries are evaluating the potential benefits of digital health solutions at the individual, population, and/or organizational levels. Additionally, driving factors are being created from the customer-side of the healthcare systems to push healthcare providers, policymakers, or researchers to embrace digital health solutions. However, healthcare providers may differ in their approaches to adopting the solutions. We cannot assume that healthcare providers are trained enough to address the requirements of integration of digital health solutions into usual daily practices. From our perspective, time has come to expand the relevant paradigms under which we have been training human resources for healthcare systems. In this article, to suggest a more comprehensive paradigm, we aim to leverage the well-known biopsychosocial model of assessing health and disease, originally introduced by George L. Engel, to include a ‘digital’ component. We explain important reasons behind our call for the paradigm expansion, from ‘biopsychosocial’ to ‘biopsychosocial-digital’ approach to health and disease. To expand the dialogue on the topic, we explain the emerging implications in understanding health and disease and therefore, in training human resources for healthcare provision and research.

  • Facebook Intervention for Young Onset Melanoma Patients and their Family Members: A Pilot and Feasibility Study

    From: Journal of Medical Internet Research

    Date Submitted: Dec 26, 2017

    Open Peer Review Period: Dec 26, 2017 - Feb 20, 2018

    Background: Despite their elevated melanoma risk, young onset melanoma patients and their families engage in low rates of skin cancer surveillance and sun protection. Interventions that improve their...

    Background: Despite their elevated melanoma risk, young onset melanoma patients and their families engage in low rates of skin cancer surveillance and sun protection. Interventions that improve their skin cancer surveillance (total cutaneous exam or TCE and skin self-exam or SSE) and prevention (sun protection) practices would likely have an impact on skin cancer morbidity and mortality, but none exist. Objective: To examine the development, feasibility, and preliminary impact of a family-focused Facebook intervention to increase SSE and sun protection. Methods: Forty-eight young onset melanoma patients and 40 family members completed measures of knowledge, beliefs, and total cutaneous exam, skin self-exam, and sun protection behaviors before and one month after joining a “secret” (i.e., private) Facebook group. Intervention content consisted of daily postings about skin cancer, skin cancer risk factors, total cutaneous exams, skin self- exams, and sun protection. Results: Patient and family member participation rates differed by recruitment setting, with acceptance rates ranging from 24.6% to 39% among families recruited from a cancer center setting and 12.7% to 61.5% among families recruited from a state registry. Among the five consecutive groups conducted, engagement, as measured by comments and likes in response to postings, increased across the groups. Post-group evaluations suggested that 69% reported that they learned something new from the content and 73% reported that group helped them learn how better sun protection, skin self-exams and exams by a doctor would benefit their family (rating > 5 on a 7-point scale). Preliminary analyses indicated increases in sun protection, SSE, TCE intentions, knowledge, sun protection benefits, SSE benefits, perceived benefits to one’s family for regular skin exams and sun protection, support for family member engagement in regular sun protection and regular SSE. Conclusions: A family-focused Facebook intervention shows promise as an feasible and efficacious method to increase sun protection and skin cancer surveillance.

  • Combining Wireless technology and Behavioral Economics to Engage Patients with cardiometabolic disease (WiBEEP): A Pilot Study

    From: Journal of Medical Internet Research

    Date Submitted: Dec 26, 2017

    Open Peer Review Period: Dec 26, 2017 - Feb 20, 2018

    Background: The long-term management of cardiometabolic diseases, such as type 2 diabetes and hypertension, is complex and can be facilitated by supporting patient-directed behavioral changes. The con...

    Background: The long-term management of cardiometabolic diseases, such as type 2 diabetes and hypertension, is complex and can be facilitated by supporting patient-directed behavioral changes. The concurrent application of wireless technology and personalized text messages (PTMs) based on behavioral economics in managing cardiometabolic diseases although promising, has not been studied. Objective: The aim of this pilot study was to evaluate the feasibility and acceptability of the concurrent application of wireless home blood pressure (BP) monitoring (as an example of “automatic hovering”) and PTMs (as an example of “nudging”) targeting pharmacotherapy and lifestyle habits in patients with type 2 diabetes and/or hypertension. Methods: The Wireless technology and Behavioral Economics to Engage Patients with cardiometabolic disease (WiBEEP) study was a single-arm, open-label, 7-week long pilot study in 12 patients (age 58.5 y) with access to a mobile phone. The study took place at Tufts Medical Center (Boston, MA) between March and September 2017. All patients received PTMs; nine patients received wireless home BP monitoring. At baseline, patients completed questionnaires to learn about their health goals and to assess medication adherence; at the end of week 7, all participants completed questionnaires to evaluate the feasibility and acceptability of the intervention and assess for medication adherence. Hemoglobin A1c was ascertained from data collected during routine clinical care in 7 patients. Results: The majority of patients reported the texts messages to be easy to understand (88%), appropriate in frequency (71%) and language (88%). All patients reported BP monitoring to be useful. Mean arterial pressure was lower at the end-of-study compared to baseline (-3.4 mmHg [95% CI, -5 to -1.8]. Mean change in HbA1c was -0.31% [95% CI, -0.56 to -0.06]. Conclusions: Among patients with type 2 diabetes and/or hypertension the combination of wireless BP monitoring and lifestyle-focused text messaging was feasible and acceptable. Larger studies will determine the long-term effectiveness of such an approach.

  • Assessment of Informatics Competencies Among Nursing Students in Saudi Arabia

    From: JMIR Medical Informatics

    Date Submitted: Dec 26, 2017

    Open Peer Review Period: Dec 26, 2017 - Feb 20, 2018

    Background: In response to the increased use of computers and technology in health-care settings and the development of communication technologies, nursing educators are constantly seeking ways to imp...

    Background: In response to the increased use of computers and technology in health-care settings and the development of communication technologies, nursing educators are constantly seeking ways to improve the informatics competencies, skills, and knowledge of undergraduate nurses. Indeed, informatics competencies impact quality of care and patient safety. Objective: We assessed informatics competencies among nursing undergraduates in Saudi Arabia and provided recommendations to improve informatics training for nurses. Methods: We conducted a cross-sectional survey of 108 female fourth-year undergraduate nurses using the 30-item Self-Assessment of Nursing Informatics Competencies Likert Scale, which evaluated basic computer knowledge and skills, attitudes to clinical informatics, and wireless device skills. Data were collected between October and December 2016, and analyzed using descriptive statistics. The response rate was 100%. Most respondents (98%) were aged 20–22 years. Results: All students reported that they used the computer several times a day, and that they had more than 2 years of computer experience. They reported competencies in attitudes to clinical informatics (mean: 4.6 ± 0.71), basic computer knowledge and skills (mean: 4.4 ± 0.69), and wireless device skills (mean: 4.3 ± 0.41). They exhibited least competency in applied computer skills (mean: 4.03 ± 0.9), which include the collection, interpretation, and extraction of patient care data. Conclusions: Our results highlight the informatics competencies of undergraduate nurses, and reveal how medical technologies and informatics applications can improve their future working experience. Improving informatics competencies will lead to a better, error-free service and a safer environment for patients.

  • Effectiveness of Serious Gaming During Multidisciplinary Rehabilitation for Patients with Complex Chronic Pain or Fatigue: A Natural Quasi-experiment

    From: Journal of Medical Internet Research

    Date Submitted: Dec 27, 2017

    Open Peer Review Period: Dec 29, 2017 - Feb 23, 2018

    Background: Current evidence for the effectiveness of specialist multidisciplinary programs for burdensome chronic pain and functional somatic syndromes drive effort to improve approaches, strategies,...

    Background: Current evidence for the effectiveness of specialist multidisciplinary programs for burdensome chronic pain and functional somatic syndromes drive effort to improve approaches, strategies, and delivery modes. It is unknown to what extent and in what respect serious gaming during regular outpatient rehabilitation can contribute to health outcomes. Objective: Study objectives are: to determine the effect of additional serious gaming on 1) physical and/or emotional functioning in general, 2) particular outcome domains, and 3) patient global impressions of change, general health, and functioning; and to determine 4) dependency of serious gaming effects on adherence. Methods: A naturalistic quasi-experiment with embedded qualitative methods was conducted. Intervention group patients received an additional guided (mindfulness based) serious gaming intervention (‘LAKA’) during week 9-12 of a 16-week rehabilitation program at 2 sites of a Dutch rehabilitation clinic. Simultaneously, 119 control group patients followed the same program without serious gaming at 2 similar sites of the same clinic. Data consisted of 10 semi-structured patient interviews and routinely collected patient self-reported outcomes. First, multivariate linear mixed modeling was used to estimate a group effect on outcome change between week 8 and 16 in 4 primary outcomes simultaneously: current pain intensity, fatigue, pain catastrophizing, and psychological distress. Secondly, similar univariate linear mixed models were used to estimate effects on particular (unstandardized) outcomes. Third, secondary outcomes (i.e. global impression of change, general health, functioning, and treatment satisfaction) were compared between groups by means of independent t-tests. Fourth, subgroups by levels of adherence were established from log-data. Influences of observed confounding factors were considered throughout analyses. Results: Out of 329 eligible patients, 156 intervention group and 119 control group patients (N=275) with mostly chronic back pain and concomitant psychosocial problems participated in the study. By 119 patients, the game was played for 75% or more. First, standardized means across the 4 primary outcomes showed a significantly more favorable degree of change during the second part of treatment for the intervention group than for the control group (β=-.119, SE=.046, P=.009). Second, the intervention group showed a greater outcome change in depressive mood (b=-2.748, SE=1.072, P=.011), but not in ‘insufficiency’ or concentration problems. Third, no significant group effects on secondary outcomes were found. Fourth, adherence was generally high and invariant. Conclusions: Present findings suggest a small favorable average effect across relevant health outcomes such as depressive mood. Further research and development are required to determine when and how serious games could be applied cost-effectively in therapy, in order to increase perceptibly relevant effects on recovery and to know for which patients, and why. Clinical Trial: www.trialregister.nl NTR6020

  • A Framework for Implementation of Mobile-based Attention Bias modification intervention

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 29, 2017

    Open Peer Review Period: Dec 31, 2017 - Feb 25, 2018

    Background: While there has been developments of Internet versions of attentional bias modification paradigms, and enhancing existing paradigms with gamification elements, to our knowledge, there has...

    Background: While there has been developments of Internet versions of attentional bias modification paradigms, and enhancing existing paradigms with gamification elements, to our knowledge, there has been a few trials that has evaluated the potential of attentional bias modification by means of smartphone applications. None of these trials have shared the developmental framework. Objective: It is our aim to explain the framework underlying the design of a smartphone or M-Health version of an attentional bias paradigm that could be personalized for various addictive disorders. Methods: A multidisciplinary team of two addiction psychiatrists, a psychologist with expertise in attentional bias modification and a computer engineer, were involved in the current development. It was decided that the smartphone version of the visual probe task should approximate that of the conventional paradigm in the initial phase. In phase one, a conventional smartphone version of a visual probe task was developed. In phase two, an intelligent server algorithm was introduced to allow for variations to the conventional visual probe task, thus allowing the same task to be utilised for other disorders. Results: Both phases of the intended development were developed across a span of three months. This framework could be adopted in various attentional bias modification interventions, and the usage of this framework would potentially drive down the costs associated with development of such M-health interventions. Conclusions: It will be of value for future research to utilise the above framework and compare the efficacy of such M-health approaches with conventional web-based approaches in the delivery of attentional bias modification interventions.

  • Experiences of using web-based and mobile technologies to support self-management of type 2 diabetes: a qualitative study

    From: JMIR Diabetes

    Date Submitted: Dec 29, 2017

    Open Peer Review Period: Dec 31, 2017 - Feb 25, 2018

    Background: The prevalence of type 2 diabetes is rising, placing increasing strain on healthcare services. Web-based and mobile technologies can be an important source of information and support for p...

    Background: The prevalence of type 2 diabetes is rising, placing increasing strain on healthcare services. Web-based and mobile technologies can be an important source of information and support for people with type 2 diabetes and may go some way towards reducing complications due to mismanagement. To date, little research has been carried out to gain an insight into people’s perspectives of using such technologies in their daily management. Objective: The purpose of this study is to understand the impact of using web-based and mobile technologies to support the management of type 2 diabetes. Methods: In-depth interviews were conducted with 15 people with type 2 diabetes to explore experiences of using web-based and mobile technologies to manage their diabetes. Transcripts were analyzed using the Framework method. Results: Technology supported users to maintain individualized and tailored goals when managing their health. Seven themes were identified as important to participants when using technology to support self-management: 1) Information, 2) Understanding individual health and personal data, 3) Reaching and sustaining goals, 4) Minimizing disruption to daily life, 5) Reassurance, 6) Communicating with health professionals; and 7) Co-ordinated care. Conclusions: Patients need to be supported to manage their condition to improve well-being and prevent further diabetes related complications arising. Technologies enabled users to get an in-depth sense of how their body reacted to both lifestyle and medication factors; something much more difficult with the use of traditional ‘standardized’ information alone. It is intended that the results of this study will inform a new questionnaire designed to assess self-management in people using web-based and mobile technology to manage their health.

  • A Web-based Interactive Tool to Reduce Childhood Obesity Risk in Urban Minority Youth: Usability Testing Study

    From: JMIR Formative Research

    Date Submitted: Dec 29, 2017

    Open Peer Review Period: Jan 2, 2018 - Feb 27, 2018

    Background: Childhood obesity is a serious public health issue among minority youth in the United States. Technology-enhanced approaches can be effective for promoting healthy behavior change. Objecti...

    Background: Childhood obesity is a serious public health issue among minority youth in the United States. Technology-enhanced approaches can be effective for promoting healthy behavior change. Objective: The purpose of this study was to test the usability of prototypes of a web-based interactive tool promoting healthy dietary behaviors to reduce childhood obesity risk in urban minority youth. Methods: African-American (AA)/Black and Latino children ages 9 to 13 were recruited to participate in two rounds of usability testing. A modified think-aloud method was utilized. Self-reported surveys and field notes were collected. Sessions were audio recorded and systematically reviewed to identify usability issues and areas for improvement. Results: Twelve children, with a mean age of 10.92 ±1.16 years (33.3% female; 66.7% AA/Black) participated. Testing highlighted overall positive experiences with the web-based interactive tool, especially related to storyline, sound effects, and color schemes. Specific usability issues were classified into six themes: appearance, content, special effects, storyline, terminology and navigation. Changes to the web-based tool after Round 1 included adding a navigation guide, making clickable icons more visible, improving graphic designs and fixing programming errors. In Round 2 of testing, the specific usability issues related to the modifications decreased. Conclusions: Preliminary findings of prototypes suggest that the use of this web-based tool could be an engaging approach to promote healthy eating behaviors among minority youth. Results of testing will inform further development and finalization of the tool, which will be tested using a two-group pilot randomized study, with the goal of reducing childhood obesity risk in minority, low-income youth.

  • Evolution of a demographic, development and environmental geospatial surveillance platform in the context of a resource constrained environment: Methodological details and lessons from SOMAARTH DDESS, Palwal (India)

    From: JMIR Public Health and Surveillance

    Date Submitted: Jan 5, 2018

    Open Peer Review Period: Jan 17, 2018 - Jan 31, 2018

    Background: Inadequate administrative health data, sub-optimal public health infrastructure, rapid and unplanned urbanization,environmental degradation and poor penetration of information technology m...

    Background: Inadequate administrative health data, sub-optimal public health infrastructure, rapid and unplanned urbanization,environmental degradation and poor penetration of information technology make the tracking of health and well being of the populations within developing countries more challenging. This necessitates setting-up comprehensive surveillance platforms integrated with the information technologies that can cater to the full spectrum of the public health problems. Objective: This manuscript aims to provide methodological insights on establishing GIS integrated comprehensive surveillance platform in resource constrained rural settings. Methods: The INCLEN (International Clinical Epidemiology Network) Trust International established a comprehensive SOMAARTH Demographic, Development and Environmental Surveillance Site (DDESS) in a northern Indian rural setting. The surveillance platform evolved through adopting four major steps: 1) site preparation 2) data construction 3) data quality assurance 4) data update and maintenance system. Arc GIS 10.3 and QGIS 2.14 software were employed for geo-spatial data construction. Surveillance data architecture was built upon the geo-referenced land parcel data sets. The composition data pertaining to the land use (residential, non-residential, and vacant), water bodies, roads, railways, community trails, landmarks, water, sanitation and food environment, weather and air quality, demographic characteristics were constructed in relational manner within the surveillance platform. Results: A comprehensive surveillance platform encompassing 0.2 million population residing in 51 villages over a land mass of 251.7 sq. Km having 32,662 households and 19,260 nonresidential features (cattle shed, shops, health, education, banking, religious institutions etc.) is established. The processes adopted for subdivision of villages into sectors helped in developing geo-referenced location identification system in a setting where no postal addresses or postal codes system were in place. Also the socially and economically homogeneous community clusters (78% of 676 sectors) which usually hide within the village aggregates were disclosed. Characterization and storage of variety of data sets critical for health and epidemiology and generation of new information e.g. water, sanitation and hygiene through geo-analytics were demonstrated. Settlement pattern was compact to the extent that 80% of habitation was concentrated in 9% of the total village area. Community involvement proved helpful in the ground-truthing of the data sets for ascertaining the level of positional, temporal and attribute accuracies and identification of small habitations, missing in the official records. Conclusions: SOMAARTH experience allowed characterization and monitoring of wide range of attributes from demography, development, and environmental domains and developed geospatial inter-phase to explore and explain their dynamic relationships, associations and pathways across multiple levels i.e. individual, household, neighborhood, and village. The methodology takes care of the common challenges faced while building information system in the developing countries. However generalizability and scalability needs to be tested in other resource constrained settings as well.

  • The effectiveness of Smartphone-Application for lifestyle improvement in noncommunicable diseases: A systematic review and meta-analyses

    From: Journal of Medical Internet Research

    Date Submitted: Dec 31, 2017

    Open Peer Review Period: Dec 31, 2017 - Feb 25, 2018

    Background: Noncommunicable diseases (NCDs) accounts for 70% of all deaths a year. The four main NCDs are cardiovascular diseases, cancers, chronic pulmonary diseases and diabetes mellitus. Fifty perc...

    Background: Noncommunicable diseases (NCDs) accounts for 70% of all deaths a year. The four main NCDs are cardiovascular diseases, cancers, chronic pulmonary diseases and diabetes mellitus. Fifty percent of persons with NCD do not adhere to prescribed treatment. Especially, adherence to lifestyle interventions, is considered as a major challenge. Smartphone-applications (apps) permits structured monitoring of health parameters as well as the opportunity to receive feedback. Objective: To review and assess the effectiveness of interventions with apps, lasting at least three months, to promote lifestyle changes in patients with NCDs. Methods: In February 2017 a literature search in five databases (EMBASE, Medline, Cinahl, Academic Research Premier and Cochrane Reviews and Trials) was conducted. Inclusion criteria was quantitative study designs including randomized and non-randomized controlled trials that included patients 18 years and above with the four main NCDs. Lifestyle outcomes were physical activity, physical fitness, modification of dietary habits and quality of life. All included studies were assessed for risk of bias using the Cochrane Collaboration`s risk of bias tool. Meta-analyses were conducted for one of the outcomes (glycated hemoglobin A1c), by using the estimate of effect of mean post-treatment with standard deviation or confidence interval. Heterogeneity was tested using the I2 test. All studies included in the meta-analyses were graded. Results: Of the 1588 records examined, nine met predefines criteria. Seven studies included diabetes patients only, one study included heart patients only and another study included both diabetes and heart patients. Statistical significant effect was shown in glycated hemoglobin A1c in five of eight studies as well in body weight in one of five studies and in waist circumference in one of three studies evaluating these outcomes. Seven of the included studies were included in the meta-analyses and demonstrated significantly overall effect on glycated hemoglobin A1c on short-term (three to six months) (p = 0.02) with low heterogeneity (I2 = 41%). In the long-term (ten to twelve months), the overall effect on glycated hemoglobin A1c was statistical significant (p = 0.009) and without heterogeneity (I2 = 0%). The quality of evidence according to `Grading of Recommendations Assessment, Development and Evaluation` was low on short-term, and moderate for long-term. Conclusions: Our review demonstrated limited research of the use of smartphone-applications for other NCDs than diabetes with a follow-up of at least three months. For diabetes, the use of apps seems to improve lifestyle factors, especially to decrease glycated hemoglobin A1c. More research with long-term follow-up should be performed to assess the effect of smartphone-application for other NCDs than diabetes. Clinical Trial: The review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42017057796.

  • Mobile Health (m-Health) for Diabetes Self-Management in the Kingdom of Saudi Arabia: Clinical Challenges, Implementation Strategies and Policy Barriers

    From: Journal of Medical Internet Research

    Date Submitted: Jan 2, 2018

    Open Peer Review Period: Jan 4, 2018 - Mar 1, 2018

    Diabetes mellitus is a major chronic disease burden and healthcare challenge in the Kingdom of Saudi Arabia. The Kingdom has one of the highest diabetes prevalence levels globally. This high prevalenc...

    Diabetes mellitus is a major chronic disease burden and healthcare challenge in the Kingdom of Saudi Arabia. The Kingdom has one of the highest diabetes prevalence levels globally. This high prevalence levels in the Kingdom is compounded with increasing economic health burden resulting from the diabetes related complications and their treatment costs. The development of m-health system and implementation strategies tailored for Saudi patients and healthcare system is important and timely to alleviate some of these healthcare and economic burdens. However, these strategies face a myriad of economic, human, social and cultural barriers that hinder the progress in this important area of healthcare delivery. The Kingdom has one of highest penetration of smart phone, Internet and social networking users in the Gulf area. Yet, this popularity is not translated appropriately to tangible mobile health (m-Health) solutions for diabetes care and self management. Also, to date no relevant m-Health policy and implementation strategy or initiative exists within the different healthcare sectors within the Kingdom. The digital savvy society and patient population is well poised to embrace these digital health solutions. However, the adoption of m-Health in the Kingdom remains low and lacks the support of the decisions makers and healthcare providers. In this paper, a perspective of mobile health for diabetes self management in the Kingdom of Saudi Arabia is presented. An overview of the current status of m-Health for diabetes self management and the clinical evidence of the work in this area within the Kingdom is also presented. A small survey study to identify the implementations barriers of m-health for diabetes care in the Kingdom and the relevant solutions is also presented and discussed with future recommendations and further work in this area.

  • Implementation of a Cardiogenic Shock Team and Clinical Outcomes (INOVA- SHOCK Registry)

    From: JMIR Research Protocols

    Date Submitted: Jan 3, 2018

    Open Peer Review Period: Jan 17, 2018 - Jan 31, 2018

    Introduction: A Cardiogenic Shock initiative focused on increased disease awareness, early multidisciplinary team activation, rapid initiation of mechanical circulatory support, and hemodynamic-guided...

    Introduction: A Cardiogenic Shock initiative focused on increased disease awareness, early multidisciplinary team activation, rapid initiation of mechanical circulatory support, and hemodynamic-guided management and improvement of outcomes in cardiogenic shock. Objectives: • To collect retrospective clinical outcomes for acute decompensated heart failure cardiogenic shock and acute myocardial infarction cardiogenic shock, and compare current versus historical survival rates and clinical outcomes. • Evaluate Inova Heart and Vascular Institute (IHVI) site specific outcomes before and after initiation of the Cardiogenic Shock team on January 1, 2017. • To compare outcomes related to early implementation of mechanical circulatory support and hemodynamic-guided management versus historical controls. • Assess survival to discharge rate, and 30 day survival rate in patients receiving intervention from the designated shock team. • Create a clinical archive of Cardiogenic Shock patient characteristics for future analysis and the support of translational research studies. Methods: Retrospective and prospective data will be collected in patients cared for at IHVI with documented cardiogenic shock as a result of acute decompensated heart failure or acute myocardial infarction. This registry will include data in patients prior to and after the initiation of the multidisciplinary Cardiogenic Shock Team on January 1, 2017. Clinical outcomes associated with early multidisciplinary team intervention will be analyzed. 142 patient were identified with two readmissions. Of 140 patients 123 met inclusion criteria. The remaining patients demonstrated 63 % survival to discharge rate, exceeding the historical norms of 45- 50%. Early intervention by a multidisciplinary team improves survival and quality of life in the clinically complex cardiogenic shock population. Clinical Trials: NCT03378739

  • The Self-Assessment Kiosk: Development and implementation of an internet resource for self-assessment of mental health and health behavior

    From: JMIR Mental Health

    Date Submitted: Jan 3, 2018

    Open Peer Review Period: Jan 4, 2018 - Mar 1, 2018

    Background: Standardized measurement of aspects of physical and mental health is useful for screening and identification of health problems. Personalized feedback of the results of standardized measur...

    Background: Standardized measurement of aspects of physical and mental health is useful for screening and identification of health problems. Personalized feedback of the results of standardized measurement can additionally influence health behavior. Treatment outcomes can be improved by monitoring feedback about health status over time. However, few resources are available that (i) are free for users, (ii) provide feedback from validated scales, and (iii) measure a wide range of health domains. Objective: Our goals were (i) to develop an internet self-assessment resource that met the criteria above and would also collect data that could be used to generate and test hypotheses about health, (ii) test its feasibility as a self-assessment and research tool, and (iii) describe the characteristics of its users. Methods: The Self-Assessment Kiosk was built using previously validated health measurement instruments and implemented on a commercial internet survey platform. Data regarding its usage and the characteristics of its users was collected over 54 weeks. The rate of accrual of new users, popularity of particular measurement domains, frequency with which multiple domains were selected for measurement and characteristics of users who chose particular questionnaires were assessed. Results: Of 1,435 visits, 570 users completed at least one measure and consented to research. Growth in the number of users over time was approximately linear. Users were skewed towards old age, higher income and higher education. More than half (55.2%) reported at least one medical condition. The median number of questionnaires completed on the first visit was four. The most commonly chosen questionnaires measured depression (61%), anxiety (60%), attachment insecurity (44%) and coping (41%). Depression and anxiety scores (both mean scores and proportion above a clinical cut-off) were intermediate between previously studied populations with and without mental illness. With respect to the sample size required to study relationships between specific domains, it was found that two to three times greater participant accrual was required for a three-variable study than for a single variable study. Conclusions: The value of the Self-Assessment Kiosk to users and the feasibility of providing this resource are supported by the steady accumulation of new users over its first year of availability in response to modest marketing. Completion of multiple measurement instruments will allow the Self-Assessment Kiosk database to be interrogated to understand the relationships between health variables. Users who select particular instruments tend to have scores that are higher than found in the general population, indicating that instruments are more likely to be selected when they are salient to users. Self-selection bias limits generalizability and needs to be taken into account when using the Self-Assessment Kiosk database as a research resource. Ethical issues that were considered in developing and implementing the Self-Assessment Kiosk are also discussed.

  • Comparing the Data Quality of GPS Devices and Smartphones for Assessing Relationships between Place, Mobility, and Health: A Field Study

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 4, 2018

    Open Peer Review Period: Jan 5, 2018 - Mar 2, 2018

    Background: Mobile devices are increasingly used to collect location-based information from individuals about their physical activities, dietary intake, environmental exposures, and mental well-being....

    Background: Mobile devices are increasingly used to collect location-based information from individuals about their physical activities, dietary intake, environmental exposures, and mental well-being. Such research, which typically uses wearable devices or smartphones to track location, benefits from the growing availability of fine-grained data regarding human mobility. However, little is known about the comparative geospatial accuracy of such devices. Objective: In this study, we compared the data quality of location information collected from two mobile devices which determine location in different ways — a GPS watch and a smartphone with Google’s Location History feature enabled. Methods: Twenty-one chronically ill participants carried both devices, which generated digital traces of locations, for 28 days. A smartphone-based brief ecological momentary assessment (EMA) survey asked participants to manually report their location at four random times throughout each day. Participants also took also part in qualitative interviews and completed surveys twice during the study period in which they reviewed recent phone and watch trace data to compare the devices’ trace data to their memory of their activities on those days. Trace data from the devices were compared on the basis of: (1) missing data days; (2) reasons for missing data; (3) distance between the route data collected for matching day and the associated EMA survey locations; and (4) activity space total area and density surfaces. Results: The watch resulted in a much higher proportion of missing data days, with missing data explained by technical differences between the devices, as well as participant behaviors. The phone was significantly more accurate in detecting home locations, and marginally significantly more accurate for all types of locations combined. The watch data resulted in a smaller activity space area and more accurately recorded outdoor travel and recreation. Conclusions: The most suitable mobile device for location based health research depends on the particular study objectives. Further, data generated from mobile devices, such as GPS phone and smart watches, requires careful analysis to ensure quality and completeness. Studies that seek precise measurement of outdoor activity and travel, such as measuring outdoor physical activity or exposure to localized environmental hazards, would benefit from use of GPS devices. Conversely, studies that aim to account for time within buildings at home or work, or that document visits to particular places (such as supermarkets, medical facilities, or fast food restaurants), would benefit from the phone’s demonstrated greater precision in recording indoor activities. Clinical Trial: N/A

  • Predicting Mood Disturbance Severity with Mobile Phone Keystroke Metadata: The BiAffect Digital Phenotyping Study

    From: Journal of Medical Internet Research

    Date Submitted: Jan 4, 2018

    Open Peer Review Period: Jan 5, 2018 - Mar 2, 2018

    Background: Mood disorders are common and associated with significant morbidity and mortality. Better tools are needed for their diagnosis and treatment. Deeper phenotypic understanding of these disor...

    Background: Mood disorders are common and associated with significant morbidity and mortality. Better tools are needed for their diagnosis and treatment. Deeper phenotypic understanding of these disorders is integral to development of these tools. This study is the first effort to use passively collected, mobile phone keyboard activity to build deep digital phenotypes. Objective: To demonstrate the feasibility of using passively collected keyboard dynamic metadata to infer mood states Methods: Within subject design of eight weeks, subjects were provided a mobile phone loaded with a customized keyboard which passively collected keystroke metadata. Subjects were administered the Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS) weekly. Linear mixed-effects models were created to predict HDRS and YMRS scores (total keystrokes n= 626,641, weekly average 9,791 ± 7,861; total accelerometer readings n= 6,660,890, weekly average 104,076 ± 68,912). Results: A statistically significant mixed-effects regression model for the prediction of HDRS-17 item scores was created: conditional R²=0.63, P=0.014. A mixed-effects regression model for YMRS scores showed the variance accounted for by random effect was zero, and so a simple linear regression model was created: R²=0.34, P=0.0011. Multiple significant variables were demonstrated for each measure. Conclusions: Mood states in bipolar disorder are correlated with specific changes in mobile phone usage. The creation of these models provides evidence for the feasibility of using passively collected keyboard metadata to detect and monitor mood disturbances.

  • The Impact of Implementation of a Clinically-Integrated Problem-based Neonatal Electronic Medical Record- Documentation Metrics, Provider Satisfaction and Hospital Reimbursement. A Quality Improvement Project

    From: JMIR Medical Informatics

    Date Submitted: Jan 8, 2018

    Open Peer Review Period: Jan 10, 2018 - Mar 7, 2018

    Background: A goal of effective EMR provider documentation platforms is to provide an efficient, concise and comprehensive notation system that will effectively reflect the clinical course, including...

    Background: A goal of effective EMR provider documentation platforms is to provide an efficient, concise and comprehensive notation system that will effectively reflect the clinical course, including the diagnoses, treatments and interventions. Objective: Fully redesign and standardize the provider documentation process, seeking improvement in documentation based upon ongoing APR-DRG-based coding records, while maintaining non-inferiority comparing provider satisfaction to our existing documentation process. We estimated the fiscal impact of improved documentation based upon changes in expected hospital payments. Methods: Employing a multidisciplinary collaborative approach, we created an integrated clinical platform that captures data entry from the obstetrical suite, delivery room, NICU nursing and respiratory therapy staff. It provides the sole source for hospital provider documentation in the form of a history and physical exam, daily progress notes, and discharge summary. Health maintenance information, follow-up appointments and running contemporaneous updated hospital course information have selected shared entry and common viewing by the NICU team. Interventions: (1) Improve provider awareness of appropriate documentation through a provider education hand-out and follow-up group discussion. (2) Fully redesign and standardize the provider documentation process building from the native Epic-based software. Measures: (1) Hospital coding department review of all NICU admissions and 3M APR-DRG based calculations of Severity of illness (SOI), risk of mortality (ROM) and case mix index (CMI) scores. (2) Balancing measure: Provider time utilization case study and survey; (3) Average expected hospital payment based upon acuity-based clinical logic algorithm and Payor mix. Results: We compared Pre-intervention (October 2015-October 2016) to Post-intervention (November 2016-May 2017) time-periods and demonstrated: (1) Significant improvement in APR-DRG derived SOI, ROM, CMI: Monthly average SOI scores increased by 11.1% (p = 0.008); Monthly average ROM scores increased by 13.5% ((p = 0.007); Monthly average CMI scores increased by 7.7% (p=0.009). (2) Time study showed increased time to complete H&P and progress notes and decreased time to complete discharge summary: H&P: time allocation increased by 47% (p = 0.053); Progress Note time allocation significantly increased by 91% (p < 0.001); Discharge summary time allocation significantly decreased by 41% (p = 0.032). (3) Survey of all providers: Overall there was positive provider perception of the new documentation process based upon a survey of the provider group. (4) Significantly increased hospital average expected payments: Comparing the PRE- and POST-intervention study periods, there was a $14,020/ month/ patient increase in Average Expected Payment for hospital charges (p < 0.001). There was no difference in payer mix during this time-period. Conclusions: A problem-based NICU documentation EMR more effectively improves documentation, without dissatisfaction by the participating providers, and improves hospital estimations of APR-DRG-based revenue.

  • Expert Consensus Survey on Digital Health Tools for Patients With Serious Mental Illness: Optimizing for User Characteristics and User Support

    From: JMIR Mental Health

    Date Submitted: Jan 5, 2018

    Open Peer Review Period: Jan 5, 2018 - Mar 2, 2018

    Background: Digital technology is increasingly being used to enhance healthcare in various areas of medicine. In the area of serious mental illness (SMI), it is important to understand the special cha...

    Background: Digital technology is increasingly being used to enhance healthcare in various areas of medicine. In the area of serious mental illness (SMI), it is important to understand the special characteristics of target users that may influence motivation and competence to use digital health tools (DHTs), as well as the resources and training necessary for these patients to facilitate the use of this technology. Objective: To conduct a quantitative expert consensus survey to identify key characteristics of target users (patients and healthcare professionals [HCPs]), barriers and facilitators for appropriate use, and resources needed to optimize the use of DHTs in patients with SMI. Methods: A panel of 40 experts in digital behavioral health who met the participation criteria completed a 19-question survey rating predefined responses on a 9-point Likert scale. Consensus was determined using a chi-square test of score distributions across 3 ranges (1–3, 4–6, 7–9). Categorical ratings of first, second, or third line were designated based on the lowest category into which the confidence interval of the mean ratings fell, with a boundary >6.5 for first line. Here, we report experts’ responses to 9 questions (265 options) that focused on (1) user characteristics that would promote or hinder the use of DHTs, (2) potential benefits/motivators and barriers/unintended consequences of DHT use, and (3) support and training for patients and HCPs. Results: Among patient characteristics most likely to promote use of DHTs, experts endorsed interest in using state-of-the-art technology, availability of necessary resources, good occupational functioning, and perception of the tool as beneficial. Certain disease-associated signs and symptoms (eg, more severe symptoms, substance abuse problems, a chaotic living situation) were considered likely to make it difficult for patients to use DHTs. Enthusiasm among HCPs for DHTs and availability of staff and equipment to support their use were identified as variables to enable HCPs to successfully incorporate DHTs into their practices. The experts identified a number of potential benefits of and barriers to use of DHTs by patients and HCPs. Most experts agreed that both HCPs and patients would need to be trained in the use of these new technologies. Conclusions: These results provide guidance to the mental health field on how to optimize the development and deployment of DHTs for patients with SMI.

  • Inter-subject differences in circadian coordination captured in real time in healthy and cancerous individual persons during their daily routine using a mobile internet platform

    From: Journal of Medical Internet Research

    Date Submitted: Jan 5, 2018

    Open Peer Review Period: Jan 6, 2018 - Mar 3, 2018

    Background: Experimental and epidemiologic studies have shown that circadian clocks disruption can play an important role in the development of cancer and metabolic diseases. The cellular clocks outs...

    Background: Experimental and epidemiologic studies have shown that circadian clocks disruption can play an important role in the development of cancer and metabolic diseases. The cellular clocks outside the brain are effectively coordinated by the body temperature rhythm. We hypothesized that concurrent measurements of body temperature and rest-activity rhythms would assess circadian clocks coordination in individual patients, thus enabling the integration of biological rhythms into precision medicine. Objective: The study aimed at the real-time demonstration of large inter-subject differences in the circadian clocks of people during their daily routine, using a mobile e-Health platform. Such critical step further aimed at the integration of circadian rhythm disorders diagnosis and treatments into precision e-medicine. Methods: Non-invasive real-time measurements of rest-activity and chest temperature rhythms were recorded during the subject’s daily life, using a dedicated new mobile e-health platform (PiCADo). It involved a chest sensor that jointly measured accelerations, 3D-orientation and skin surface temperature every 1-5 min, and relayed them out to a mobile gateway via Bluetooth-Low-Energy. The gateway tele-transmitted all stored data to a server via GPRS every 24 h. The technical capabilities of PiCADo were validated in 55 healthy subjects and 12 cancer patients, whose rhythms were e-monitored during their daily routine for 3-30 days. Spectral analyses enabled to compute rhythm parameters values, with their 90% confidence limits, and their dynamics in each subject. Results: All the individuals displayed a dominant circadian rhythm in activity with maxima occurring from 12:09 to 20:25. This was not the case for the dominant temperature period, which clustered around 24 h for 51 subjects (76.1%), and around 12 h for 13 others (19.4%). Statistically significant sex- and age- related differences in circadian coordination were identified in the non-cancerous subjects, based upon the range of variations in temperature rhythm amplitudes, maxima (acrophases), and phase relations with rest-activity. The circadian acrophase of chest temperature was located at night for the majority of people, but it occurred at daytime for 26% of the non-cancerous people and 33.3% of the cancer patients, hence supporting important inter-subject differences in circadian coordination. Sex, age and cancer significantly impacted on circadian coordination. Conclusions: Complementing rest-activity with chest temperature circadian e-monitoring revealed striking inter-subject differences regarding human circadian clocks coordination and timing during daily routine. To further delineate the clinical importance of such finding, the PiCADo platform is currently applied for both the assessment of health effects resulting from atypical work schedules, and the identification of the key determinants of circadian disruption in cancer patients.

  • Universal versus conditional three-day follow-up visit for children with unclassified fever at the community level in Ethiopia: study protocol for a cluster randomized controlled non-inferiority trial

    From: JMIR Research Protocols

    Date Submitted: Jan 8, 2018

    Open Peer Review Period: Jan 10, 2018 - Jan 24, 2018

    Under World Health Organization’s (WHO) integrated Community Case Management (iCCM) strategy, febrile children seen by community health workers (CHW) without a diagnosable illness and without danger...

    Under World Health Organization’s (WHO) integrated Community Case Management (iCCM) strategy, febrile children seen by community health workers (CHW) without a diagnosable illness and without danger signs are advised to return after two days, regardless of symptom resolution. This advice might be unnecessary and place additional time and cost burdens on caregivers and CHWs. However, the safety of not following up children with unclassified fever is unknown. Through a two-arm cluster randomized controlled non-inferiority trial, the safety of conditional follow-up of unclassified fever, i.e. non-severe illness with fever, no malaria, pneumonia, diarrhea, or danger signs, compared to universal follow-up after two days will be established. The study is conducted in three districts in Southwest Ethiopia. Twenty-five health facilities were randomized to one of two intervention arms; all 144 health posts and the 282 CHWs are included. All enrolled children are followed up on day seven for re-assessment. If still sick on day seven, additional follow-up takes place on days 14 and 28. To demonstrate that there is no significant increase in the percentage of children deteriorating clinically, the sample size needed for a non-inferiority margin of 4%, a power of 80%, an alpha of 5%, and a design effect of 3, is 4284 children with unclassified fever. Main outcome is treatment failure on day seven, defined as death, hospitalization, one or more danger signs, or persistent fever. This study addresses the question whether there is any benefit to recommending universal follow-up among children seen for non-severe unclassified fever, or whether parents can be counselled to return in the event the fever persists, using a cluster randomized controlled trial design embedded in a national program. Outcomes will be relevant for policy makers and are important for the evaluation of current and future WHO guidelines for management of children with fever.

  • The user-informed development of the SPLENDID eating detection sensor

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 5, 2018

    Open Peer Review Period: Jan 6, 2018 - Mar 3, 2018

    Background: The available methods for monitoring food intake—which for a great part rely on self-report—often provide biased and incomplete data. Currently, no good technological solutions are ava...

    Background: The available methods for monitoring food intake—which for a great part rely on self-report—often provide biased and incomplete data. Currently, no good technological solutions are available. Hence, the SPLENDID eating detection sensor (i.e., an ear-worn device) was developed to enable complete and objective measurements of eating events. The technical performance of this device has been described before. To date, literature is lacking a description of how such a device is perceived and experienced by potential users. Objective: To describe how potential users perceived and experienced the SPLENDID eating detection sensor during the different stages of its development. Methods: Potential users evaluated the eating detection sensor at different stages of its development: 1) At the start twelve health professionals (e.g., dieticians or personal trainers) were interviewed and a focus group was held with five potential end-users (m/w = 0/5, age: 22±2 yrs., BMI: 22.5±1.9 kg/m2) to find out about their thoughts on the concept of the eating detection sensor. 2) The first prototypes of the eating detection sensor were tested in a laboratory setting where 23 participants (m/w = 13/10, age: 23±3 yrs., BMI: 22.6±3 kg/m2) reported their experiences. 3) The first wearable version of the eating detection sensor was tested in a semi-controlled study where 22 young, overweight adults (m/w = 3/19, age: 23±2 yrs., BMI: 28.0±2.3 kg/m) used the sensor on two days and reported their experiences. 4) The final version of the sensor was tested in a 4-week feasibility study by 20 young, overweight adults (m/w = 4/16, age: 25±2 yrs., BMI: 28.8±2.8 kg/m2) who reported their experiences. Results: Most individuals were enthusiastic about the concept across the different stages of development. It, however, was stressed multiple times that it is critical that the device is discrete and comfortable to wear for a longer period of time. The experiences of the potential users with the eating detection sensor show that some participants would like the sensor to be less noticeable, but that the device needs to be further improved on wearer comfort especially. In final study the eating detection sensor received a grade of 3.7 for wearer comfort, on a scale of 1 to 10. Moreover, experienced discomfort was the main reason for wearing the eating detection sensor less than two hours a day. The participants reported to have used the eating detection sensor on, on average, 19 out of 28 days. Conclusions: The SPLENDID eating detection sensor is a promising new device that can facilitate the collection of reliable food intake data, as shown by its technical potential, which has been described before. Potential users are enthusiastic, but in order to be successful the wearer comfort and discreteness of the device need to be improved. Clinical Trial: n.a.

  • Tobacco-Smoking, Alcohol-Drinking, and Betel-Quid Chewing Behaviors: Development and Use of a Web-Based Survey System

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 6, 2018

    Open Peer Review Period: Jan 7, 2018 - Mar 4, 2018

    Background: Tobacco smoking, alcohol drinking, and betel-quid chewing are risk behaviors with severe impacts on health. However, healthcare providers commonly have limited time to assess clients’ to...

    Background: Tobacco smoking, alcohol drinking, and betel-quid chewing are risk behaviors with severe impacts on health. However, healthcare providers commonly have limited time to assess clients’ tobacco-smoking, alcohol-drinking, and betel-quid chewing behaviors and intervene, if needed. Objective: To develop a web-based survey system and explore tobacco smoking, alcohol drinking, and betel-quid chewing behaviors. Methods: Patients and their family members/friends were recruited from gastrointestinal medical-surgical, otolaryngology, orthopedics, and rehabilitation clinics/wards at a medical center in northern Taiwan. Data for this descriptive study were extracted from a large series of research studies. The web-based survey system was built using a LAMP stack (Linux, Apache, MySQL, PHP) solution. The web survey was set up to include four questionnaires: the Chinese-version Fagerstrom Tolerance Questionnaire, the Chinese-version Alcohol Use Disorders Identification Test, the Betel Nut Dependency Scale, and a sociodemographic form with number of chronic diseases. After participants completed the survey, the system automatically calculated their score, categorized their risk level for each behavior, and immediately presented and explained their results. Results: Most patient participants (n=782) were not addicted to nicotine (70.3%), had low-risk alcohol drinking (86.7%), and were not betel-quid dependent (98.5%). Most patients’ family members and friends (n=425) were also not addicted to nicotine (80.2%), had low-risk alcohol drinking (94.4%), and were not betel-quid dependent (99.1%). Conclusions: The web-based survey was completed within 5-10 minutes, was easy to administer, and had no missing data. Healthcare providers can use this web-based survey system to save time in assessing these risk behaviors in clinical settings. Considering that these three behaviors, particularly when combined, dramatically increase the risk of esophageal cancer, suitable and convenient interventions are necessary for public health in Taiwan. Clinical Trial: N/A

  • Feasibility of Smartphones for Real-time Assessment of Adherence Behavior and Symptom Exacerbation for High Risk Youth and Adolescents with Asthma: A Pilot Study

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 10, 2018

    Open Peer Review Period: Jan 11, 2018 - Mar 8, 2018

    Background: Youth and adolescents with high-risk asthma have poor medication adherence, limited access to care, and are frequently seen in the acute care setting. Objective: Our purpose was to design...

    Background: Youth and adolescents with high-risk asthma have poor medication adherence, limited access to care, and are frequently seen in the acute care setting. Objective: Our purpose was to design and test the feasibility of using smartphone technology to assess contextual factors that may impact changes in daily adherence and identify new symptom episodes among high risk children with asthma in their home environment. Methods: Children 8-17 years with high risk asthma from two children’s hospitals were eligible for the 2-month study. An App was downloaded on participants’ phones at enrollment. Daily text reminders to complete ecological momentary assessment of asthma symptoms and other contextual factors such as emotional state through the App were sent. Bluetooth inhaler devices were used to measure inhaler use with the ability to review and manually enter data. Acceptability was assessed with surveys, key informant interviews (KII), and frequency of days with asthma data. KII data were used in an iterative design approach to identify challenges, strengths, and maximize use. Generalized linear mixed modelling was used to determine contextual factors associated with changes in daily adherence. Results: We enrolled 14 children (8-16 years; 93% of whom were African-American). Over the 2-month study period participants reported coughing (45%), wheezing (25%), chest tightness (17%), and boredom (49%). Controller medication adherence was 30% and increased significantly on days with asthma symptoms or boredom. Data were received on 89% of study days. Surveys and KIIs suggested acceptability. Challenges reported during the study included lost or damaged phones and available memory. Conclusions: Patients and families reported acceptability in using smartphones for real-time asthma monitoring. Overall medication adherence was low but increased significantly on days with reported asthma symptoms or boredom, suggesting contextual factors may be associated with a change in adherence behavior. Clinical Trial: N/A

  • Innovative approach for enhancing awareness of HIV, hepatitis B and hepatitis C in the general population: the BaroTest 2016 study protocol

    From: JMIR Research Protocols

    Date Submitted: Jan 8, 2018

    Open Peer Review Period: Jan 10, 2018 - Jan 24, 2018

    Background. Despite substantial screening for HIV, Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infections in France, a great number of infected persons remain undiagnosed. In this context, San...

    Background. Despite substantial screening for HIV, Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infections in France, a great number of infected persons remain undiagnosed. In this context, Santé publique France experimented with a new screening approach for HBV, HCV, and HIV infection, based on home self-sampling using dried blood spot (DBS) for blood collection. The objectives of the BaroTest study were to assess the acceptability and feasibility of this approach and to update the prevalence estimates of HBV, HCV, and HIV infections in the general population. Methods/design. Participants were enrolled using the 2016 Health Barometer, a national cross-sectional telephone survey based on a large representative sample of the general population aged 15 to 75 years (N=15000). Upon completion of the questionnaire, eligible persons were invited to receive a self-sampling kit delivered by standard postal mail and to return the DBS card to the laboratory. The laboratory then was responsible for reporting the results to the study participant. Acceptability of the protocol was based on the percentage of eligible individuals agreeing to receive the self-sampling kit, on the proportion of people returning the DBS card and, finally, on the proportion of participants out of the total eligible population. The feasibility of the approach was based on the number of participants with adequately filled blood spots and the number of participants with blood spots for which at least one virological analysis could be performed. A complex system of reminders was implemented to increase the participation rate. Accordingly, we assumed that 35% of eligible persons would accept and return their DBS card, representing approximately 5,000 individuals. Since the highest expected prevalence was for HBV infection, estimated at 0.65% in 2004, 5,000 persons would make it possible to estimate this prevalence with an accuracy of approximately 0.22%. All indicators can be analysed according to the characteristics of the participants collected in the Health Barometer questionnaire. Discussion. The BaroTest results will help to inform new strategies for HIV, hepatitis B and C screening and - if the study’s acceptability and feasibility results prove conclusive – will encourage the expansion of the current screening offer to include home self-sampling. BaroTest was linked to a randomised telephone survey, which uses a complex call protocol to increase the likelihood of interviewing hard-to-reach individuals and to achieve a high response rate. The Health Barometer provides a reliable updated assessment of the burden of HBV, HCV and HIV infections in the general population in France, while reducing the costs typically associated with this type of research. Trial registration. BaroTest was approved by the French Ethics Committee (05/11/2015) and the Commission on Information Technology and Liberties (24/12/2015). The study has been registered by the French medical authority under number 2015-A01252-47 on 10/11/2015.

  • Benefit of watching live visual inspection with acetic acid and Lugol on women's anxiety: a randomized controlled trial of an educational intervention conducted in a low-resource setting.

    From: Journal of Medical Internet Research

    Date Submitted: Jan 8, 2018

    Open Peer Review Period: Jan 10, 2018 - Mar 7, 2018

    Background: Women undergoing pelvic examination for cervical cancer screening can experience periprocedural anxiety. Objective: Our aim was to assess the anxiety level experienced by women undergoing...

    Background: Women undergoing pelvic examination for cervical cancer screening can experience periprocedural anxiety. Objective: Our aim was to assess the anxiety level experienced by women undergoing visual inspection with acetic acid and lugol iodine (VIA/VILI) examination, with or without watching the procedure on a digital screen. Methods: This prospective study took place at the Dschang District Hospital, Cameroon. HPV-positive women, aged 30-49 years old, were recruited in a cervical cancer screening campaign and invited to participate to the study during the 12-months follow-up control visit, including VIA/VILI examination. Before the procedure, participants were randomized with a 1:1 ratio in a control group (CG) who underwent a pelvic examination in the usual practice and were verbally informed and an intervention group (IG), where participants were verbally informed and watched the procedure live on a digital screen. Women’s anxiety was assessed before and immediately after the exam, using Spielberg’s State Anxiety Inventory (STAI). A two-sided Student t-test and Mann-Whitney Wilcoxon test were used to compare the mean STAI score for each question before and after VIA/VILI. Results: A total of 118 women were included in the study (CG: 60, IG: 58). The mean age was 39.1 (±5.2) years. The mean STAI baseline scores before the exam were similar between the two groups (CG: 33.6±10.9, IG: 36.4±11.8, P = .17). The STAI score after pelvic examination was significantly reduced for both groups (CG: 29.3±11.2, IG: 28.5±12.0). Overall, the difference of the STAI score between before and after the pelvic examination was similar for the two groups (IG: 7.9±14.3, CG: 4.2±9.0, P=.1). However, women’s emotional state, such as “I feel secure” and “I feel strained”, were improved in IG as compared to CG (P=.01). Conclusions: Watching live VIA/VILI procedure improved the emotional state but did not reduce the periprocedural anxiety. Further larger studies should assess women's satisfaction with watching their pelvic examination in real time to determine if this procedure should be include in VIA/VILI routine practice. Clinical Trial: clinicaltrials.gov, NCT02945111.

  • Comparing the effect of gain-frame and loss-frame SMS on the knowledge and practice of mothers with children less than 6 years of age in the field of children oral health: A randomized controlled trial

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 8, 2018

    Open Peer Review Period: Jan 10, 2018 - Mar 7, 2018

    Background: Along with growing number of mobile phone users, mobile health (m-Health) has provided new opportunity to communicate, educate, motivate, empower, and provide access to health services for...

    Background: Along with growing number of mobile phone users, mobile health (m-Health) has provided new opportunity to communicate, educate, motivate, empower, and provide access to health services for individuals and groups. Several studies have shown the necessity to educate mothers about their children's oral health. However, based on the available data the impact of different health message frames is differs from culture to culture. Objective: this study aimed to compare the effect of gain-frame and loss-frame SMS on knowledge and practice of mothers with children under the age of 6 in the field of children oral health. Methods: This study is a randomized controlled trial conducted in 2016 in kindergartens and preschool centers of Shiraz, Iran. Sample consisted of 240 mothers who had at least one child less than 6 years old. Random cluster sampling method was used. Data was collected before and 3 to 4 weeks after the intervention. Results: results showed that knowledge and practice scores were statistically significant after the intervention (P=0.66). Tukey test results showed a significant difference in the post-test knowledge mean scores between the control group (8.86 ± 2) with gain-frame (11.77 ± 2.16, P<0.001) and loss-framed groups (12.06±1.92, P<0.001). Moreover, there was a significant difference in the post-test practice mean scores between the control group (56.05±11.46) with gain-frame (60.69±7.77, P<0.001) and loss-frame groups (60.39±8.88, P<0.001). However, there was no significant difference between post-test scores of the gain-frame and loss-frame mean scores (P=0.69). Conclusions: Gain-frame and loss-frame SMS did not have different impacts on the knowledge and practice of mothers about children's oral health, but both improved them. Therefore, it is suggested that regardless of the text messages framing, this method should be used more in educating mothers. Clinical Trial: IRCT-2016042727647N1

  • Impact of Cross-Jurisdictional Data Exchange on the Estimating of HIV Population Living in District of Columbia

    From: JMIR Public Health and Surveillance

    Date Submitted: Jan 16, 2018

    Open Peer Review Period: Jan 17, 2018 - Jan 31, 2018

    Background: As many jurisdictions implement campaigns to end the HIV epidemic, it has become increasingly important have accurate HIV surveillance data. HIV-related laboratory data collected as part o...

    Background: As many jurisdictions implement campaigns to end the HIV epidemic, it has become increasingly important have accurate HIV surveillance data. HIV-related laboratory data collected as part of routine surveillance activities provide the foundation for characterizing local trends in disease burden. Due to strict policies around data security, HIV surveillance data has not been shared routinely between health departments. In the District of Columbia (DC) metropolitan area, which includes Maryland (MD) and Virginia (VA), it has become evident that many persons living with HIV move across the region and/or receive care outside of their residential jurisdiction. This is has made it critical that all three jurisdictions work together to routinely share data. Objective: This evaluation was designed to assess the impact of cross jurisdictional data-sharing on the quality of HIV surveillance data in the District of Columbia, specifically assessing the impact on the estimate of persons living with HIV in DC. Methods: The health departments of DC, MD and VA entered into cross-jurisdictional data sharing agreements in 2014, and regular data exchange occurred in 2017. These agreements allowed for the exchange of case information (e.g. current residential address) and laboratory information (e.g. test types, result dates and results) from the enhanced HIV/AIDS Reporting System (eHARS). Data was transferred for individuals with evidence having a residential address in a partnering jurisdiction at the time of HIV diagnosis and/or evidence of receiving HIV-related diagnostic or care services at a facility located in a partnering jurisdiction. Data received were matched to DC eHARS. Information received from associated with existing reported cases, were uploaded into eHARS. Datasets were frozen before and after the upload of exchange information. Current residential address prior to the data exchange was compared to residential address after the exchange to assess any misclassifications. This comparison served as the basis for this evaluation of the data exchange. Results: The data exchange between DC, MD and VA improved the completeness of local HIV surveillance data by reducing the number cases misclassified as DC residents. The exchange of data assisted in reducing the number of cases needing Routine Interstate De-Duplication Report (RIDR) resolution. Continued data exchanges, enhances the ability to monitor the local epidemic. Conclusions: The cross-jurisdictional HIV surveillance data exchange among DC, Maryland and Virginia improved the completeness of local HIV surveillance data by reducing the number cases misclassified as DC residents. Additionally, exchange of data benefited the DC DOH in reducing the number of cases that needed Routine Interstate De-Duplication Report (RIDR) resolution. Continued cross-jurisdictional HIV surveillance data exchanges in the DC metropolitan area may reduce the burden of RIDR resolution and enhance the ability of DC DOH to monitor progress and gaps across the HIV care continuum. Other U.S. jurisdictions may benefit from exploring the utility of similar protocols.

  • Habit App: Feasibility of a Weight Loss Problem Solving App

    From: Journal of Medical Internet Research

    Date Submitted: Jan 9, 2018

    Open Peer Review Period: Jan 10, 2018 - Mar 7, 2018

    Background: Reviews of weight loss mobile applications (“apps”) have revealed they include very few evidence-based features, relying mostly on self-monitoring. Unfortunately, adherence to self-mon...

    Background: Reviews of weight loss mobile applications (“apps”) have revealed they include very few evidence-based features, relying mostly on self-monitoring. Unfortunately, adherence to self-monitoring is often low, especially among patients with motivational challenges. One behavioral strategy that is leveraged in virtually every visit of behavioral weight loss interventions and is specifically used to deal with adherence and motivational issues is problem solving. Problem solving has been successfully implemented in depression mobile apps, but not yet in weight loss apps. Objective: The present study describes the development and feasibility testing of Habit app which was designed to automate problem solving therapy for weight loss. Methods: Two iterative single-arm pilot studies were conducted to evaluate the feasibility and acceptability of Habit app. In each pilot study, adults who were overweight or obese were enrolled in an 8-week intervention that included the Habit app plus support via a private Facebook group. Feasibility outcomes included retention, app usage, usability, and acceptability. Changes in problem solving skills and weight over 8 weeks are described, as well as app usage and weight change at 16 weeks. Results: In Pilot 1, app usage and retention were high, but acceptability and usability ratings were mixed. Findings informed updates to the app and protocol in Pilot 2. In Pilot 2, app usage, retention, and usability were high, but acceptability ratings were mixed. In both pilots, participants lost weight. In neither pilot was an effect on problem solving skills observed. Conclusions: Problem solving therapy for weight loss is feasible to implement in a mobile app environment, however automated delivery may not impact problem solving skills as has been observed previously via human delivery. Clinical Trial: Clinical Trials Registration: NCT02192905

  • Temporal associations between social activity and mood, fatigue, and pain in older adults with HIV: An ecological momentary assessment study

    From: JMIR Mental Health

    Date Submitted: Jan 9, 2018

    Open Peer Review Period: Jan 9, 2018 - Mar 6, 2018

    Background: Social isolation is associated with increased risk for mental and physical health problems. Older persons living with HIV (PLWH) are more socially isolated than their younger counterparts...

    Background: Social isolation is associated with increased risk for mental and physical health problems. Older persons living with HIV (PLWH) are more socially isolated than their younger counterparts or older persons without HIV; however, little is known about factors related to engagement in social activity among older PLWH. Objective: To examine real-time relationships among social activity, mood, fatigue, and pain in a sample of older PLWH. Methods: Twenty older PLWH, recruited from UCSD’s HIV Neurobehavioral Research Program in 2016, completed smartphone-based ecological momentary assessment (EMA) surveys five times/day for one week. Participants reported current social activity (alone vs. not alone; number of social interactions), and levels of mood (sadness, happiness, stress), fatigue, and pain. Mixed-effects regression models were used to analyze concurrent and lagged associations among social activity, mood, fatigue, and pain. Results: Participants (mean age=58.8, SD=4.3) reported being alone 63% of time on average during waking hours. Being alone was related to lower concurrent happiness (b=-0.300; p=0.008). In lagged analyses, social activity predicted higher levels of fatigue later in the day (b=-1.089; p=0.002), and higher pain levels predicted being alone in the morning with a reduced likelihood of being alone as the day progressed (b=0.945; p=0.021). Conclusions: Use of EMA elucidated a high rate of time spent alone among older PLWH. Promoting social activity despite presence of pain or fatigue may improve happiness and psychological well-being in this population.

  • Assessing the Quality of Websites Relating to Complementary and Integrative Health: A Review of Five Domains

    From: Journal of Medical Internet Research

    Date Submitted: Jan 9, 2018

    Open Peer Review Period: Jan 11, 2018 - Mar 8, 2018

    Background: In recent years, we have seen both an increase in the utilization of complementary and integrative health (CIH) care, and an increase in information-seeking behavior focused on complementa...

    Background: In recent years, we have seen both an increase in the utilization of complementary and integrative health (CIH) care, and an increase in information-seeking behavior focused on complementary and integrative health. Thus, understanding the quality of CIH information that is available on the Internet is an imperative. Though there have been a limited number of studies that have evaluated the quality of websites providing information about specific CIH-related topics, a broad evaluation of CIH websites has yet to be conducted. Objective: This study was designed to fill that gap. We set out to perform an assessment of website quality in five CIH domains: acupuncture, homeopathy, massage, reiki and yoga. Our research had three main aims: 1) to evaluate the quality of these websites; 2) to evaluate characteristics of websites which may affect readers’ perceptions of websites, specifically message content, structural features, and presentation style; and 3) to investigate the extent to which harms, benefits and purposes of use are stated on websites. Methods: This study employed a systematic search strategy to identify websites in each of the target domains to be evaluated. The websites were then classified by type, and a set of checklists focusing on quality, message content, structural features, and presentation style were used to evaluate the websites. Lastly, we performed content analysis to identify harms, benefits, and perceived purposes of use. Results: There were similarities across domains in terms of their overall quality and their message content. Across all domains, a high proportion of websites received a score of 2 on ownership, currency, interactivity and navigability. Scores were more variable with respect to authorship, balanced presentation of information and the use of sources of information. However, there were differences in terms of their structural features and presentation style. Acupuncture and reiki sites tended to include more external links, and yoga, fewer. The presence of physical locations was more common among homeopathy and massage websites. Additionally, there was variation across domains in the extent to which the websites contained domain-specific terminology. Websites tended to provide a large list of potential benefits, while reporting of harms was scarce. Conclusions: There is a need to emphasize inclusion of authorship attribution, balanced presentation of information, and source attribution in online CIH information. There is also a need to better understand how individuals may interact with CIH websites, and to develop tools to assist people to interpret the CIH-related information that they encounter.

  • Combining online and offline peer support groups in mental health care: A qualitative study of service users’ experiences

    From: JMIR Mental Health

    Date Submitted: Jan 9, 2018

    Open Peer Review Period: Jan 9, 2018 - Mar 6, 2018

    Background: Peer support groups for people with long-term mental health problems are at the heart of recovery-oriented approaches in mental health care. When conducted face-to-face (offline) or on the...

    Background: Peer support groups for people with long-term mental health problems are at the heart of recovery-oriented approaches in mental health care. When conducted face-to-face (offline) or on the Internet (online), peer support groups have proven to have differing strengths and weaknesses. Little is known about the benefits and challenges of combining the two formats. Objective: The aim of this study was to gain insights into the benefits and challenges of combining online and offline peer support groups facilitated through an Internet intervention designed to support recovery processes. Methods: In this exploratory and descriptive study, an e-recovery portal called ReConnect was used by service users in two mental health communities in Norway for 6-12 months. The portal included an online peer support forum which also facilitated participation in local in-person ReConnect-cafés. Both formats of peer support were facilitated by an employed service user consultant with lived experience of mental health problems and with training in peer support. Qualitative data about service users’ experiences of using the portal were collected through focus groups and individual interviews and inductively analyzed thematically with focus on benefits and challenges of peer support online and offline. Results: A total of 14 service users 22-63 years of age with various diagnoses, receiving services at both primary and specialist levels of mental health care participated in three focus groups and 10 individual interviews. Two main themes were identified in the analysis: 1) balancing anonymity and openness, and 2) enabling connectedness. These themes are further illustrated with the subthemes: i) dilemmas of anonymity and confidentiality, ii) towards self-disclosure and openness, iii) new friendships, and iv) networks in the local community. Three of the subthemes mainly describe benefits. Challenges were more implicit and cut across the subthemes. Identified challenges were linked to transitions from anonymity to revealing one’s identity, how to protect confidentiality, or to participation at face-to-face meetings in the local community. Conclusions: Our study suggests that online peer support groups and offline meetings complement each other, and the combination is mainly beneficial to users. The identified benefits appeared to arise from participants’ options of one format or the other, or that they could combine formats in ways that suited their individual values and comfort zones. We also identified challenges related to combination of formats, and both formats require appropriate facilitation of peer support. Combining online formats that enable anonymity, a non-judgmental atmosphere, and 24/7 accessibility regardless of location, with offline formats that foster local, in-person community ties, is a promising concept for facilitating recovery-oriented care, and warrants continued research.

  • To Use or Not to Use – a Descriptive Study of Lumbar Spine Fusion Patients’ Use of an Internet Support Group

    From: Journal of Medical Internet Research

    Date Submitted: Jan 9, 2018

    Open Peer Review Period: Jan 10, 2018 - Mar 7, 2018

    Background: Use of the Internet within a healthcare context offers possibilities, not only to provide information, but also to establish support online. Internet Support Groups (ISGs) are often used b...

    Background: Use of the Internet within a healthcare context offers possibilities, not only to provide information, but also to establish support online. Internet Support Groups (ISGs) are often used by patients with cancer or depression, offering potentials and advantages not provided by face-to-face support. Use of an ISG could be beneficial in patients undergoing lumbar spine fusion (LSF), accommodating isolation after surgery, providing a sense of social life, and contributing to the overall health-related quality of life providing peer support. However, research indicates that LSF patients are often not Internet users, as they often belong to the low-income group, have low education, and are of older age. However, knowledge of LSF patients' use of ISG is limited. Objective: This study describes and analyses the use of an ISG in Danish patients undergoing instrumented LSF due to degenerative spine disorders. Methods: A prospective, randomized controlled trial of 114 patients, half of whom were randomized to receive access to an ISG and half to a control group with no access. This study is a prospective cohort where the population comprised those patients randomized to access the ISG (n=57). Sociodemographic characteristics (gender, age, marital status, employment status, and level of education) and information on psychological wellbeing (symptom of anxiety and depression) were obtained at baseline, 1-5 weeks prior to surgery, and the use of the ISG was registered from baseline until 3 months after surgery. Results: Eight participants were excluded. Thus, 49 participants comprised the study population, with a mean age of 53 years (range 29-77), 57% female, 84% not living alone, 70% unemployed, and the majority (69%) had secondary education as their highest education. Approximately one-third of the participants had symptoms of depression (33%), and one-third had symptoms of anxiety (31%), half of these overlapped, having both anxiety and depression. A total of 43 of the 49 participants (88%) took the opportunity to access the ISG. We found no correlations between sociodemographic data and the degree to which participants accessed the ISG. Women were more prone to be active users (P=0.04) and more often contributed with posts to the ISG. Finally, participants who were active users and contributed with posts or comments had more interactions (P<0.001) and pageviews (P<0.001). Conclusions: Sociodemographic characteristics were not predictors of ISG use in this study. However, accessibility, the ability to try using the ISG, perceived usefulness of the ISG, and motivation seem to be important facilitators of the use of an ISG website. In addition, we found that women were more prone to be active users of the ISG. Clinical Trial: Data management and security were approved by the Danish Data protection agency (J.no. 2014-41-3583) and the trial was registered at Clinical Trials.gov (record NCT02615483).

  • Expert Consensus Survey on Digital Health Tools: Optimizing Design Features for Patients With Serious Mental Illness

    From: JMIR Mental Health

    Date Submitted: Jan 9, 2018

    Open Peer Review Period: Jan 18, 2018 - Mar 15, 2018

    Background: Digital health tools (DHTs) are increasingly being used to enhance healthcare. However, developing a DHT for patients with serious mental illness (SMI) poses unique challenges, given certa...

    Background: Digital health tools (DHTs) are increasingly being used to enhance healthcare. However, developing a DHT for patients with serious mental illness (SMI) poses unique challenges, given certain disease characteristics associated with this population. Currently, there are no standardized guidelines for designing DHTs for patients with SMI. Objective: To assess expert opinion on (1) product features that support patient initial/sustained engagement in using a DHT, (2) mitigation of patient characteristics that can interfere with product engagement and outcomes, and (3) incorporation of goal setting and rewards/reinforcement into DHTs. Methods: The survey followed the expert consensus methodology. A panel of selected experts completed a 19-question survey and rated predefined responses on a 9-point Likert scale. A chi-square test of score distribution across 3 ranges of values (1–3, 4–6, 7–9) was used to determine the presence of consensus. CIs of the mean ratings were used to designate first-, second-, or third-line categorical ratings, with a lower limit boundary >6.5 for first-line rating. Results of questions pertaining to product features and patient engagement are reported here. Results: The experts strongly agreed that ease of use was the most valuable feature for promoting initial engagement with DHTs (mean [SD] rating, 8.7 [0.5]). For sustained engagement, the experts strongly endorsed both ease of use and ease of incorporating the DHT into the fabric of the patient’s life. To mitigate predefined patient characteristics that can interfere with product engagement and outcomes, the experts consistently recommended an intuitive user interface. Additional recommendations were made on a number of design element considerations such as short, simple, and few tasks; limited inclusion of jargon; and use of visualization. The experts emphasized the need to test the DHTs in the intended user population and to provide in-person training. Integrating goal setting into the design of a DHT was considered feasible by 71% of the experts. For effective engagement with DHTs, individualization of goals and rewards was deemed important. Conclusions: For optimal use of DHTs by individuals with SMI, it is imperative to tailor the design elements to the unique needs of this population. In this study, the experts provided recommendations on several design features of DHTs that would be useful in promoting patient engagement. The experts also identified strategies to mitigate negative effects that can result from illness-related and other contextual characteristics. These expert panel recommendations can guide future development of DHTs for persons with psychiatric illness.

  • What Theoretical Domains Framework Elements do Parents want in a Pediatric Health Behavior App?: A Crowdsourced Social Validity Study

    From: Journal of Medical Internet Research

    Date Submitted: Jan 9, 2018

    Open Peer Review Period: Jan 10, 2018 - Mar 7, 2018

    Background: Background: Most pediatric studies do not include parent stakeholders in the design of the intervention itself and many pediatric mobile health interventions are not meaningfully dissemina...

    Background: Background: Most pediatric studies do not include parent stakeholders in the design of the intervention itself and many pediatric mobile health interventions are not meaningfully disseminated after the trial period ends. As a consequence, the consumer desire for mobile apps targeting pediatric health behavior is likely to be met by commercial products that are not theory or evidence based and may not take stakeholder preferences into account. Objective: Objective: To assess parent preference for mobile app features that map onto specific Theoretical Domains Framework (TDF) elements. Methods: Methods: The current study is a crowdsourced social validity study of 183 parents who were asked to rate their preferences for mobile app features that correspond to elements of the TDF. The TDF organizes a large number of theoretical models and constructs into into three components: 1) capability, 2) motivation, and, 3) opportunity. Parents of children were recruited through Amazon Mechanical Turk. Results: Results: The majority of participants were Android smartphone users, Caucasian, and approximately 37 years old. Results revealed broad acceptability of communication, motivation, and opportunity domains. However, the degree to which each domain was valued varied within behavioral category. Parents demonstrated a preference for increasing procedural knowledge for physical activity and diet behaviors over sleep (F (2,545) = 5.18, p = 0.006). Similarly, parents valued self-monitoring as more important for physical activity than sleep (F (2, 546) = 4.04, p = 0.018). When asked about the value of features to help children develop skills; parents preferred those features for dietary behavior over sleep (F (2, 546) = 3.57, p = .029). Parents perceived that goal-setting features would be most useful for physical activity over sleep and diet (F (2, 545) = 5.30, p = .005). Incentive features within the app were seen as most useful for physical activity over sleep (F (2, 546) = 4.34, p = 0.014). Conclusions: Conclusions: The current study presents a low-cost strategy for involving a large number of stakeholders in the discussion of how health behavior theory should be applied in a mobile health intervention. Our approach is innovative in that it took a scientific framework (i.e., TDF) and made it digestible to parents so that they could then provide their opinions about features that might appear in a future app. Our survey items discriminated between various health behaviors allowing stakeholders to communicate the different health behaviors that they would like a TDF feature to change. Moreover, we were able to develop a set of consumer opinions about features that were directly linked to elements of the TDF.

  • A Systematic Literature Review of Shared Decision Making in Cancer Care

    From: Journal of Participatory Medicine

    Date Submitted: Jan 9, 2018

    Open Peer Review Period: Jan 10, 2018 - Mar 7, 2018

    Background: Shared decision making (SDM) is a process in which health care providers and patients relate to and influence each other as they collaborate in making decisions about patients’ health ca...

    Background: Shared decision making (SDM) is a process in which health care providers and patients relate to and influence each other as they collaborate in making decisions about patients’ health care. Hypothesized as a means to improve quality of care, successful applications of SDM in routine cancer care have not been widely documented. Objective: The objective of this study was to examine the literature to determine if elements of SDM implementation between cancer patients and their clinicians were more or less successful at improving the quality of care and health outcomes. Methods: A systematic literature search of SDM approaches and outcomes in cancer care was conducted using PubMed and EMBASE. An integrative model for SDM was used to classify elements included in SDM intervention studies and the resulting outcomes. Results: From 1,018 unique publications, 23 articles meeting eligibility criteria were included. Only three studies addressed elements of patient-clinician interaction as part of the study objectives. Interventions included decision aid (DA) evaluation (n=22) and clinician communication training (n=1). SDM elements commonly included were: defining/explaining the problem (n=23); presenting options (n=19); discussing pros and cons (n=17); assessing patient priorities and preferences (n=17); clinician knowledge and recommendations (n=15); and making or deferring treatment decisions (n=12). The most frequently-measured outcomes were patient-reported outcomes including treatment preference or decision (n=12), decisional conflict (n=10), patient satisfaction (n=10), patient participation (n=9), and patient knowledge (n=7). No clear patterns demonstrating relationships between SDM elements and outcomes were identified. Information on how patients and clinicians utilized DA information to promote SDM was limited. Conclusions: Evaluation of SDM in cancer care has been increasing. However, the term “SDM” was generally applied to studies that focused on the development and/or evaluation of DAs which limited the current analyses to a review of SDM elements as part of the DAs. Most studies did not include a qualitative or quantitative measure of SDM specific to patient-clinician communication and interaction. Instead, there was an underlying assumption that SDM occurred organically with DA implementation. Without a qualitative or quantitative measure of SDM, identification of successful SDM elements and their relationships to patient outcomes remains unclear. Additional research is warranted on SDM implementation and measurement in real-world cancer care settings.

  • Sustaining an Online Learning Community for Internal Medicine Sub-interns Across Sites via an Enterprise Microblogging Platform

    From: JMIR Medical Education

    Date Submitted: Jan 11, 2018

    Open Peer Review Period: Jan 12, 2018 - Mar 9, 2018

    Background: Although the Clerkship Directors in Internal Medicine (CDIM) has created a core subinternship curriculum, the traditional experiential subinternship may not expose students to all topics....

    Background: Although the Clerkship Directors in Internal Medicine (CDIM) has created a core subinternship curriculum, the traditional experiential subinternship may not expose students to all topics. Furthermore, academic institutions often use multiple clinical training sites for the student clerkship experience. Objective: We aimed to sustain an online learning community across geographically disparate sites via enterprise microblogging to increase subintern exposure to CDIM’s curriculum. Methods: Internal medicine sub-interns utilized Yammer®, a HIPAA-secure enterprise microblogging platform, to post questions, images, and index conversations for searching. Sub-interns were required to submit 4 posts and participate in 4 discussions during their rotation. Faculty reinforced key points, answered questions, and monitored HIPAA compliance. Results: Fifty-six medical students rotated on an internal medicine subinternship from July 2014-June 2016. Eighty-four percent of the students returned the post-rotation survey. Over the first 3 months, 100% of CDIM curriculum topics were covered. Compared to the pilot year, the scale-up year demonstrated a significant increase in number of students with >10 posts (scale-up 49% versus pilot year 19%; p=.03) and perceived educational experience (58% scale-up versus 14% pilot year; p=.006). Very few students (6%) noted privacy concerns, but fewer students in the scale-up year found Yammer® a safe learning environment. Conclusions: Supplementing the sub-internship clinical experience with an enterprise microblogging platform increased sub-internship exposure to required curricular topics and was well-received. Future work should address concerns of safe learning environment.

  • Patient testing of a mobile health app and review of educational materials designed for gout patient self-management

    From: Journal of Medical Internet Research

    Date Submitted: Jan 9, 2018

    Open Peer Review Period: Jan 11, 2018 - Mar 8, 2018

    Background: Gout is a form of chronic arthritis caused by elevated serum uric acid (SUA) and culminates in painful gout attacks. Effective uric acid-lowering therapies exist, however adherence is low....

    Background: Gout is a form of chronic arthritis caused by elevated serum uric acid (SUA) and culminates in painful gout attacks. Effective uric acid-lowering therapies exist, however adherence is low. This is partly due to the lack of support for patients to self-manage their disease. Mobile health applications (apps) have been used in self-management of chronic conditions. However, not all are developed with patients, limiting their effectiveness. Objective: This study aimed to design an effective gout self-management app by collecting feedback from gout patients. Methods: Two mixed-methods studies were conducted. In Study 1, researchers developed a short educational video and written materials about gout management, designed to be embedded into an app. Six interviews and one focus group were held with gout patients to gather feedback on these materials. Usability testing in Study 2 involved additional gout patients using a pilot version of Healthy.me Gout, a gout self-management app, for two weeks. Following the trial, patients participated in an interview about their experiences using the app. Results: Patients viewed the gout educational material positively, appreciating the combined use of video, text and images. Patients were receptive to using a mobile app to self-manage their gout. Feedback about Healthy.me Gout was generally positive, with patients reporting that the tracking and diary features were most useful. Patients also provided suggestions for improving the app and educational materials. Conclusions: These studies involved patients in the development of a gout self-management app. Patients provided insight to improve the app’s presentation and usability, and general lessons on useful features for chronic disease apps. Gout patients enjoyed tracking their SUA concentrations and gout attack triggers. These capabilities can be translated to self-management apps for chronic diseases that require monitoring of pathological values, medication adherence and/or symptoms. Future health app design should integrate patient input and be developed iteratively to address concerns identified by patients.

  • A systematic review of telemedicine utilization in caregivers of cancer patients

    From: Journal of Medical Internet Research

    Date Submitted: Jan 10, 2018

    Open Peer Review Period: Jan 13, 2018 - Mar 10, 2018

    Background: Recent decades have seen a growing number of published studies and systematic reviews examining different telehealth interventions targeting patients and their effects on patients’ wellb...

    Background: Recent decades have seen a growing number of published studies and systematic reviews examining different telehealth interventions targeting patients and their effects on patients’ wellbeing and quality of life. However, there is a less definite picture on telemedicine tools aimed at the family members and caregivers of adult cancer patients. Objective: This systematic review aims to provide a more complete framework regarding carers’ telemedicine tools implemented in all phases of cancer care, to identify what are the main considered outcomes, to analyse the role of telehealth and the usability and feasibility trends in supporting the patient’s carers. Methods: A literature search was systematically conducted in the following databases: Web of Science, Cochrane Library, PubMed, Scopus, CINAHL, Embase, Google Scholar, and Ovid PsychINFO. Inclusion criteria were the use of English language, publication on peer-reviewed journals, the description of a telehealth implemented intervention, the focus on caregivers of adult cancer patients at any stage of the disease. The study selection was conducted up to November 2017. Included papers were critically appraised using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and quality of evidence was graded by outcome using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) system. Results: Twenty-four studies were included in the final selection. In 21 out of 24 studies the patient-caregiver dyad was analysed, and the study population dealt with different types of cancer at different stages. Included studies considered the caregiver’s condition both from an individual and a relational point of view. Along with psychosocial variables, some papers monitored engagement and user satisfaction regarding web-based platforms or telehealth interventions. All studies reported significant improvements in some of the investigated areas, but they often showed small effect sizes. Different telehealth intervention formats were adopted: web-based platform, and telephone calls. Some of the included studies referred to the same project, but on samples with different cancer diagnoses or with new versions of already-developed interventions. Conclusions: Reported outcomes seem to suggest that we are in an exploratory phase. There is still a need of more detailed and targeted research hypotheses. Clarifying caregiver’s needs related to telehealth tools and better defining outcome measures may allow to obtain more significant results.

  • Confocal laser endomicroscopy and optical coherence tomography for the diagnosis of prostate cancer: a needle-based, in vivo feasibility study protocol (IDEAL phase 2A)

    From: JMIR Research Protocols

    Date Submitted: Jan 10, 2018

    Open Peer Review Period: Jan 11, 2018 - Jan 25, 2018

    Background: Focal therapy for prostate cancer (PCa) has been proposed as an alternative treatment to whole-gland therapies in selected men to diminish side effects in localized prostate cancer. Since...

    Background: Focal therapy for prostate cancer (PCa) has been proposed as an alternative treatment to whole-gland therapies in selected men to diminish side effects in localized prostate cancer. Since existing PCa imaging cannot offer complete PCa disease characterization, multi-core systematic biopsies are recommended (transrectal or transperineal). Optical imaging techniques such as confocal laser endomicroscopy (CLE) and optical coherence tomography (OCT) allow in-vivo, high-resolution imaging, and can provide real-time visualization and analysis of tissue and have the potential to offer additive diagnostic information. Objective: This study has two seperate primary objectives. The first is to assess the technical feasibility and safety of in-vivo focal imaging with CLE and OCT. The second is to identify and define characteristics of PCa and normal prostate tissue in CLE and OCT imaging by comparing these images with the corresponding histopathology. Methods: In this prospective, in vivo feasibility study, needle-based CLE and OCT imaging will be performed prior to biopsy or surgery in patients before undergoing TTMB or radical prostatectomy. First, CLE and OCT will be performed in 4 patients (2 for each imaging modality) undergoing TTMB to assess the feasibility and safety of CLE and OCT. If proven to be safe and feasible, CLE and OCT will be performed in 10 patients (5 for each imaging modality) undergoing radical prostatectomy. CLE and OCT images will be analyzed by independent, blinded observers. CLE and OCT-based qualitative and quantitative characteristics and histopathology will be compared. The study complies with the IDEAL stage 2a recommendations. Results: At present the study is enrolling patients, results and outcomes are expected at the end of 2018. Conclusions: CLE and OCT are promising optical imaging techniques that can visualize and analyze tissue structure, grade, and architecture real-time. It can potentially provide real-time, high-resolution microscopic imaging and tissue characteristics of PCa in conjunction with MRI/TRUS fusion-guided biopsy procedures. This study will provide insight into the feasibility and tissue-specific characteristics of CLE and OCT for real-time optical analysis of PCa. Clinical Trial: The study protocol for Focal Prostate Imaging is registered in the Dutch Central Committee on Research Involving Human Subjects with the number NL57326.018.17 on July 7th, 2017, and on Clinicaltrials.gov as registration number NCT03253458 on August 18th, 2017.

  • The sky’s the limit: A longitudinal study on how Facebook improves the psychological well-being of individuals experiencing homelessness

    From: Journal of Medical Internet Research

    Date Submitted: Jan 10, 2018

    Open Peer Review Period: Jan 13, 2018 - Mar 10, 2018

    Background: Background: Online social networks are a powerful communicative element whose use is increasingly widespread. Persons in a extreme social exclusion like persons experiencing homelessness (...

    Background: Background: Online social networks are a powerful communicative element whose use is increasingly widespread. Persons in a extreme social exclusion like persons experiencing homelessness (IEH) can be beneficiated of the positive elements of communication and relationship associated with social network sites. Objective: Objective: This study suggests the comparison of a Facebook training course and an office software course and their effect on psychological well being in a group of IEH. Methods: Methods: Experimental and longitudinal study was designed. A sample of IEH were assigned to the Facebook group or the office software group randomly and their social skills, Self-Esteem, Self-Efficacy and Life Satisfaction were measured on four occasions: pre test, at the end of the training course, one month later and three months later. A mixed ANOVA of repeated measures (2x4) was performed. Results: Results: A total of 92 IEH participated in the study. The number of cases in which the 4 observations were completed was 71 (35 in the intervention group and 36 in the control group). The mixed ANOVA of repeated-measures and the multiple regression analysis indicated a significant increase of the four analyzed parameters, more significant in social skills and Self-Esteem. The critical level associated to the interaction Time*Program were significant in all variables and levels. Therefore, the scores in the 4 analyzed constructs were not equal according to the program carried out throughout the work. The effect size associated to the interaction Time*Program in the scores of social skills was large (Eta2 = .32), in the self-esteem and selt-efficacy scores it was medium, (Eta2 = .13) and in satisfaction with life scores it was small (Eta2 = .09). The results of the adjustment of the different models of multiple linear regression indicate that the number of hours devoted weekly to the use of Facebook was a predictor of the increase in the scores of social skills (B = 3.43, r2 = .405) and self-esteem (B = .382). Age (B = .175) and self-efficacy (B = .09) were also variables which with independence and in equal conditions predicted the self-esteem (r2 = .29). Finally, self-esteem (B = .69) was also a predictor variable of the increase of satisfaction with life (r2 = .195). Conclusions: Conclusion: These findings suggest that Facebook could be a key element in homeless psychological wellbeing and socialization.

  • Smartphone and wearable sensors based m-Health approach for mental disorders – a systematic review and link to m-RESIST project

    From: JMIR Mental Health

    Date Submitted: Jan 11, 2018

    Open Peer Review Period: Jan 18, 2018 - Mar 15, 2018

    The rapid growth in smart sensors integration in mobile phones and wearable devices may impact on mental care integrating subjective investigation based o questionnaires, interviews and diaries with a...

    The rapid growth in smart sensors integration in mobile phones and wearable devices may impact on mental care integrating subjective investigation based o questionnaires, interviews and diaries with a continuous monitoring of the behaviour through motor activity analysis and smartphone usage description. m-RESIST (Mobile Therapeutic Attention for Patients with Treatment Resistant Schizophrenia) is an EU H2020 funded project aimed at designing and validating an innovative therapeutic programme for treatment-resistant schizophrenia exploiting information from smartphone and wearable sensors for behavioural tracking to support intervention administration. In the frame of m-RESIST research, this article reviews ongoing research trends on the integration of smartphone and wearable sensors data in therapeutic programs for persons with psychiatric symptoms or disorders. The systematic literature search, performed through Scopus and PubMed databases with a predefined set of relevant keywords, located 46 studies on the topic in the time frame between 1st September 2009 and 30th November 2017. Several studies investigated bipolar disorders and depression, depression symptoms, stress and symptoms of stress while only few addressed persons with schizophrenia. In most of these studies, the data from sensors associate with psychiatric status or with psychiatric symptoms. The usability in clinical practice needs to be scrutinized more thoroughly, m-RESIST is carrying on a multi centred trial with patients to assess acceptance and compliance issues.

  • Examining the Impact of Trauma-Informed Cognitive Behavioral Therapy on Perinatal Mental Health Outcomes Among Survivors of Intimate Partner Violence: The PATH Study Design

    From: JMIR Research Protocols

    Date Submitted: Jan 12, 2018

    Open Peer Review Period: Jan 14, 2018 - Jan 28, 2018

    Background: Intimate partner violence (IPV) is a pervasive public health problem, impacting the health and quality of life of survivors worldwide. The trauma of IPV is associated with a high incidenc...

    Background: Intimate partner violence (IPV) is a pervasive public health problem, impacting the health and quality of life of survivors worldwide. The trauma of IPV is associated with a high incidence of mental illness, namely depressive and anxiety disorders, as well as post-traumatic stress disorder (PTSD). Moreover, literature endorses cognitive behavioral therapy (CBT) intervention for those with symptomology consistent with anxiety disorders, mood disorders and PTSD; however, efficacy has not been evaluated among a population of pregnant survivors of IPV. Objective: To explore the efficacy of trauma-informed cognitive behavioral therapy on maternal and child health outcomes for pregnant women with PTSD, depression, or anxiety symptomology resulting from IPV; and to test the validity and feasibility of study methodology to support the successful implementation of a full-scale randomized controlled trial. Methods: The PATH (Promoting Attachment Through Healing) study will utilize a mixed-methods approach grounded in an intersectional feminist framework to explore the effectiveness of trauma-informed CBT for pregnant survivors of IPV. Study participants will be recruited through a hospital-based Perinatal Mental Health Clinic (London, Ontario, Canada). Cohort 1: A feasibility sample of 20 pregnant women will be selected to engage in an eight-session antenatal CBT intervention facilitated by the program’s perinatal clinical nurse specialist (PCNS), with evaluation at baseline, and two-months postpartum (intervention and online question) and six and twelve months postpartum (online questionnaire only). Cohort 2: Concurrently, a retrospective audit of 100 medical charts (50 charts of perinatal women who received CBT and 50 charts of women who did not receive perinatal CBT) from the past five years. The efficacy of the intervention will be based on a reduction of mental illness symptomology, improved maternal-infant attachment, maternal coping, and maternal quality of life as well as feasibility of the protocol and acceptability of the intervention from the women’s perspective. Inductive content analysis of all qualitative data will be used to determine common themes. Additionally, descriptive statistics, including measures of central tendency and dispersion, will be computed for all continuous variables. Alternatively, frequency tables will be constructed for all categorical variables. Results: The work reported here is in the proposal phase. Once the protocol is implemented, we will report the results in a follow-up paper. Conclusions: Findings will be utilized to assess the acceptability of the study methodology and protocol for a full-scale randomized controlled trial. Furthermore, if CBT is proven effective for treatment of pregnant survivors of IPV, this intervention could be readily adopted by healthcare and social support services, thereby contributing to an improved standard of care for this unique population. Clinical Trial: ClinicalTrials.gov 10016616

  • Traditional and web-based technologies to improve partner notification following syphilis diagnosis among MSM in Lima, Peru: a pilot, randomized controlled trial

    From: Journal of Medical Internet Research

    Date Submitted: Jan 14, 2018

    Open Peer Review Period: Jan 14, 2018 - Mar 11, 2018

    Background: Patient-initiated partner notification (PN) following diagnosis of a sexually transmitted infection (STI) is a critical component of disease control within MSM sexual networks. We conducte...

    Background: Patient-initiated partner notification (PN) following diagnosis of a sexually transmitted infection (STI) is a critical component of disease control within MSM sexual networks. We conducted a randomized, controlled trial to evaluate the effect of two different PN technologies on notification outcomes following syphilis diagnosis among MSM in Peru: 1) A web-based notification system (www.inSPOT.org); and 2) Patient-delivered partner referral cards. Objective: We conducted a randomized, controlled trial to evaluate the effect of two different PN technologies on notification outcomes following syphilis diagnosis among MSM in Peru: 1) A web-based notification system (www.inSPOT.org); and 2) Patient-delivered partner referral cards. Methods: From 2012-2014, we screened 1,625 MSM in Lima, Peru for syphilis infection. We enrolled 370 MSM with symptomatic primary or secondary syphilis (n=58), or with asymptomatic latent syphilis diagnosed by serology (RPR/TPPA; n=312). Prior to enrollment, potential participants used a Computer-Based Self-Interviewing (CASI) system to enumerate their recent sexual partnerships and provide details of their three most recent partners. Eligible participants were randomly assigned to one of four intervention arms: 1) Counseling and Patient-Initiated Web-Based PN [n=95]; 2) Counseling with Web-Based PN and Partner Referral Cards [n=84]; 3) Counseling and Partner Referral Cards [n=97]; 4) Simple PN Counseling (Control) [n=94]. Self-reported PN was assessed after 14-days among 354 participants who returned for follow-up assessment. Results: The median age of enrolled participants was 27 (IQR: 23-34), with a median of 2 partners (IQR: 1-5) reported in the past month. MSM provided with access to web-based PN (Arms 1 and 2) or printed partner referral cards (Arms 2 and 3) were more likely than those who received only counseling (Arm 4) to have notified one or more of their sexual partners (OR: 2.18 [95% CI: 1.30-3.66], p=0.003 and 1.68 [95% CI: 1.01-2.79], p=0.045, respectively). The fraction of partners notified was also greater in both the Web-Based PN (241/421; 57.2%, p<0.001) and Referral Card (240/467; 51.4%, p=0.006) arms, compared to the Control arm (82/232; 35.3%). Conclusions: Both new, web-based technologies and traditional printed materials support patient-directed notification and improve self-reported outcomes among MSM with syphilis. Additional research is needed to refine use of these PN tools in specific partnership contexts. Clinical Trial: The clinical trial was registered with www.clinicaltrials.gov (Protocol Number NCT01720641).

  • Treating Perfectionism: Follow-up for Two Different Clinical Trials of Internet-based Cognitive Behavior Therapy with Guided Self-Help

    From: Journal of Medical Internet Research

    Date Submitted: Jan 17, 2018

    Open Peer Review Period: Jan 17, 2018 - Mar 14, 2018

    Background: Background: Perfectionism can become a debilitating condition that may negatively impact functioning in multiple areas, including mental health. Prior research has indicated that Internet-...

    Background: Background: Perfectionism can become a debilitating condition that may negatively impact functioning in multiple areas, including mental health. Prior research has indicated that Internet-based Cognitive Behavior Therapy (ICBT) can be beneficial, but few studies have included follow-up data. Objective: Objective: The current study explored the long-term benefits of ICBT with guided self-help, delivered as two separate randomized controlled trials conducted in Sweden and the United Kingdom (UK). Methods: Method: In total, 120 participants randomized to ICBT were included in both intention-to-treat and completer analyses, n = 78 (Swedish trial) and n = 62 (UK trial). Primary outcome measure was the Frost Multidimensional Perfectionism Scale, subscale Concern over Mistakes (FMPS CM). Secondary outcome measures varied between the trials and consisted of the Clinical Perfectionism Questionnaire (CPQ; both trials), the Patient Health Questionnaire – 9 Items (PHQ-9; Swedish trial), the Generalized Anxiety Disorder – 7 Items (GAD-7; Swedish trial), and the Depression Anxiety and Stress Scale – 21 Items (DASS-21; UK trial). Follow-up occurred after six months for the UK trial, and twelve months for the Swedish trial. Results: Results: Analysis of Covariance revealed a significant difference between pre-treatment and follow-up in both cases. Intention-to-treat within-group effect sizes Cohen’s d were 1.21 (Swedish trial), 95% Confidence Interval (CI) [0.86, 1.54], and 1.24 (UK trial), 95% CI [0.85, 1.62] for the FMPS CM. Furthermore, 29 (59.2%; Swedish trial) and 15 (42.9%; UK trial) of the participants met criteria for recovery on the FMPS CM. Significant improvements were also found for the CPQ, 1.32 (Swedish trial), 95% CI [0.97, 1.66], and 1.49 (UK trial), 95% CI [1.09, 1.88], the PHQ-9, 0.60, 95% CI [0.28, 0.92], the GAD-7, 0.67, 95% CI [0.34, 0.99], and the DASS-21, 0.50 [0.13, 0.85]. Conclusions: Conclusions: The results are promising for the use of ICBT as a way of targeting perfectionism, but the findings need to be replicated and include a comparison condition.

  • Using video technology to increase treatment completion for patients with latent tuberculosis infection on 3-months isoniazid and rifapentine

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 16, 2018

    Open Peer Review Period: Jan 16, 2018 - Mar 13, 2018

    Background: Since January 2013 the New York City (NYC) Health Department TB Program has offered persons diagnosed with latent tuberculosis infection (LTBI) the 3-month, once-weekly isoniazid and rifap...

    Background: Since January 2013 the New York City (NYC) Health Department TB Program has offered persons diagnosed with latent tuberculosis infection (LTBI) the 3-month, once-weekly isoniazid and rifapentine (3HP) treatment regimen. Patients on this treatment are monitored in-person under directly observed therapy (DOT). To address patient and provider barriers to in-person DOT, we piloted the used a videoconferencing software application to remotely conduct DOT (VDOT) for patients on 3HP. Objective: We evaluated the implementation of VDOT for patients on 3HP and whether treatment completion for patients on 3HP increased when monitored using VDOT compared to using the standard in-person DOT. Methods: Between February and October 2015, patients diagnosed with LTBI at any of the four NYC Health Department TB clinics who met eligibility criteria for treatment with 3HP under VDOT (V3HP) were followed-up until treatment completion or 16 weeks after treatment initiation, whichever came first. Treatment completion of V3HP patients were compared to historical data on treatment completion of patients on 3HP under clinic-based in-person DOT. Outcomes of video sessions with V3HP patients were collected and analyzed. Results: During the pilot period, 50 (70%) of 71 eligible patients were place on V3HP. Treatment completion among V3HP patients was 88% (44/50) compared to 65% (196/302) among 3HP patients on clinic DOT (P < .001). A total of 360 video sessions were conducted for V3HP patients with a median of 8 sessions per patient (range: 1-11), and a median time of 4 minutes (range: 1-59 minutes) per session. Adherence issues (e.g. >15 minutes late) during video sessions occurred 104 times. No major side effects were reported by V3HP patients. Conclusions: The NYC TB program observed higher treatment completion among patients on 3HP with VDOT than historically seen with clinic DOT. Expanding the use of VDOT may improve treatment completion and corresponding outcomes for LTBI.

  • Usability Study on Mobile Data Collection Support for Large-Scale Healthcare Scenarios

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 12, 2018

    Open Peer Review Period: Jan 13, 2018 - Mar 10, 2018

    Background: Many research domains still heavily rely on paper-based data collection procedures despite numerous drawbacks. However, the QuestionSys framework is intended to empower researchers as well...

    Background: Many research domains still heavily rely on paper-based data collection procedures despite numerous drawbacks. However, the QuestionSys framework is intended to empower researchers as well as clinicians with no programming skills to develop their own smart mobile applications in order to collect data in their specific scenarios. Objective: In order to validate the feasibility of this model-driven end-user programming approach, a study with N=80 participants was conducted. Methods: Across 2 sessions (7 days between Session 1 and Session 2), participants had to model 10 data collection instruments (5 at each session) with the developed configurator component. Thereby, performance measures like time and operations needed and the resulting errors were evaluated. Participants were separated in two groups (i.e., novices vs. experts) based on prior knowledge in process modeling, which is one fundamental pillar of the QuestionSys approach. Results: T-tests revealed that novices showed significant learning effects in errors, operations, and time during the use of the configurator (all p < .05) and experts showed learning effects in operations and time (both p < .05) but not in errors as the experts' errors were already very low at the first modeling of a data collection instrument. Moreover, regarding time and operations needed, novices got significantly better after 3rd modeling task than experts were after the 1st one (t-Tests; both p < .05). With regard to errors, novices did not get significantly better at any of the 10 data collection instruments than experts were at the 1st modeling task, but novices' error rates in all 5 data collection instruments at Session 2 were not significantly different anymore from the ones of experts at the 1st modeling task. During the 7 days without using the configurator (from Session 1 to Session 2), the experts' learning effect of Session 1 remained stable, but the novices' learning effect of Session 1 lessened significantly regarding time and operations (t-Tests; both p < .05). Conclusions: In conclusion, novices are able to use the configurator properly and show fast (but still instable) learning effects so that they become as good as experts already after little experience with the configurator. Researchers and clinicians can use the QuestionSys configurator to develop data collection applications for smart mobile devices on their own.

  • Responsiveness, reliability, and minimally important and minimal detectable change of three electronic patient reported outcome measures for low back pain: a validation study

    From: Journal of Medical Internet Research

    Date Submitted: Jan 15, 2018

    Open Peer Review Period: Jan 15, 2018 - Mar 12, 2018

    Background: The Roland Morris Disability Scale (RMDQ), Visual Analogue Scale of pain intensity (VAS) and Numerical Rating Scale (NRS) are three of the four most commonly used outcome measures in trial...

    Background: The Roland Morris Disability Scale (RMDQ), Visual Analogue Scale of pain intensity (VAS) and Numerical Rating Scale (NRS) are three of the four most commonly used outcome measures in trials of interventions for low back pain. Their validity in paper form is well-established. Few data are available on the metric properties of electronic counterparts. Objective: To establish responsiveness, minimal important change (MIC) thresholds, reliability, and minimal detectable change (MDC95) for electronic (e) versions of the RMDQ, VAS, and NRS as delivered via iOS app, Android app, and web app. Methods: We recruited people with back pain who visited osteopaths. We invited participants to complete the eRMDQ, eVAS, and eNRS at baseline, one-week, and six-weeks, along with a health transition question (TQ) at one and six weeks. Data from participants with self-reported recovery were used in responsiveness and MIC analyses, using Receiver Operator Characteristic curves with the TQ as the external criterion. Data from self-reported stable patients were used for analyses of reliability (ICC agreement) and minimal detectable change (MDC95). Results: We included 442 participants. At one and then six-weeks, ROC AUCs were 0.69 (95%CI 0.59 to 0.80) then 0.67 (0.46 to 0.87) for the eRMDQ; 0.69 (0.58 to 0.80) then 0.74 (0.53 to 0.95) for the eVAS; and 0.73 (0.66 to 0.80) then 0.81 (0.69 to 0.92) for the eNRS. Associated MIC thresholds were estimated as 1 then 2, 13 then 7, and 2 then 1 points, respectively. Over one-week in stable and ‘about the same’ participants ICCs were 0.87 and 0.84 for the eRMDQ, with MDC95 of 4 and 5; 0.31 and 0.61 for the eVAS with MDC95 of 39 and 34; and 0.52 to 0.67 with MDC95 of 4 and 3 for the eNRS. Conclusions: The eRMDQ was reliable with borderline adequate responsiveness. The eNRS was responsive with borderline reliability. While the eVAS had adequate responsiveness it did not have an attractive reliability profile. Thus, the eNRS might be preferred over the eVAS for measuring pain intensity. The observed electronic outcome measures’ metric properties are within the range of values reported in the literature for their paper counterparts and are adequate for measuring within a back pain population. Clinical Trial: N/A

  • Show Me Health Plans: Dissemination of a Web-based Decision Aid for Health Insurance Plan Decisions

    From: Journal of Medical Internet Research

    Date Submitted: Jan 17, 2018

    Open Peer Review Period: Jan 17, 2018 - Mar 14, 2018

    Background: The rate of uninsured has decreased dramatically since the passage of the Affordable Care Act. To make an informed decision, consumers need assistance to understand the advantages and disa...

    Background: The rate of uninsured has decreased dramatically since the passage of the Affordable Care Act. To make an informed decision, consumers need assistance to understand the advantages and disadvantages of health insurance plans and select a suitable plan. The Show Me Health Plans (SMHP) web-based decision support tool was developed to improve health insurance decision quality. In response to the promising effectiveness of SMHP in a randomized controlled trial (RCT) and the growing need for web-based health insurance decision support, the study team used expert recommendations for dissemination and implementation processes, engaged external stakeholders, and released the SMHP tool so that it was available to the general public. Objective: The purpose of this study was to examine public dissemination of the web-based SMHP tool in the state of Missouri, and to evaluate the impact of SMHP in its dissemination phase compared to the RCT. Methods: This study used a cross-sectional observational design. Dissemination phase users were compared with users in the RCT study across the same outcome measures. Time spent using SMHP tool, knowledge, importance rating of 9 health insurance features, and intended plan choice match with algorithm predictions were examined. Results: During the dissemination phase between November, 2016 and January, 2017, 10,180 users visited the SMHP tool. 1,069 users were included in analyses. Dissemination phase users were more likely to live outside St. Louis City or County (p < 0.001), were less likely to be below the federal poverty level (p<0.0001), and had a higher income (p=0.03). Tool users from St. Louis City or County had higher overall time spent on the SMHP tool than those from other Missouri counties (p=0.04); this association was not observed in the RCT. Total time spent on the tool was not correlated with knowledge scores. Knowledge was associated lower poverty levels (p=0.009). The users in RCT phase were more likely to select an insurance plan that match the tool’s algorithm recommendations (p <0.001) compared with the dissemination phase users. Conclusions: The study suggests that a higher income population may be more likely to seek information and online help when making a health insurance plan decision, and that tool users in the dissemination phase were more selective in the information they reviewed. This study provides an example of ways to disseminate and implement an empirically tested web-based decision aid tool. Disseminating web-based tools is feasible and may attract a large number of potential users, educate them on basic health insurance information, and make recommendations based on personal information and preference. However, those in the general public may differ in their demographics and use of web-based tools compared to participants in a research trial.

  • A Systematic Review of Mindfulness-Based Apps for Adults with a COPD or Lung Cancer History

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 12, 2018

    Open Peer Review Period: Jan 12, 2018 - Mar 9, 2018

    Background: Up to 70% of lung cancer survivors are also affected by chronic obstructive pulmonary disease (COPD), a common, debilitating, comorbid disease characterized by symptoms such as breathlessn...

    Background: Up to 70% of lung cancer survivors are also affected by chronic obstructive pulmonary disease (COPD), a common, debilitating, comorbid disease characterized by symptoms such as breathlessness and fatigue. These distressing symptoms detract from a survivor’s quality of life Objective: To identify and evaluate evidence-based, commercially available apps for promoting mindfulness-based strategies among adults with a COPD or lung cancer history. Methods: An interdisciplinary research team used 19 keyword combinations in the search engines of Google and iOS app stores in May 2017. Evaluations were conducted on apps’ (1) content, (2) usability heuristics, (3) grade-level readability, and (4) cultural sensitivity. Results: The search resulted in 768 apps (508 in iOS and 260 in Google stores). Nine apps met the inclusion criteria and received further evaluation. Only one app had below an eighth-grade reading level; the ninth did not have enough text to calculate a readability score. None of the 9 apps met the cultural sensitivity evaluation criteria. Conclusions: This systematic review identified critical design flaws that may affect the ease of using the apps in this study. Few mobile apps promote mindfulness-based strategies among adults with a COPD or lung cancer history, but those that exist, overall, do not meet the latest scientific evidence. Recommendations include more stringent regulation of health-related apps; use of evidence-based frameworks and participatory design processes; following evidence-based usability practices; use of culturally sensitive language and images; and ensuring that content is written in plain language. Clinical Trial: N/A

  • The Use of Wearable Activity Trackers Among Older Adults: A Focus Group Study of Tracker Perceptions, Motivators, And Barriers in Different Stages of Behavior Change

    From: Journal of Medical Internet Research

    Date Submitted: Jan 12, 2018

    Open Peer Review Period: Jan 13, 2018 - Mar 10, 2018

    Background: Physical activity benefits older adults by protecting against morbidity and mortality. Wearable activity trackers (WATs) offer the opportunity to increase physical activity through continu...

    Background: Physical activity benefits older adults by protecting against morbidity and mortality. Wearable activity trackers (WATs) offer the opportunity to increase physical activity through continuous monitoring. We explore the nuances of WAT use and adoption among older adults using the transtheoretical model (TTM) of behavior change. Objective: We investigate older adults’ perceptions and uses of WATs in different stages of WAT adoption. Methods: Data for the research come from 10 focus groups. The first set of focus groups was with participants who had never used WATs. These focus groups included a WAT trial. Other focus groups (without the trial) were conducted with short-term, long-term, and former WAT users. Results: Older adults in different WAT use stages liked and wished for different WAT features, with long-term users being the most diverse and sophisticated users of WATs. Long-term users had developed a habit of WAT use while other participants needed to employ various encouragement strategies. Social support, with the focus on collaboration, was the primary motivator for long-term users, while short-term and former users focused on competition, and non-users engaged in vicarious WAT use experiences. Finally, long-term users were more likely to see benefits of WATs while other participants focused on obstacles related to WAT use. Conclusions: WATs may be an effective technology to encourage physical activity among older adults. Yet, WATs alone are not likely to be successful in changing behavior. Tailored approaches based on the TTM stage of change as well as motivations, facilitators, and specific WAT characteristics that are important for older adults will ensure successful long-term use. Clinical Trial: NA

  • Flu-tracking Ability of Flu-Report: A New Influenza-tracking Smartphone Application Based on a Self-administered Questionnaire

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 18, 2018

    Open Peer Review Period: Jan 18, 2018 - Mar 15, 2018

    Background: Influenza outbreaks are a major public health concern worldwide and influenza infections can spread rapidly. Thus, early detection of signs of an influenza pandemic is important for preven...

    Background: Influenza outbreaks are a major public health concern worldwide and influenza infections can spread rapidly. Thus, early detection of signs of an influenza pandemic is important for preventing global outbreaks. Development of information and communications technologies for influenza surveillance has recently increased. These systems can estimate influenza activity faster than conventional influenza surveillance systems. Unfortunately, few influenza tracking systems using information and communications technologies are available in Japan. Objective: The aim of this study was to evaluate the flu-tracking ability of “Flu-Report,” a new influenza-tracking smartphone application that uses a self-administered questionnaire for early detection of signs of influenza activity. Methods: Flu-Report was used to collect influenza-related information (i.e., dates on which influenza infections were diagnosed) from November 2016 to March 2017. Study subjects consisted of adult volunteers from throughout Japan, who also provided information about their cohabiting family members. The utility of Flu-Report was evaluated by comparison with conventional influenza surveillance information and basic information for an existing large-scale influenza-tracking system, which is an automatic surveillance system based on electronic records regarding prescription drug purchases. Results: The information registered in Flu-Report included approximately 10,094 volunteers. In total, 2,134 subjects were <20 years, 6,958 subjects were 20–59 years, and 1,002 subjects were ≥60 years. Between November 2016 and March 2017, 347 subjects declared that they had influenza for the 2016 season. Flu-Report-derived influenza infection time series data displayed a good correlation with basic information obtained for the existing large-scale influenza surveillance system (ρ=0.65, P<0.01). However, the influenza morbidity ratio of our subjects was approximately a quarter of the mean influenza morbidity rate of the Japanese population. The influenza morbidity ratio from Flu-Report was 5.1% among subjects aged <20 years, 3.2% among subjects aged 20–59 years, and 0.6% among subjects aged ≥60 years. In contrast, influenza morbidity ratios of Japanese individuals aged <20 years, 20–59 years, and ≥60 years were recently estimated at 32.0–37.4%, 8.2–9.1%, and 2.7–4.4%, respectively. Conclusions: Flu-Report makes it easy to obtain near real-time information about influenza activity via the accumulation of self-administered questionnaires. However, users of Flu-Report may be influenced by selection bias, which is a common issue associated with surveillance using information and communications technologies. Nevertheless, Flu-Report has the potential to provide basic data that could help to detect influenza outbreaks.

  • The Conceptual Modeling of Interoperability Framework of Heart Sound Monitor

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 14, 2018

    Open Peer Review Period: Jan 15, 2018 - Mar 12, 2018

    Background: Heart sound monitor (HSM), a device suitable for home-use, can be used to record heart sounds and to store, transmit or analyze those recordings. It enables cardiac reserve telemonitoring...

    Background: Heart sound monitor (HSM), a device suitable for home-use, can be used to record heart sounds and to store, transmit or analyze those recordings. It enables cardiac reserve telemonitoring which has been largely evolved and widely used in recent years. Nevertheless, the designers of HSM paid little attention to the consistency of its information model and data interaction, and because of that, the collected heart sounds data could not be shared and aggregated effectively. Thus, the device’s development and its application in telehealth service are hindered. Objective: In order to solve the above problem and to build interoperability for HSM devices, this paper proposes a HSM interoperability framework that is composed of the hierarchical information model and the transport-independent interaction model, which is constructed by using standardized modeling methods. Methods: The authors collected and studied the common device-output information of HSM involved in the cardiac reserve telemonitoring, leveraged the standardized interoperability framework defined in ISO/IEEE 11073 Personal Health Device (11073-PHD) standards to model the static data structure and dynamic interaction behaviors of HSM. Results: Via the meta analysis, the authors identified that the common device-output information of HSM mainly includes the phonocardiogram (PCG), the feature parameters of PCG, the ratio of diastolic to systolic duration (D/S), for example, and the threshold data, device status, sensor location, etc. Based on such information, an 11073-PHD-compliant domain information model has been successfully created. This enables the interoperability between HSM and aggregation device, allowing inter-device plug&play using service model and communication model. A prototype of this design has been implemented and validated via the Continua Enabling Software Library. Conclusions: The ISO/IEEE 11073-PHD standard framework has the potential to accommodate the HSM device. The standard-compliant domain information models can be established to cover the common HSM device-output information. Findings in this paper may be taken as a reference for standard developing organizations to establish a standardized interoperability framework for HSM.

  • “Which are the best mobile apps for obesity prevention and treatment?”: A user-centered study with employees from a Lebanese university

    From: Journal of Medical Internet Research

    Date Submitted: Jan 14, 2018

    Open Peer Review Period: Jan 14, 2018 - Mar 11, 2018

    Background: Evaluating the quality of mHealth apps for weight loss and weight management is important to understand whether these can be used for obesity prevention and treatment. Recent reviews call...

    Background: Evaluating the quality of mHealth apps for weight loss and weight management is important to understand whether these can be used for obesity prevention and treatment. Recent reviews call for more research on multi-dimensional aspects of app quality, especially involving end-users, as there are already many expert reviews on this domain. However, no quantitative study has investigated how lay persons see popular apps for weight management and how they perceive different dimensions of app quality. Objective: To explore how lay persons evaluate the quality of six free weight management apps (MyDietCoach, SparkPeople, Lark, MyFitnessPal, MyPlate, MyDietDiary), which achieved the highest quality ratings in a related and recent expert review. Methods: A user-centered study was conducted with 36 employees of a Lebanese university. Participants enrolled in the study on a rolling basis between October 2016 and March 2017. Participants were randomly assigned an app to use for two weeks. App quality was evaluated at the end of the trial period using the Mobile App Rating Scale (user version, uMARS). uMARS assesses the dimensions of ‘engagement’, ‘functionality’, ‘aesthetics’, ‘information’, and ‘subjective quality’ on 5-point scales. Internal consistency and inter-rater agreement were examined. The associations between uMARS scores and background characteristics were also explored using non-parametric tests. Analyses were completed in November 2017. Results: Overall, the six apps were of moderately good quality (Md uMARS score=3.6, IQR=0.3). The highest total uMARS scores were achieved by Lark (M=4.0, SD=0.5) and MyPlate (M=3.8, SD=0.4), which also achieved the highest subjective quality scores (Lark: M=3.3, SD=1.4; MyPlate: M=3.3, SD=0.8). ‘Functionality’ was the highest-rating domain (Md=3.9, IQR=0.3), followed by ‘aesthetics’ (Md=3.7, IQR=0.5), ‘information’ (Md=3.7, IQR=0.1), and ‘engagement’ (Md=3.3, IQR=0.2). ‘Subjective quality’ was judged low (Md=2.5, IQR=0.9). Overall, ‘subjective quality’ was strongly and positively related (p<0.001) with total uMARS score (rho=0.75), ‘engagement’ (rho=0.68), ‘information’ and ‘aesthetics’ (rho=0.60), but not ‘functionality’ (rho=0.40, p=0.02). Higher ‘engagement’ scores were reported among healthy (p=.003) and obese individuals (p=.034), who also showed higher total uMARS (p=.038), and ‘subjective quality’ (p=.047) scores. Conclusions: Even if the apps were considered highly functional, they were relatively weak in engagement and subjective quality scores, which indicate a low propensity of using the apps in the future. As engagement was the sub-domain most strongly associated with subjective quality, app developers and researchers should focus on creating apps that are engaging, holding constant the functionality, aesthetics, and information quality. The tested apps (in particular Lark and MyPlate) were perceived as more engaging and of higher quality among healthy, obese individuals, making them a promising mode of delivery for self-directed interventions promoting weight control among the sampled population or in similar and comparable settings. Clinical Trial: None.

  • Popular Nutrition-Related Mobile Apps: A Relative Reliability Assessment

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 14, 2018

    Open Peer Review Period: Jan 14, 2018 - Mar 11, 2018

    Background: Nutrition-related apps are commonly used to provide information about the users’ dietary intake, but limited research has been performed on the evaluation of their reliability. Objective...

    Background: Nutrition-related apps are commonly used to provide information about the users’ dietary intake, but limited research has been performed on the evaluation of their reliability. Objective: To evaluate the relative reliability of popular nutrition-related apps for the assessment of energy and available macro- and micronutrients against a standard method. Methods: Dietary analysis of 24-hour weighed food records (n = 20) were compared between five nutrition-related apps: S Health, MyFitnessPal, FatSecret, Noom Coach and Lose It!, and DietPlan6 (reference method). Estimates of energy, macronutrients (carbohydrate, protein, fat, saturated fat and fibre) and micronutrients (sodium, calcium, iron, vitamin A and vitamin C) were compared using t-tests and Wilcoxon signed-rank tests, correlation coefficients and Bland-Altman plots. 24-hour weighed food records from 20 participants (female/male, 15/5; mean age, 36.3 years; mean body mass index, 22.9 kg/m2) recruited from previous controlled studies conducted at the Hugh Sinclair Unit of Human Nutrition, University of Reading, UK. Results: No significant difference in estimation of energy and saturated fat intake between DietPlan6 and the diet apps was observed. Estimates of protein and sodium intake were significantly lower using Lose It! and FatSecret than DietPlan6. Lose It! also gave significantly lower estimates for other reported outputs: carbohydrate, fat, fibre and sodium, compared with DietPlan6. For S Health and MyFitnessPal, calcium, iron and vitamin C were all significantly under-estimated compared with DietPlan6, although there was no significant difference for vitamin A. No other significant differences were observed between DietPlan6 and the apps. Correlation coefficients ranged from -0.12 for iron (S Health vs. DietPlan6) to 0.91 for protein (FatSecret vs DietPlan6). Noom Coach was limited to energy output but it had a high correlation with DietPlan6 (r=0.91) and S Health had the greatest variation of correlation, with energy at 0.79. Bland-Altman analysis revealed potential proportional bias for vitamin A. Conclusions: The findings suggest that the apps provide comparable estimates of energy and saturated fat intake compared with DietPlan6. With the exception of Lose It!, the apps also provided comparable estimates of carbohydrate, total fat and fibre. Two apps displayed a tendency to underestimate protein and sodium (FatSecret and Lose It!). Apart from vitamin A, the estimates of micronutrient intake (calcium, iron and vitamin C) by the two apps (S Health and MyFitnessPal) were inconsistent and less reliable. Lose It! was the less comparable app in relation to DietPlan6. As the use and availability of apps grows, this study helps clinicians and researchers to make better-informed decisions about using these apps in research and practice.

  • Safer Prescribing and Care for the Elderly (SPACE): Protocol of a Cluster RCT in Primary Care

    From: JMIR Research Protocols

    Date Submitted: Jan 14, 2018

    Open Peer Review Period: Jan 14, 2018 - Jan 28, 2018

    Background: High-risk prescribing, adverse drug events and avoidable adverse drug event hospitalisations are common. The single greatest risk factor for high-risk prescribing and adverse drug events i...

    Background: High-risk prescribing, adverse drug events and avoidable adverse drug event hospitalisations are common. The single greatest risk factor for high-risk prescribing and adverse drug events is the number of medicines a person is taking. More people are living longer and taking more medicines for multiple long-term conditions. Most on-going prescribing occurs in primary care. The most effective, cost-effective, and practical approach to safer prescribing in primary care is not yet known. Objective: To test the effect of the Safer Prescribing And Care for the Elderly (SPACE) intervention on high-risk prescribing of non-steroidal anti-inflammatory and anti-platelet medicines, and related adverse drug event hospitalisations. Methods: Cluster randomised controlled trial. The clusters will be primary care practices. Data collection and analysis will be at the level of patient. Results: Recruitment will start in 2018. Conclusions: This study addresses an important translational gap, testing an intervention designed to prompt medicines review and support safer prescribing in routine primary care practice. Clinical Trial: Australian New Zealand Clinical Trials Registry: ACTRN12618000034235 12/01/2018 http://www.ANZCTR.org.au/ACTRN12618000034235.aspx

  • Using co-creation in the process of designing a smartphone application for adolescents and young adults with cancer (AYAs).

    From: Journal of Medical Internet Research

    Date Submitted: Jan 15, 2018

    Open Peer Review Period: Jan 15, 2018 - Mar 12, 2018

    Background: Adolescent and young adult (AYA) oncology and hematology is a developing field of medicine, focusing on a population that faces many challenges throughout medical treatment and beyond. Mob...

    Background: Adolescent and young adult (AYA) oncology and hematology is a developing field of medicine, focusing on a population that faces many challenges throughout medical treatment and beyond. Mobile health (mHealth) interventions provide exciting new opportunities for improvement of health-related quality of life (HRQoL) in AYA cancer patients. Many smartphone applications (apps) are currently available for AYAs with cancer; however, very few apps for AYAs with cancer have been designed with direct input from AYAs themselves or have demonstrated their effectiveness and benefit. Objective: The objective of this project was to develop the prototype of a smartphone app for AYAs with cancer through the process of co-creation, with the active input of AYA who have received treatment for cancer directly impacting content and design. Methods: Patients were recruited from a population of Danish AYAs who had received treatment for cancer between the ages of 15-29. The co-creation process was completed over the course of three workshops and intermittent ad hoc meetings, where the recruited AYAs worked in coordination with a nurse, a doctor, and two representatives from a digital agency and app developer. During each workshop, participants prioritized their goals for the app. After new app content was developed, feedback was requested from the participants, and changes were made accordingly. This iterative process continued until consensus on final product features and design were achieved. Healthcare professionals provided minimal input, and primarily performed observational roles in the workshops, with direct interaction limited to introducing the project and explaining measurement features of the app in development. Results: Three key features to be included in the prototype app were identified from the co-creation workshops: 1) a community forum, 2) an information library, and 3) a symptom and side effect tracking tool. Bright, warm colors were selected for the app by the participating AYAs. The final prototype will be launched for pilot testing and implementation testing in February of 2018. Conclusions: The process of co-creation is user-involved process that can create an end-product that is useful and customized for the target population. This process, as such, is a beneficial process to utilize when addressing the specific needs of AYAs with cancer. The results of the here described app prototype will be evaluated in more detail in the near future. However, this description of the co-creation process in app development can be utilized for the creation of other mHealth interventions.

  • Dear Editor

    From: Journal of Medical Internet Research

    Date Submitted: Jan 15, 2018

    Open Peer Review Period: Jan 16, 2018 - Mar 13, 2018

    ...

  • Matching openEHR specifications and General Data Protection Regulation requirements

    From: Journal of Medical Internet Research

    Date Submitted: Jan 15, 2018

    Open Peer Review Period: Jan 19, 2018 - Mar 16, 2018

    Background: The concerns about privacy and personal data protection resulted in reforms of the existing legislation in European Union (EU). The General Data Protection Regulation (GDPR) aims to reform...

    Background: The concerns about privacy and personal data protection resulted in reforms of the existing legislation in European Union (EU). The General Data Protection Regulation (GDPR) aims to reform the existing directive on the topic of personal data protection of the European Union citizens, with a strong emphasis on more control of the citizens over their data and in the establishment of rules for the processing of personal data. OpenEHR is a standard that embodies many principles of interoperable and secure software for electronic health records, and has been advocated as the best approach for the development of HIS. Objective: This work aims to understand to what extent the openEHR standard can help in the compliance to the GDPR requirements. Methods: A list of requirements for a Hospital Information Systems (HIS) to support the compliance with GDPR, and also a list of the openEHR specifications were made. The requirements were categorized and compared with the specifications by specialists on openEHR and GDPR. Results: 53 GDPR requirements, and 8 openEHR specification items were identified. The openEHR specifications matched 32% (n=17) GDPR requirements. All the openEHR specifications were aligned with GDPR requirements. Conclusions: This work reinforces the openEHR initial claim, showing that openEHR has a good fit also when privacy and data protection are incorporated by design in the system development. By using an openEHR based EHR the institutions are closer to becoming compliant with GDPR while safeguarding the medical data.

  • Nutrigenomics technology interface tools for consumers and health professionals: Protocol of a mixed methods study

    From: JMIR Research Protocols

    Date Submitted: Jan 15, 2018

    Open Peer Review Period: Jan 16, 2018 - Jan 30, 2018

    Background: While nutrition is a widely accepted tool for the prevention of long-term health conditions, current approaches have not adequately reduced chronic disease morbidity. Nutrigenomics has gre...

    Background: While nutrition is a widely accepted tool for the prevention of long-term health conditions, current approaches have not adequately reduced chronic disease morbidity. Nutrigenomics has great potential, however, it is complicated to implement. There is a need for products based on nutrition-related gene test results which are easily understood, accessible and utilized. Objective: The primary objective of this study is to compare the efficacy of a non-practitioner assisted direct-to-consumer (DTC) self-driven approach to nutrigenomics versus a personalized practitioner-led method. The secondary aims are to use this data combined with participant feedback to generate more effective nutrigenomics-based products. Methods: This 4-month study used a mixed-methods design that included: 1) a phase 1 randomized control trial that examined the effectiveness of a multi-faceted, nutrition-based gene test (components assessed included the major nutrients, food tolerances, food taste and preferences, and vitamins) in changing health behaviours; followed by 2) qualitative investigation that explored participants’ experiences. The study recruited 55 healthy males and females (35-55 years) randomized as a 2:1 ratio where 36 received the intervention (gene-test results plus personalized nutrition report) and 19 were assigned to the control group (gene-test results report emailed). Both groups received follow-up emails with nutrition-related tips and reminders. The primary outcomes of interest measures included changes in diet (nutrients, healthy eating index), self-efficacy, quality of life and anthropometrics (BMI, waist:hip) measured at baseline, post-intervention (3 and 6 weeks), and the final visit. After the study has been completed, participants in the control group will also receive their personalized nutrition report. Results: To date, only three participants have dropped out due to reasons such as not completing all required data collection forms or they were later found to be ineligible (retention of 95% of participants). Most participants are female, married, and had post-secondary education. Conclusions: This study will leverage quantitative and qualitative findings, which will guide the development of nutrigenomics-based products in electronic formats that are user-friendly for consumers and health professionals. While the quantitative data have not been analyzed yet, the overwhelming interest in the study and the extremely high retention rate exhibit a great degree of interest in this field, and a definite need for further studies. Clinical Trial: The study protocol is registered with U.S. National Library of Medicine (www.clinicaltrials.gov; Trial registration #NCT03310814).

  • A Survey of Privacy-Preserving Techniques for Reuse of Distributed Health Data

    From: Journal of Medical Internet Research

    Date Submitted: Jan 15, 2018

    Open Peer Review Period: Jan 19, 2018 - Mar 16, 2018

    Background: Large amounts of detailed electronic health data are being collected. Reuse of these data has enormous potential for scientific discoveries that enables the improvement of healthcare syste...

    Background: Large amounts of detailed electronic health data are being collected. Reuse of these data has enormous potential for scientific discoveries that enables the improvement of healthcare systems’ effectiveness, efficiency, and quality of care. However, health data reuse should protect the privacy interests of the stakeholders (i.e., patients and healthcare providers) and promote public good through research. This is particularly challenging when the data are distributed across several data custodians. Objective: This paper aims to give an overall overview of existing privacy-preserving techniques for distributed data reuse and their practical applications. Methods: We searched for review papers that are focused on privacy-preserving techniques for different stages of distributed data reuse, such as creating dataset that satisfy a given criteria, analyzing the dataset, and releasing statistical results. We analyzed the identified techniques in terms of privacy, data utility, efficiency, and scalability. Practical uses of the techniques are also discussed when there is actual use. Results: Several privacy-preserving data reuse techniques have been identified. The techniques are developed for different stages of distributed data reuse based on de-identification, secure multi-party computation (SMC), or a combination of these two building blocks. Different combinations of the techniques need to be applied for the whole stages of distributed data reuse. Some of the surveyed techniques protect the privacy of data custodians in addition to individuals. The main challenge for de-identification based data reuse techniques is making a balance between utility and privacy. Whereas, efficiency and scalability are the main challenges for SMC based techniques. Conclusions: Enormous progress has been made towards making privacy-preserving reuse of distributed data possible. However, there are only few practical uses of the available techniques. the problem of distributed data reuse also requires governance, legal, and ethical frameworks, as well as the technical solutions. It is not clear whether consent, data-use agreement, and ethics review are required for practical uses of the techniques.

  • Machine Intelligence to Assist Visually Impaired People: A Big Data Deep Neural Network Adventure

    From: JMIR Rehabilitation and Assistive Technologies

    Date Submitted: Jan 15, 2018

    Open Peer Review Period: Jan 15, 2018 - Mar 12, 2018

    Background: Blindness or vision impairment, one of the top ten disabilities among men and women, targets more than 7 million Americans of almost all ages. Accessible visual information is of paramount...

    Background: Blindness or vision impairment, one of the top ten disabilities among men and women, targets more than 7 million Americans of almost all ages. Accessible visual information is of paramount importance to improve independence and safety of blind and visually-impaired people, and there is a pressing need to develop smart automated systems to assist their navigation, particularly in unfamiliar healthcare environments, such as clinics, hospitals, and urgent cares. Objective: The main objective of the current contribution was to develop computational vision algorithms composed with deep neural network to assist visually impaired individual's mobility in clinical environments by accurately detecting doors, stairs, and signages, the most remarkable landmarks. Methods: A dataset of indoor landmarks of interests was collected from Marshfield Clinic in Marshfield. To increase the accuracy and stability of predictive model, an augmented dataset was generated by adding several variations to the collected one. A deep convolutional neural network (CNN), namely “AlexNet” was then utilized and trained with both datasets. The CNN model was configured in two different strategies: (1) Transfer Learning (TL), (2) Feature Extraction (FEx) combined with three different classifiers, namely Support Vector Machine (SVM), Naïve Bayesian (NB) and K-Nearest Neighbor (KNN). To speed up the training process and make a real-time decision, NVIDIA GPU Quadro M5000 was employed. Results: The CNN is trained with TL and FEx approaches using 10%, 20% and 30% of both collected and augmented datasets. While training time of FEx model is in the order of a few minutes, TL model requires 10-20 times more time. The average object recognition time of both approaches is less than 0.3 seconds. The accuracy of recognizing objects of interest is more than 98% regardless of training size. However, the accuracy of TL model varies from about 60% to 99% with respect to the training size. Conclusions: Even though GPU processors extremely increase the speed of computing compared with CPUs, training time of TL approach is unbearable. However, both approaches on the stage of test sample evaluation are fast enough to be used in real-time applications. FEx accompanied with either NB, SVM or KNN classifiers achieves accuracy of greater than 98% even with small training set size. To compete with FEx approach with respect to accuracy, recall and precision, TL requires larger training set. For detecting three objects of interest that are common in any health care facility, the CNN model based on FEx is a pragmatic option. The proposed framework has the potential to recognize a variety of objects in the indoor environment, and ultimately to help visually-impaired people navigate their way in the clinic independently.

  • Is the Patient Suited or Not? Clinicians’ Selection Criteria for Video Visits in OutPatient Care

    From: Journal of Medical Internet Research

    Date Submitted: Jan 17, 2018

    Open Peer Review Period: Jan 17, 2018 - Mar 14, 2018

    Background: Video mediated meetings with patients were introduced in outpatient care at a hospital in Sweden. New behaviours and tasks emerged due to changes of roles, work processes and responsibilit...

    Background: Video mediated meetings with patients were introduced in outpatient care at a hospital in Sweden. New behaviours and tasks emerged due to changes of roles, work processes and responsibilities. The study investigates effects of digital transformation, in this case how video visits in outpatient care change work processes and introduces new tasks. Objective: Through real-time, social interactional features of preparing for and conducting video visits, the study examines which patients the clinicians considered as suitable for video visits and why, in order to increase the value of these visits for further improvement of the concept video visits. Methods: Qualitative methods have been used including 14 observations of video visits at two different clinics and 14 follow-up interviews with clinicians. Transcriptions of interviews and field notes were thematically analysed, discussed and synthesised into themes. Results: From the interviews, 25 different arguments for selecting a specific patient/relative for video visits were identified. Analysing interviews and field notes also reviled not expressed reasons that played a part in the selection process. The expressed arguments, as well as the implicit reasons, of why a patient was given the opportunity of video visits, can be understood as selection criteria for helping clinicians in their decision of whom to offer video visits or not. The criteria identified in the collected data were divided into the three categories: The patient has the right conditions, Needs to practically facilitate the treatment, and Enabling the content of the treatment. Conclusions: Not all patients undergoing treatment programs should be offered video visits. When selecting patients it is important to consider if the patient has the right conditions, if there are needs to practically facilitate the treatment, and if there is a need to enable the content of the treatment. A set of criteria to be used in the selection process and a method for how and when to involve the patient in the decision is recommended to be developed.

  • mHealth Functionalities for HIV Care: Results from a Co-Design Process across Five European Clinical Sites

    From: Journal of Medical Internet Research

    Date Submitted: Jan 16, 2018

    Open Peer Review Period: Jan 16, 2018 - Mar 13, 2018

    Background: Despite advances in testing and treatment, HIV incidence rates within European countries are at best stable or else increasing. mHealth technology has been advocated to increase quality an...

    Background: Despite advances in testing and treatment, HIV incidence rates within European countries are at best stable or else increasing. mHealth technology has been advocated to increase quality and cost-effectiveness of health services while dealing with growing patient numbers. However, studies suggested that mHealth applications are rarely adopted and often considered of low quality by users. Only a few studies (conducted in the US) have involved people living with HIV (PLWH) in the design of mHealth. Objective: The goal of this study was to facilitate a co-design process among PLWH and clinicians across five clinical sites in the European Union to inform the development of an mHealth platform to be integrated into clinical care pathways. We aimed to (1) elicit experiences of living with HIV and of working in HIV care, (2) identify mHealth functionalities that are considered useful for HIV care, and (3) identify potential benefits as well as concerns about mHealth. Methods: Between January and June 2016, 14 co-design workshops and 22 semi-structured interviews were conducted, involving 97 PLWH and 65 clinicians. Data were analysed thematically and iteratively, drawing on grounded theory techniques. Results: Findings were established into three thematic clusters: (1) ‘Approaching the mHealth platform’, (2) ‘Imagining the mHealth Platform’, and (3) ‘Anticipating the mHealth Platform’s Implications’. Co-design participants approached the mHealth platform with pre-existing concerns arising from their experiences of receiving or providing care. PLWH particularly addressed issues of stigma and questioned how mHealth could enable them to manage their HIV. Clinicians problematized the compatibility of mHealth with existing IT systems and questioned which patients should be targeted by mHealth. Imagining the potential of mHealth for HIV care, co-design participants suggested ‘medical functionalities’ (accessing test results, managing medicines and appointments, and digital communication channels), ‘social functionalities’ (peer-support network, international travel, etc.), and ‘general features’ (security and privacy, credibility, language, etc.). Co-design participants also anticipated potential implications of mHealth for self-management and the provision of care. Conclusions: Our approach to co-design enabled us to facilitate early engagement in the mHealth platform enabling patient and clinician feedback to become embedded in the development process at a pre-prototype phase. Although the technologies in question were not yet present, understanding how users approach, imagine and anticipate technology formed an important source of knowledge and proved highly significant within the technology design and development process. Clinical Trial: -

  • Digital technology with carers of people with psychosis: a systematic review

    From: JMIR Mental Health

    Date Submitted: Jan 16, 2018

    Open Peer Review Period: Jan 18, 2018 - Mar 15, 2018

    Background: Several million people across the globe are living with psychotic disorders, which are severe mental health conditions that adversely affect quality of life and life expectancy. Informal c...

    Background: Several million people across the globe are living with psychotic disorders, which are severe mental health conditions that adversely affect quality of life and life expectancy. Informal carers (families) are known to play an important role in facilitating patient recovery outcomes, although their own health and wellbeing can also be negatively impacted by the illness. The application of novel digital interventions in mental health care for patient groups is rapidly expanding; interestingly, however, far less is known about their role with family carers. Objective: The current study sought to systematically identify the application of digital interventions that focus on informal carers of people with psychosis and describe their outcomes. Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, a systematic search of four electronic databases (Embase, Medline, PsycINFO and Web of Science) from inception to 30th June 2017 was undertaken. The search also included the Cochrane database and hand searches of reference lists of relevant papers. Results: The search approaches identified nine studies, derived from eight unique datasets. Most studies were assessments of feasibility and undertaken in the United States of America. Interventions were predominately web based with a focus on improving carer knowledge and understanding about psychosis. Conclusions: The results offered preliminary support for the feasibility and acceptability of digital interventions in informal carer populations in psychosis. However, the findings underpinned a clear need for greater development in the range of carer focused digital approaches on offer and a robust evaluation of their outcomes. The use of digital approaches with carer populations seemingly lags someway behind the significant developments observed in patient groups.

  • Building a community knowledge commons for learning networks: The Learning Exchange

    From: Journal of Medical Internet Research

    Date Submitted: Jan 17, 2018

    Open Peer Review Period: Jan 17, 2018 - Mar 14, 2018

    Background: Learning Networks are distributed learning health systems that enable collaboration, at scale, to improve health and healthcare. A key requirement for such networks is having a way to crea...

    Background: Learning Networks are distributed learning health systems that enable collaboration, at scale, to improve health and healthcare. A key requirement for such networks is having a way to create and share information and knowledge in furtherance of the work of the community. Objective: We describe a Learning Exchange - a bespoke, scalable knowledge management and exchange platform initially built and tested for improving pediatric inflammatory bowel disease outcomes in the ImproveCareNow (ICN) Network - and assess evidence of its acceptability, feasibility, and utility in facilitating creation and sharing of information in furtherance of the work of the community and as a model for other communities. Methods: The process of designing, prototyping and pilot testing utilized a combination of interaction design, quality improvement, and co-production methodologies in an iterative process. Results: The Learn Exchange has over 1000 users and supported sharing of resources across all care centers in ICN. Users reported that the Learning Exchange has facilitated their work and resulted in increased ability to find resources relevant to local information needs. Conclusions: The Learning Exchange is acceptable, feasible and useful as a knowledge management and exchange platform in service of the work of ICN. Experience with the ICN Learning Exchange suggests that the design principles are extensible to other chronic care Learning Networks.

  • The human factor: Value of interactions of a Clinician-Educator

    From: JMIR Human Factors

    Date Submitted: Jan 16, 2018

    Open Peer Review Period: Jan 17, 2018 - Jan 31, 2018

    The power and outreach of the media is enormous and has re-structured our society today. The author acknowledges the impact, appreciates the outreach. However, we question the relative lack of focus o...

    The power and outreach of the media is enormous and has re-structured our society today. The author acknowledges the impact, appreciates the outreach. However, we question the relative lack of focus on physical human interactions and express concern over future training efforts. We compare and attempt to highlight the components of two interaction scenarios- those of teacher-student, and those of physician-patient. The physician-educators need to generate a discussion regarding the value of each interaction. As a teacher, there is value in online classrooms, and a different value to face to face interactions. Similarly, a physician can have major outreach impact by online, tele-medicine and tele-education efforts, but in some instances, may need to have the human, physical interaction with the patient. The value to these interactions depends on the roles in which these interactions are experienced. Medical education training must incorporate an understanding of the unique value of different interactions.

  • Adolescent personality profile and internet addiction

    From: JMIR Mental Health

    Date Submitted: Jan 17, 2018

    Open Peer Review Period: Jan 18, 2018 - Mar 15, 2018

    Background: Previous research into effects of personality on internet addiction in adolescents has produced inconclusive results. Adolescents are considered to be at risk of Internet addiction because...

    Background: Previous research into effects of personality on internet addiction in adolescents has produced inconclusive results. Adolescents are considered to be at risk of Internet addiction because of their physical and psychological immaturity and negative effects of Internet use are more obvious in this age group. Objective: To determine the characteristics of adolescent personality that are most often associated with normal, moderate or serious Internet addiction and how these characteristics reflect on the six dimensions of Internet addiction. Methods: The study included 1078 male and female adolescents aged 11-18 years from Croatia, Poland, and Finland. The Internet addiction was assessed using Young's Internet Addition Test. A 30-item five-factor personality inventory, i.e., a Croatian version of the Goldberg's International Personality Item Pool, was used for personality assessment. Data were analyzed using a correlation analysis. Results: The level of Internet addiction did not significantly vary across different levels of neuroticism (P<.001); extraversion (P=.053); openness to experience (P<.001), and conscientiousness (P=.022). High and very high levels of openness were found in (46/241, 19%) of adolescents without Internet addiction and (92/241, 38%) adolescents with moderate and serious Internet addiction. Thus, openness was more pronounced in those more addicted to the Internet. Adolescents with moderate and serious Internet addiction showed higher levels of neuroticism, openness to new experience, and conscientiousness in comparison with adolescents evaluated as normal Internet users, whereas no difference was found for extraversion and agreeableness (P>.05). Conclusions: Analysis of correlation between five big personality traits and Internet addiction indicated that neuroticism, extraversion, and openness to new experience were more common among adolescents with moderate and serious Internet addictio

  • Assessing Physical Activity in Rehabilitation after Cardiac Surgery using Wearable Technology

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 17, 2018

    Open Peer Review Period: Jan 17, 2018 - Mar 14, 2018

    Background: Wearable technology is finding its way in clinical practices. Physical Activity (PA) describes patient’s functional status after cardiac surgery and in remote monitoring by use of PA tr...

    Background: Wearable technology is finding its way in clinical practices. Physical Activity (PA) describes patient’s functional status after cardiac surgery and in remote monitoring by use of PA trackers. Objective: The aim of this work is to assess the usability of a wearable fitness tracker, to monitor patients who underwent coronary artery bypass surgery, by either the conventional Off-Pump procedure (OPCAB) or robotically assisted CABG (RA-MIDCAB). We hypothesized a faster recovery of functional status after RA-MIDCAB in the first weeks after discharge. Methods: Patients undergoing RA-MIDCAB or OPCAB were included. Each patient received a Fitbit Charge Heart Rate PA tracker (Fitbit Inc., San Francisco, CA, USA) following discharge. Rehabilitation progress was assessed by measuring the number of steps and physical activity level (PAL) daily. PAL was calculated as energy expenditure divided by basic metabolic rate. Results: 10 RA-MIDCAB patients with a median age of 68 (IQR: [60;76]) and 12 OPCAB patients with a median age of 69 (IQR: [65;76]) were included. Baseline characteristics were comparable except for BMI (RA-MIDCAB: 26 Kg/m² [24;27] versus OPCAB: 29 Kg/m² [27;31]; P<0.001, respectively). Intubation time (P<0.05) was significantly lower in the RA-MIDCAB group. A clear trend, although not statistically significant, was observed towards a higher number of steps in RA-MIDCAB patients in the first week following discharge. Conclusions: Wearable PA trackers can describe functional status in a cardiac rehabilitation setting after surgery. RA-MIDCAB patients have an advantage in recovery in the first weeks of revalidation reflected by the number of steps and PAL, measured by the Fitbit Charge HR, compared to OPCAB patients. However, unsupervised assessment of daily PA varied greatly and this could involve consequences for the use of these trackers as research tools. Clinical Trial: S59757

  • Effects of the Digital Transformation: Disturbances and Limitations Using Video Visits in Outpatient Care

    From: Journal of Medical Internet Research

    Date Submitted: Jan 17, 2018

    Open Peer Review Period: Jan 17, 2018 - Mar 14, 2018

    Background: Video mediated meetings with patients were introduced in outpatient care at a hospital in Sweden. New behaviours and tasks emerged due to changes of roles, work processes and responsibilit...

    Background: Video mediated meetings with patients were introduced in outpatient care at a hospital in Sweden. New behaviours and tasks emerged due to changes of roles, work processes and responsibilities. The study investigates effects of digital transformation, in this case how video visits in outpatient care change work processes and introduces new tasks, in order to further improve the concept of video visits. Objective: Through real-time, social interactional features of preparing for and conducting video visits, the study examines clinicians’ perceived limitations and disturbances, and how the conditions between patients and clinicians may change when using video visits instead of face-to-face meetings in outpatient care. Methods: Qualitative methods have been used including 14 observations of video visits at two different clinics and 14 followup interviews with clinicians. Transcriptions of interviews and field notes were thematically analysed, discussed and synthesised into themes. Results: Disturbances and limitations related to the technology were related to time; a flexibility to schedule the meeting unbound of place, frustrations when the other part was late for the scheduled meeting, and that more experienced users of video visits usually waited longer before logging in. They were also related to sound; problems getting the sound to work satisfactory during the video visits, and problems with the image. Disturbances and limitations related to the surroundings were related to both the patient’s and the clinician’s environment; the principle of video technology in itself may affect the experience and the content of the consultation, and the surrounding chosen changes the conditions for and reduces the participants’ field of view. Conclusions: We could see 1) a transformation of roles and responsibilities when turning from face-to-face meetings to video visits, 2) that video visits add new circumstances, with a risk of introducing disturbances and limitations, that in turn affects the content of the meeting, 3) that avoiding negative disturbances during a video visit, requires a sensibility from the clinician’s side as well as a trust in the patient’s judgement, 4) that both expected and unexpected disturbances and limitations during a video visit affect the clinician’s behaviour, feelings, the content of the meeting and how the clinician’s relate to the different components of the concept, and 5) that there is a change of roles introduced when conducting video visits, e.g., the clinician taking the first line support if both (s)he and the patient encounter problems with the technology.

  • Mixed-Methods Evaluation of the Phased Implementation of a National Telehealth Weight Management Program for Veterans

    From: JMIR Diabetes

    Date Submitted: Jan 17, 2018

    Open Peer Review Period: Jan 20, 2018 - Mar 17, 2018

    Background: The burden of obesity is high among U.S. veterans yet many face barriers to engaging in in-person, facility-based treatment programs. To improve access to weight-management services, the V...

    Background: The burden of obesity is high among U.S. veterans yet many face barriers to engaging in in-person, facility-based treatment programs. To improve access to weight-management services, the Veterans Health Administration (VHA) developed TeleMOVE®, a home-based 82-day curriculum that utilizes in-home messaging devices to promote weight loss in VHA patients facing barriers to accessing facility-based services. Objective: Our primary aims were to establish preliminary evidence for the program to engage the priority population based on the number of patients enrolled per site as well as the program’s clinical effectiveness as demonstrated by average weight lost per patient. A secondary aim was to understand factors influencing implementation variability across demonstration sites to develop recommendations to inform the national TeleMOVE dissemination. Methods: We employed a formative mixed-methods design to evaluate the phased implementation of TeleMOVE programming at nine demonstration sites and to compare patient- and site-level measures of program uptake. Data was collected between October 1, 2009 and September 30, 2012. Twenty-eight stakeholders were recruited to provide contextual details while patient-level program outcomes were extracted from VHA patient care databases. Program stakeholders were recruited to participate in two rounds of semi-structured interviews about aspects of implementation processes, site-level contextual factors, and daily program delivery. Administrative data was used to evaluate program enrollment rates and clinical outcomes. To assess preliminary clinical effectiveness, weight loss outcomes for veterans who enrolled in TeleMOVE were compared to outcomes for participants enrolled in standard MOVE! at each demonstration site as well as to national averages during the first two years of program implementation. Results: Program uptake was high at two sites, delayed-high at one site, low at three sites, and three late-adopting sites declined interviews. At six months post-enrollment, mean weight loss was comparable for TeleMOVE (n=417) and MOVE! (n=1543) participants at -5.2 lb (SD=14.4) and -5.1 lb (SD=12.2), respectively (p=.91). All sites reported high program complexity because TeleMOVE required more staff time per participant than MOVE! due to logistical and technical assistance issues related to the devices. High-uptake sites overcame implementation challenges by leveraging strong communication networks with stakeholders, adapting the program to patient needs whenever possible, setting programmatic goals and monitoring feedback of results, and taking time to reflect and evaluate on delivery to foster incremental delivery improvements whereas, low-uptake sites reported less leadership support and effective communication among stakeholders. Conclusions: This evaluation of the phased implementation of a new clinical telehealth program demonstrates the value of partnership-based research in which researchers not only provide operational leaders with rapid and responsive feedback regarding the effectiveness of a new clinical program but also relevant feedback into contextual factors related to implementation to enable adaptations for national rollout of the program.

  • mHealth to Increase Treatment Utilization among Recently Incarcerated Homeless Adults: The Link2Care Study Protocol

    From: JMIR Research Protocols

    Date Submitted: Jan 17, 2018

    Open Peer Review Period: Jan 17, 2018 - Jan 31, 2018

    Background: There is a significant revolving door of incarceration among homeless adults. Homeless adults who receive the professional coordination of individualized care (i.e., case management) durin...

    Background: There is a significant revolving door of incarceration among homeless adults. Homeless adults who receive the professional coordination of individualized care (i.e., case management) during the period following their release from jail experience fewer mental health and substance use problems, are more likely to obtain stable housing, and are less likely to be re-incarcerated. This is because case managers work to meet the various needs of their clients by helping them to overcome barriers to needed services (e.g., food, clothing, housing, job training, substance abuse and mental health treatment, medical care, medication, social support, proof of identification, legal aid). Many barriers (e.g., limited transportation, inability to schedule appointments, limited knowledge of available services) prevent homeless adults who were recently released from incarceration from obtaining available case management, crisis management, substance abuse, and mental health services. Objective: The Link2Care study will assess the effectiveness of a smart phone application for increasing case management and treatment service utilization, and in turn reducing homelessness and re-arrest. The goals of this research are to: 1) assess the impact of an innovative smart phone application that will prompt and directly link recently incarcerated homeless adults to community-based case management services and resources, and 2) utilize in-person and smart phone-based assessments to identify key variables (e.g., alcohol/drug use, social support, psychological distress, quality of life) that predict continued homelessness and re-arrest. Methods: Homeless adults (N=432) who enroll in a shelter based Homeless Recovery Program after release from the Dallas County Jail will be randomly assigned to one of three treatment groups: 1) usual shelter-based case management (UCM), 2) UCM plus a study provided smart phone (UCM+SP), and 3) UCM with a study-provided smart phone that is preloaded with an innovative case management app (SPCM). Those assigned to SPCM receive smart phones that prompt (twice weekly) connections to shelter-based case managers. The app will also offer direct links to case managers (available during normal business hours) and crisis interventionists (available 24 hours a day, 7 days a week), with the touch of a button. Results: Recruitment is expected to begin in the spring of 2018, and the study will conclude in 2021. Conclusions: This research represents an important step toward integrated service connection and healthcare service provision for one of the most underserved, high need, and understudied populations in the U.S. Clinical Trial: NCT03399500

  • Development and Evaluation of a Mobile Decision Support System for Hypertension Management in the Primary Care Setting in Brazil

    From: Journal of Medical Internet Research

    Date Submitted: Jan 18, 2018

    Open Peer Review Period: Jan 18, 2018 - Mar 15, 2018

    Background: Despite being an important cardiovascular risk factor, hypertension (HT) has low control levels worldwide. Computerized clinical decision support systems (CDSS) might be effective in reduc...

    Background: Despite being an important cardiovascular risk factor, hypertension (HT) has low control levels worldwide. Computerized clinical decision support systems (CDSS) might be effective in reducing blood pressure, with a potential impact in reducing cardiovascular risk. Objective: To evaluate the feasibility and usability of a CDSS, named TeleHAS, in the care of patients with HT in the context of primary care setting in a middle income country, as well as the physician’s satisfaction with its use. Methods: The TeleHAS application consists of a platform integrating clinical and laboratory data of a particular patient, from which it performs cardiovascular risk calculation and provides evidence-based recommendations derived from Brazilian and international guidelines for the management of HT and cardiovascular risk. Ten family physicians of different primary care units in Montes Claros city, Brazil, were randomly selected to use the application for the care of hypertensive patients for 6 months. After 3 months, the feasibility and usability of the CDSS in the routine care of the health teams was evaluated through standardized questionnaire and semi-structured interviews. After 6 months, another questionnaire and semi-structured interviews were applied to test the satisfaction of the physicians with the application. Results: Throughout the study, clinicians registered 535 patients with HT, at an average of 1.24 consultations per patient. Women accounted for 80% of participant doctors, median age 31.5 years (interquartile range 27-59 years). As for feasibility, 100% of medical users claimed it is possible to use the application in the primary care setting and for 80% of them it is easy to incorporate its use in the daily routine and home visits. Nevertheless, 70% of physicians claimed that the time taken to fill out the CDSS causes significant delays in service. Clinicians evaluated the TeleHAS as good (80% of users), with easy filling blanks and friendly interface (100%) and with the potential to improve patients’ treatment (100%). Ninety percent of physicians had access to new knowledge about cardiovascular risk and HT through the application recommendations and found it useful to promote prevention and optimize treatment. Conclusions: In this study, a CDSS developed to assist the management of patients with HT was applicable in the context of primary health care setting in a middle income country, with good user’s satisfaction and potential to improve adherence to evidence-based practices.

  • Reproductive Health and Medication Concerns for Patients with Inflammatory Bowel Disease: Investigation of Information-Seeking and Concerns Using Social Listening

    From: Journal of Medical Internet Research

    Date Submitted: Jan 17, 2018

    Open Peer Review Period: Jan 18, 2018 - Mar 15, 2018

    Background: Inflammatory bowel disease (IBD) affects many patients of reproductive age. Most IBD medications are safe to use during pregnancy and breastfeeding, but despite this, observational studies...

    Background: Inflammatory bowel disease (IBD) affects many patients of reproductive age. Most IBD medications are safe to use during pregnancy and breastfeeding, but despite this, observational studies note that women, particularly those with Crohn’s Disease, have higher rates of voluntary childlessness due to concerns surrounding medication side effects, passing the disease to their offspring, fear of infertility and advice given by treating physician. Moreover, many women perceive medications to be unsafe during pregnancy. We employ social listening of online forums and social media to explore how patients with IBD understand, discuss, and act on the perceived risks and benefits associated with taking IBD medications during pregnancy and breastfeeding. Objective: The objective of this study was to gain a more thorough understanding of how individuals taking IBD medications during key reproductive periods make decisions about their medications to inform clinical practice. Having a better understanding about why patients stop or refuse to take certain medications during key reproductive periods may allow clinicians to address specific beliefs and attitudes during office visits. Methods: We collected posts from 3,000 social media sites posted over a 3-year period and analyzed posts using qualitative content analysis. After an initial read-through of the posts, we created a preliminary codebook using inductive methods and grounded the codes in the data. We created new codes as we continued to code the data and iteratively coded the posts, re-coding all posts with new codes as we constructed them. We then organized the codes into larger categories. Results: We identified 7 main themes in 1818 social media posts. Patients used social media to (1) seek advice about medication use related to reproductive health (N = 253, 14%); (2) express beliefs about the safety of IBD therapies (N = 135, 7%); (3) discuss personal experiences with medication use (N = 304, 17%); and (4) articulate fears and anxieties about the safety of IBD therapies (N = 210, 12%). Patients also discussed their (5) physician-patient relationships, (N=57, 3%), (6) concerns around infertility and IBD medications, (N = 316, 18%) and (7) IBD symptoms during and after pregnancy and breastfeeding periods (N = 206, 11%). Conclusions: Beliefs around medication safety play an important role in whether patients with IBD decide to take medications during pregnancy and breastfeeding. Increased provider education and better patient decision-making tools may help patients better understand the risks and benefits of medication use during pregnancy and breastfeeding.

  • The Complexity of Mental Health App Privacy Policies: A Potential Barrier to Privacy

    From: Journal of Medical Internet Research

    Date Submitted: Jan 17, 2018

    Open Peer Review Period: Jan 18, 2018 - Mar 15, 2018

    Background: In 2017, the Indian Supreme Court ruled that privacy is a fundamental right of every citizen. While smartphone apps have the potential to help people with non-communicable diseases, they o...

    Background: In 2017, the Indian Supreme Court ruled that privacy is a fundamental right of every citizen. While smartphone apps have the potential to help people with non-communicable diseases, they often contain complex privacy policies which consumers may not understand. This complexity may impede consumers’ ability to make decisions regarding privacy, a critical issue due to the stigma of mental illness. Objective: Our objective is to determine whether mental health apps have more complex privacy policies than diabetes apps. Methods: The study utilizes privacy policies extracted from apps. Apps pertained to diabetes or mental health, and were of Indian origin. Privacy policy reading complexity was compared between the two types of apps using a series of fifteen readability measures. The universe of applicable apps on the Google Play store, as viewed between May and June 2017, was considered. The measures of readability were compared using Chi-square tests. Results: No significant difference was found between the privacy policy readability of the diabetes apps versus the mental health apps for each of the measures considered. As the mean Flesch-Kincaid Grade Level was 13.9 for diabetes apps and 13.6 for mental health apps, the mean policy was written at a college level. Privacy policies in the 25th percentile of complexity were also written at a college level for both types of apps. Conclusions: Privacy policy complexity may be a barrier for informed decision making. Clinical Trial: NA

  • Reproductive cancers among South African Black men: A scoping review protocol

    From: JMIR Research Protocols

    Date Submitted: Jan 18, 2018

    Open Peer Review Period: Jan 18, 2018 - Feb 1, 2018

    Background: The absence of information on reproductive cancer in Black men in South Africa creates a knowledge gap about health outcomes. Consequently, it is necessary to map the existing information...

    Background: The absence of information on reproductive cancer in Black men in South Africa creates a knowledge gap about health outcomes. Consequently, it is necessary to map the existing information in order to formulate research that addresses the knowledge gap. To establish the range, nature and extent of published research on reproductive cancer in Black men in South Africa, an intensive scoping literature search has been designed. Methods: This study is a rigorous scoping review, conducted by five researchers and intends to explore and uncover the depths of existing research and identify research gaps. The literature search is conducted through online databases and policy documents. The process includes title, abstract and paper review and data abstraction, as espoused by Arksey and O’Malley (2005). Data is analysed using critical thematic analysis. This is mostly a web-based search no human subjects are to be used and does not require obtaining ethics clearance. Discussion: no other scoping or systematic review have been conducted on this topic from the continent. Therefore there is no coherent evidence that indicates the research gaps for future research on reproductive cancer for Black men. The proposed scoping review is necessary to advance science borne of a systematic approach. This scoping protocol outlines the methodology for critical literature appraisal to identify the topics in literature on Black men with reproductive cancer and possibly point out to new areas of research gaps. Conclusion: This protocol is sufficient for the purposes of this study and contributes meaningfully to research on male reproductive cancers in South Africa. This protocol also provides an audit trial to ensure scientific rigour and reproducibility of the research findings

  • Digital interventions to support people in recovery from substance use disorders: a review of feasibility and effects

    From: Journal of Medical Internet Research

    Date Submitted: Jan 18, 2018

    Open Peer Review Period: Jan 18, 2018 - Mar 15, 2018

    Background: The development and evaluation of digital interventions aimed at preventing or treating substance use related problems and disorders is a rapidly growing field. Previous reviews of such in...

    Background: The development and evaluation of digital interventions aimed at preventing or treating substance use related problems and disorders is a rapidly growing field. Previous reviews of such interventions reveal a large and complex picture with regard to targeted users, utilization, and efficacy. Objective: The objective of this review is to investigate the feasibilty and effects of the subset of digital interventions developed specifically for digital platforms, that are focused on supporting people in recovery from Substance Use Disorders, helping them to achieve their substance use goals, and to develop a more satisfying life situation. This group of interventions has not been targeted in prior reviews. Methods: The review is based on a systematic search in Pubmed, Embase, PsychInfo and Cochrane Library. Of the 1142 identified papers, 714 were first excluded as obviously not relevant. Of the remaining papers, 21 were found to be previous reviews, 269 was on interventions aimed at reducing hazardous alcohol or cannabis use and 94 was on digitized versions of treatment interventions that were not developed originally for digital platforms. The remaining 44 papers were all read in full and systematically scored by both authors. Results: The 44 papers cover 29 unique interventions, of which 34 have been published after 2013. Based on the number of features or modules, the interventions were categorized as simple or complex. Eleven of the 19 simple interventions and six of the 10 complex interventions had been studied with quantitative controlled methodologies. Fourteen of the 19 simple interventions were integrated in other treatment or support systems, mainly delivered as smartphone apps, while six of the ten complex interventions were designed as “stand alone” interventions, most often delivered on a platform combining desktop/web and smartphone technologies. The interventions were generally easy to implement, but the implementation of the complex interventions was found to be more dependent on sustained organizational support. 70-90% of the participants found the interventions to be useful and easy to use. The rates of sustained use were also generally high, except for simple interventions with an open internet-based recruitment and some information and education modules of the complex interventions. Across all interventions, slightly more than half (55%) of the studies with control groups generated positive findings on one or more substance use outcomes, with 54% of the interventions also found to be efficacious in one or more studies. In the positive studies, effects were typically in the small to moderate range, with a few studies yielding larger effects. Due to stronger control conditions, simple interventions were less likely to produce positive effects. Conclusions: The digital interventions included in this review are in general feasible but are not consistently effective in helping people in recovery from SUD reduce their substance use or achieving other recovery goals.

  • Similarities in postoperative recovery and health care contacts within 14 days in males and females with mHealth follow up

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 18, 2018

    Open Peer Review Period: Jan 18, 2018 - Mar 15, 2018

    Background: BACKGROUND. Earlier studies have reported that females are prone to experience a poorer recovery compared to men. One research group has developed a smartphone application (app) called RAP...

    Background: BACKGROUND. Earlier studies have reported that females are prone to experience a poorer recovery compared to men. One research group has developed a smartphone application (app) called RAPP (Recovery Assessment by Phone Points) that includes the Swedish Quality of Recovery questionnaire (SwQoR). Objective: OBJECTIVE. The aim of this study was to investigate sex differences in postoperative recovery and number of health care contacts within 14 postoperative days in a cohort of day surgery patients using RAPP. Methods: METHODS. This study was a secondary analysis from a single-blind randomized controlled trial. Conducted at four day surgery settings in Sweden from October 2015 to July 2016. Included were 494 patients (220 male and 274 female) undergoing day surgery. Results: RESULTS. There were no significant sex differences in postoperative recovery or health care contacts. Subgroup analysis showed that females < 45 years of age reported significantly higher global scores in SwQoR (hence a poor recovery) on postoperative days 1-10 compared to females ≥45 years. Males < 45 years of age reported significantly higher global scores on postoperative day 2-6 compared to males ≥45 years. No significant sex differences were seen when comparing different age groups. Conclusions: CONCLUSIONS. This study indicates that there are sex similarities in postoperative recovery and health care contacts. However, subgroup analysis showed that age might be an independent factor for poorer recovery in both female and male. This knowledge can be used when informing patients what to expect after discharge. Clinical Trial: NCT02492191.

  • Designing emails aiming to increase family physicians’ use of an online audit and feedback tool to improve cancer screening rates

    From: JMIR Human Factors

    Date Submitted: Jan 18, 2018

    Open Peer Review Period: Jan 18, 2018 - Feb 1, 2018

    Background: Providing clinical performance data to health professionals, a process known as audit and feedback, can play an important role in health system improvement. However, audit and feedback too...

    Background: Providing clinical performance data to health professionals, a process known as audit and feedback, can play an important role in health system improvement. However, audit and feedback tools can only be effective if the targeted health professionals access and actively review their data. Email is a popular channel for communicating with physicians and could be used to encourage engagement with performance data; however, little guidance exists for the development of effective email messages in this context. Objective: To describe the process of developing email content to promote the use of Cancer Care Ontario’s Screening Activity Report (SAR) that incorporates user input and behaviour change techniques (BCTs). The SAR is an online tool with patient-level data that is intended to help Ontario family physicians improve rates of timely and appropriate screening in their practice. Methods: Our interdisciplinary research team first identified BCTs shown to be effective in other settings that could be adapted to promote use of the SAR. We then developed draft BCT-informed email content. Next, we conducted co-creation workshops with physicians who had logged in to the SAR more than once over the past year. Participants provided reactions to researcher-developed BCT-informed content and helped to develop an email that they believed would prompt their colleagues to use the SAR. Content from co-creation workshops was brought to focus groups with physicians who had not used the SAR in the past year. We analyzed notes from co-creation workshops and focus groups to inform decisions about content. Finally, eight emails were created to test BCT-informed content in a 2X2X2 factorial randomized experiment. Results: We identified three key tensions during the development of the email that required us to balance user input with scientific evidence, organizational policies, and our scientific objectives: 1) conflict between user preference and scientific evidence, 2) privacy constraints around personalizing unencrypted emails with performance data, 3) using co-creation methods in a study with the objective of developing an email that featured unique BCT-informed content. Conclusions: Teams tasked with developing content to promote health professional engagement with audit and feedback or other quality improvement tools might consider co-creation processes for developing communications that are informed by both users and BCTs. Teams should be cautious about making decisions solely based on user reactions since what users seem to prefer is not always the same as what works. Furthermore, implementing user recommendations may not always be feasible. Teams may face tensions when using co-creation methods to develop a product with the simultaneous goal of having unique variables to test in later studies. The expected role of users, evidence, and the implementation context all warrant consideration to determine whether and how co-creation methods could help to achieve design and scientific objectives.

  • InformedTogether: A decision aid to support shared decision making about mechanical ventilation in severe COPD patients

    From: Journal of Participatory Medicine

    Date Submitted: Jan 19, 2018

    Open Peer Review Period: Jan 19, 2018 - Mar 16, 2018

    Background: Severe COPD patients are often unprepared to make decisions about accepting/foregoing intubation for respiratory failure. We developed a web-based decision aid, InformedTogether, to facil...

    Background: Severe COPD patients are often unprepared to make decisions about accepting/foregoing intubation for respiratory failure. We developed a web-based decision aid, InformedTogether, to facilitate severe COPD patients’ preparation for decision making about whether to accept IMV for respiratory failure. Objective: Herein, we describe feasibility testing of the InformedTogether decision aid. Methods: Mixed methods, pre-post intervention feasibility study in outpatient pulmonary and geriatric clinics. Clinicians used InformedTogether with severe COPD patients. Patient-participants completed pre/post assessments pertaining to InformedTogether use. Outcomes measured were: feasibility/acceptability; communication (COMRADE, MCCS, OPTION scales); effectiveness of InformedTogether on changing patients’: knowledge, decisional conflict (DCS), and motivation. Results: We enrolled 11 clinicians and 38 COPD patients at 6 sites. Feasibility/acceptability: Clinicians and patients gave positive responses to acceptability questions (mean 74.1/89 max, s.d. 7.24; and 59.63/61, s.d. 4.49 respectively). Communication: 96% of clinicians stated InformedTogether improved communication (modified MCCS mean 44.54/49 (s.d. 2.97)). Mean OPTION score 32.03/48 (s.d. 9.27)), and mean COMRADE Satisfaction 4.31/5.0, s.d. 0.58; COMRADE Confidence 4.18/5.0, s.d. 0.56. 80% of patients discussed preferences with their surrogates by 1-month. Effectiveness: Knowledge scores increased significantly after using InformedTogether (mean difference 3.61; s.d. 3. 44 p <0.0001) and Decisional Conflict decreased (mean difference DCS pre/post -13.76; s.d. 20.39; p < 0.006). Motivation increased after viewing the decision aid. Conclusions: InformedTogether supports high quality communication and shared decision making among COPD patients, clinicians and surrogates. The increased knowledge and opportunity to deliberate and discuss treatment choices after using InformedTogether should lead to improved decision making at the time of critical illness.

  • “As if neck injuries did not exist”: A qualitative interview study of patients' and relatives' perceptions of online information on whiplash injuries

    From: Journal of Medical Internet Research

    Date Submitted: Jan 18, 2018

    Open Peer Review Period: Jan 18, 2018 - Mar 15, 2018

    Background: If purposefully designed, patient information can support patients in making well-founded decisions about their care. The study was initiated to improve the online information about whipla...

    Background: If purposefully designed, patient information can support patients in making well-founded decisions about their care. The study was initiated to improve the online information about whiplash injuries at the patient information portal of the Swedish government. Objective: The aim is to describe how patients and relatives perceive the national online information about whiplash injuries. Methods: Five interviews were made with patients (n = 10) who had had a whiplash injury and with relatives (n = 3) of such patients. Interviews were held, until no more categories appeared and we estimated that saturation was reached. The interviews were taped, transcribed verbatim and analysed by means of conventional content analysis. Results: Two themes emerged from the latent content analysis: on the one hand, a confidence and trust in the public health care system (hereinafter health care), and on the other, a disappointment with health care encounters. Conclusions: We found that taking part of the online information had caused distress to most of the study participants because of discrepancy between the sender’s authority and deficient information. The online information on whiplash injuries may greatly impact patients’ care decisions as well as their physical, mental and social wellbeing. We would recommend that patient information about whiplash injuries is made highly informative, with less emphasis on psychology and a patient wide perspective on pathophysiology, prognosis and treatment.

  • Clinical feasibility of monitoring resting heart rate using a wearable activity tracker in patients with thyrotoxicosis: prospective longitudinal observational study

    From: Journal of Medical Internet Research

    Date Submitted: Jan 18, 2018

    Open Peer Review Period: Jan 19, 2018 - Jan 27, 2018

    Background: The symptoms and signs of thyrotoxicosis are non-specific and difficult to assess its clinical status with conventional physical examination and history taking. Palpitation or increased he...

    Background: The symptoms and signs of thyrotoxicosis are non-specific and difficult to assess its clinical status with conventional physical examination and history taking. Palpitation or increased heart rate is one of the key symptom or sign of thyrotoxicosis and easiest parameters to quantify. Objective: We assessed the association of the resting heart rate measured by wearable activity tracker (WD-rHR) with thyroid function and its clinical application in patients with thyrotoxicosis. Methods: Thirty patients with thyrotoxicosis and ten controls who could use the smartphone and applications were included at Seoul National University Bundang Hospital. They were instructed to use the wearable activity tracker during the study period, data on changes in heart rate were collected. The primary outcomes were verification of changes in WD-rHR during the treatment of thyrotoxicosis, and associations between WD-rHR and thyroid function. Odds ratio was computed per one standard deviation (1SD) increase in WD-rHR in relation to risk of thyrotoxicosis. These results were compared with that of conventionally obtained rHR at clinic visits (on-site rHR) or hyperthyroidism symptom scale (HSS). Results: WD-rHR was higher in thyrotoxic patients compared to controls, and decreased in association with improvement of thyrotoxicosis. WD-rHR was associated with serum free thyroxine (T4) concentration (B=1.674, P < .001) and clinical thyroid function status. These associations were superior to on-site rHR (B=1.485, P < .001) and similar to HSS (B=1.717, P < .001). WD-rHR also showed the highest odds ratio for thyrotoxicosis (3.843 [95% CI 2.067 – 7.144]) compared with on-site rHR or HSS (2.114 [1.365 – 3.273] or 3.601 [2.190 – 5.923], respectively). Conclusions: WD-rHR can provide more accurate information about the thyroid function than other clinical parameters, and has potential to improve the management of thyrotoxicosis. Clinical Trial: Clinicaltrials.gov NCT03009357

  • Activity Trackers, Relational Affordances, and Device Ecologies of Fitness Technologies

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 19, 2018

    Open Peer Review Period: Jan 20, 2018 - Mar 17, 2018

    Background: With the proliferation of activity-tracking devices and other smart tools, more users leverage these technologies to track their physical and fitness-related activities. The research on th...

    Background: With the proliferation of activity-tracking devices and other smart tools, more users leverage these technologies to track their physical and fitness-related activities. The research on the benefits (and limitations) of these devices tends to focus on the use of a single tool, leaving out the interactions among multiple technologies, and how these interactions influence the way users perceive affordances of activity trackers. Objective: The research on the benefits (and limitations) of fitness tacking devices to date tends to focus on the use of a single tool, leaving out the interactions among multiple technologies. Building from an ecological perspective, this work extend the research on activity-tracking devices by providing insight into the relationships among activity tracking devices and other fitness-related technologies within the device ecology of technologies around the user. Methods: This exploratory, qualitative study is based on 29 semi-structured, in-depth interviews with users of Fitbit fitness tracking devices. Results: Analysis of the interviews revealed competitive and complementary interactions among various fitness tracking devices, and explained how these interactions influenced the way users perceived affordances of fitness trackers in a device ecology. Conclusions: The affordances of fitness devices are not enacted in isolation but are relational to those of other technological options and differing personal preferences and goals of the user.

  • Social processes of online empowerment on a cancer patient discussion form: using text mining to analyze linguistic patterns of empowerment processes

    From: Journal of Medical Internet Research

    Date Submitted: Jan 19, 2018

    Open Peer Review Period: Jan 20, 2018 - Mar 17, 2018

    Background: Peer-to-peer online support groups and the discussion forums in these groups can help patients by providing opportunities for increasing their empowerment. Most previous research on online...

    Background: Peer-to-peer online support groups and the discussion forums in these groups can help patients by providing opportunities for increasing their empowerment. Most previous research on online empowerment and online social support uses qualitative methods, or questionnaires to gain insight into the dynamics of online empowerment processes. Objective: The overall goal of this study was to analyze the presence of the empowering processes in the online communication of people affected by cancer, using text mining techniques. Use of these relatively new methods enable to study social processes such as empowerment on large scale and with unsolicited data, avoiding unintended biases caused by research tools. Methods: The sample consisted of 5534 messages in 1708 threads by 2071 by users of a forum for cancer patients and their relatives. Supervised and unsupervised text mining techniques were used to explore the online communication of the users. Supervised text mining techniques were applied to operationalize empowerment: a random subsample of 2051 messages in the forum was manually labeled with five empowerment processes (sharing narrative, asking a question, providing information, emotional support, reference to information), using a coding scheme based on knowledge from previous research. Machine learning classifiers (Linear Support Vector Classification and Logistic regression) were then trained on the content of the messages with their manually assigned labels and the remainder of the sample was automatically labeled with empowerment processes using the generated model. For the unsupervised part, the messages in the sample were automatically labeled with categories from the Linguistic Inquiry and Word Count (LIWC). Subsequently, the supervised and unsupervised data were studied in conjunction. Empowerment was studied in relation to the intensity of online participation in relation to the LIWC categories. Results: The precision of the automatic labeling was 85.6%, which was considered to be sufficient for automatically labeling the complete corpus and doing further analyses on the labeled data. 62.9% of the messages contained a narrative, 23.8% a question, and 27.5% informational support. Emotional support and references to external sources were less frequent. Users with more posts more often referred to an external source, provided informational support, and emotional support (Kendall τ > 0.2, p < 0.001) and less often shared narratives (Kendall τ = -0.297, p < 0.001). A number of LIWC categories are significant predictors for the empowerment processes. Words expressing assent (‘ok’, ‘yes’) and emotional processes (expressions of feelings) are significant positive predictors for emotional support (p = 0.002). Conclusions: Empowerment processes are associated with intensity of online use. The relation between linguistic analyses and empowerment processes indicates that empowerment processes can be identified from the occurrences of specific linguistic cues.

  • Mobile applications for blood pressure monitoring: a systematic review

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 19, 2018

    Open Peer Review Period: Jan 20, 2018 - Mar 17, 2018

    Background: Using a mobile application for self-management could make it easier for patients to get insight into their blood pressure patterns. However, little is known about the availability, quality...

    Background: Using a mobile application for self-management could make it easier for patients to get insight into their blood pressure patterns. However, little is known about the availability, quality, and features of mobile apps targeting blood pressure. Objective: To determine the availability, functionality, and quality of mobile applications that could be used for blood pressure monitoring purposes. Methods: The systematic literature review framework was applied to the search, screening, and assessment of applications. We included all English and Dutch mobile applications targeting blood pressure that were available in the official app stores of Android and iOS. Two independent assessors determined eligibility and quality of the applications using the five point Mobile App Rating Scale. Quality scores of the applications with and without 17 a priori selected characteristics were compared using independent sample t-tests. Results: A total of 184 applications (104 Android, 80 iOS) met the inclusion criteria. The mean overall Mobile App Rating Scale score was 2.63 (95%CI 2.55, 2.71) for Android and 2.64 (95%CI 2.56, 2.71) for iOS. The applications ‘Bloeddruk’ (4.1) and ‘AMICOMED BP’ (3.6) had the highest quality scores on the Android and iOS platforms, respectively. Of the application characteristics recorded, only pricing, in-app advertisements, and local data storage were not associated with the quality scores. In only 3.8% of the apps, involvement of medical experts in its development was mentioned, whereas none of the apps was formally evaluated and published in peer-reviewed journals. Conclusions: This study provides an overview of the best applications currently available in the application stores and important key features for self-management that can be used by healthcare providers and patients with hypertension to identify a suitable application targeting blood pressure monitoring. However, the majority of the applications targeting blood pressure monitoring were of poor quality. Therefore, it is important to involve medical experts in the developmental stage of health-related mobile applications to improve the quality of these applications.

  • Behind the scenes of online therapeutic feedback in blended therapy for depression: a mixed methods observational study

    From: Journal of Medical Internet Research

    Date Submitted: Jan 19, 2018

    Open Peer Review Period: Jan 19, 2018 - Jan 27, 2018

    Background: In internet-delivered cognitive-behavioral therapies (iCBT), written feedback by therapists is a substantial part of therapy. However, it is not yet known how this feedback should be given...

    Background: In internet-delivered cognitive-behavioral therapies (iCBT), written feedback by therapists is a substantial part of therapy. However, it is not yet known how this feedback should be given best and which specific therapist behaviors and content are most beneficial for patients. General instructions for written feedback are available, but the uptake and effectiveness of these instructions in iCBT have not been studied yet. Objective: To identify therapist behaviors in written online communication to patients in blended CBT for adult depression in routine secondary mental health care; to identify the extent to which the therapists adhere to feedback instructions; and to explore whether therapist behaviors and adherence to feedback instructions are associated with patient outcome. Methods: Adults receiving blended CBT for depression in routine mental health care were recruited in the context of the European implementation project MasterMind. A qualitative content analysis was used to identify therapist behaviors in online written feedback messages, and a checklist for the feedback instruction adherence of the therapists was developed. Correlations were explored between the therapist behaviors, therapist instruction adherence, and patient outcomes (number of completed online sessions and symptom change scores). Results: 45 patients received 219 feedback messages given by 19 therapists. The most frequently used therapist behaviors were informing, encouraging and affirming. However, these were not related to patient outcomes. Although infrequently used, confronting was positively correlated with session completion (r=.342, P=.02). Therapists adhered to most of the feedback instructions. Only two feedback aspects were correlated with session completion: The more therapists adhere to instructions containing structure (limiting to two subjects and sending feedback within three working days) and readability (short sentences and short paragraphs) the less online sessions were completed (r=-.340, P=.02 and r=-.361, P=.02 respectively). No associations were found with depression symptom change scores. Conclusions: The therapist behaviors found in this study are comparable to previous research. The findings suggest that online feedback instructions for therapists provide sufficient guidance to communicate in a supportive and positive manner with patients. However, the instructions might be improved by adding more ‘therapeutic’ techniques besides the focus on style and form.

  • Title: Playing Telephone: Understanding the state of medication decision making in growing healthcare teams in the time of electronic health records

    From: Journal of Medical Internet Research

    Date Submitted: Jan 19, 2018

    Open Peer Review Period: Jan 20, 2018 - Mar 17, 2018

    Background: Primary care needs to be patient-centred, integrated and interprofessional to help patients with complex needs manage the burden of medication-related problems. Considering the growing pro...

    Background: Primary care needs to be patient-centred, integrated and interprofessional to help patients with complex needs manage the burden of medication-related problems. Considering the growing problem of polypharmacy, there is increasing attention on how and when medication-related decisions should be coordinated across multi-disciplinary care teams. Improved knowledge on how integrated EHRs can support interprofessional shared decision-making for medication therapy management is necessary to continue to improve patient care. Objective: This objective of this study was to examine how physicians and pharmacists understand and communicate patient-focused medication information with each other and how this knowledge can influence the design of electronic health records. Methods: This study is part of a broader cross-Canada study between patients and health care providers around how health-related decisions are made and communicated. We visited community pharmacies, team-based primary care clinics, and independent-practice family physician clinics throughout Ontario, Nova Scotia, Alberta, and Quebec. Semi-structured interviews were conducted with physician and pharmacists. A modified version of the Multidisciplinary Framework Method was used to analyze the data. Results: Data was collected at 19 pharmacies and 9 medical clinics and we identified six main themes from 34 health care professionals. Interprofessional Shared Decision Making was not occurring and clinicians made decisions based on their understanding of the patient. Physicians and pharmacists reported indirect Communication, incomplete Information specifically missing insight into indication and adherence, and misaligned Processes of Care further compounded by electronic health records not designed to facilitate collaboration. Scope of Practice examined professional and workplace boundaries for pharmacists and physicians that were internally and externally imposed. Physicians decided on the degree of the Physician/Pharmacist Relationship which was often predicated by co-location. Conclusions: When managing medications, there was limited communication and collaboration between primary care providers and pharmacists. Pharmacists were missing key information around reason for use, and physicians required accurate information around adherence. EHRs are a potential tool to help clinicians communicate information to resolve this issue. EHRs need to be designed to facilitate interprofessional medication management, so that pharmacists and physicians move beyond task-based work toward a collaborative approach Clinical Trial: n/a

  • Evaluation and validation of the general process of parenteral nutrition using mHealth technologies.

    From: JMIR mHealth and uHealth

    Date Submitted: Jan 20, 2018

    Open Peer Review Period: Jan 20, 2018 - Mar 17, 2018

    Background: Any system applied to the control of parenteral nutrition (PN) ought to prove that the process meets the established requirements and to include a repository of records to host and evaluat...

    Background: Any system applied to the control of parenteral nutrition (PN) ought to prove that the process meets the established requirements and to include a repository of records to host and evaluate the information about PN processes at any time. Objective: To evaluate the mHealth application and validate its effectiveness in monitoring the management of the parenteral nutrition process. Methods: Study of evaluation and validation of the general process of parenteral nutrition using mHealth application. The units of analysis were the PN bags prepared and administered at the Son Espases University Hospital (HUSE), Palma, Spain, from June 1 to September 6, 2016. Evaluation of the application it was used the Post-Study System Usability Questionnaire (PSSUQ) and subsequent analysis using the Cronbach's Alpha coefficient. Validation was carried out by checking the compliance of control for all the operations on each of the stages (validation and transcription of the prescription, preparation, conservation and administration) and monitoring the operational control points and critical control points. Results: The results obtained from 387 bags were analyzed, with 30 interruptions of the administration. The fulfillment of the stages was 100%, including non-critical nonconformities in the storage control. The average deviation in the weight of the bags was less than 5% and the infusion time did not present deviations greater than 1 hour. Conclusions: The developed application successfully passed the evaluation and validation tests and it can be considered as adequate to carry out the monitoring procedures for the overall PN process.

  • Video outpatient consultations: a case study of real-world implementation at macro, meso and micro level

    From: Journal of Medical Internet Research

    Date Submitted: Jan 20, 2018

    Open Peer Review Period: Jan 20, 2018 - Jan 29, 2018

    Background: There is much interest in virtual consultations using video technology. Randomized controlled trials have shown video consultations to be acceptable, safe and effective in selected conditi...

    Background: There is much interest in virtual consultations using video technology. Randomized controlled trials have shown video consultations to be acceptable, safe and effective in selected conditions and circumstances. But this service model has rarely been mainstreamed and sustained in real-world settings. Objective: To a) define good practice and inform implementation of video outpatient consultations, and b) generate transferable new knowledge about challenges to scaling up and routinizing this service model. Methods: Multi-level mixed-method study of Skype™ video consultations (micro-level) embedded in an organizational case study (meso-level), taking account of national context and wider influences (macro-level). The study followed the introduction of video outpatient consultations in three clinical services (Diabetes, Diabetes Antenatal, Cancer Surgery) in a National Health Service acute trust (covering three hospitals) in London, UK. Data sources included 36 national-level stakeholders (exploratory and semi-structured interviews); longitudinal organizational ethnography (300 hours of observations; 24 staff interviews); 30 videotaped remote consultations; 17 audiotaped face-to-face consultations; and national and local documents. Data were analysed using sociotechnical change theories and the Roter Interactional Analysis System. Quantitative data included uptake of video consultations by staff and patients and micro-categorization of different kinds of talk. Qualitative data addressed staff and patient experience and organizational and system drivers. Results: When clinical, technical and practical preconditions were met, video consultations in this setting appeared safe and were popular with some patients and staff. Compared with face-to-face consultations for similar conditions, video consultations were very slightly shorter; patients did slightly more talking; and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Video consultations appeared to work better when clinician and patient already knew and trusted each other. Some clinicians used Skype™ adaptively to respond to patient requests for ad hoc encounters in a way that appeared to strengthen supported self-management. The reality of establishing video outpatient services in a busy and financially stretched acute hospital setting proved more complex and time-consuming than originally anticipated. By the end of this study, between 2 and 22 percent of consultations were being undertaken remotely by participating clinicians. In the remainder, clinicians chose not to participate or video consultations were considered impractical, technically unachievable or clinically inadvisable. Technical challenges were typically minor but potentially prohibitive. Conclusions: Video outpatient consultations appear safe, effective and convenient for patients in situations where participating clinicians judge them clinically appropriate, but such situations are a fraction of the overall clinic workload. As with other technological innovations, some clinicians will adopt readily while others will need incentives and support. There are complex challenges to embedding video consultation services within routine practice in organizations that are hesitant to change, especially at a time of austerity. Clinical Trial: Not applicable.

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