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JMIR Preprints contains pre-publication/pre-peer-review preprints intended for community review. 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:

  • Exploratory Study of funding and commercialization strategies for sustainable adoption and scale-up of mHealth initiatives in the LMICs.

    From: JMIR mHealth and uHealth

    Date Submitted: May 20, 2016

    Open Peer Review Period: May 25, 2016 - Jul 20, 2016

    Background: The new Sustainable Development Goals consist of 17 goals among which Universal Health Coverage (SDG3) and Partnerships for the Goals (SDG17) are two of the most relevant for our purposes....

    Background: The new Sustainable Development Goals consist of 17 goals among which Universal Health Coverage (SDG3) and Partnerships for the Goals (SDG17) are two of the most relevant for our purposes. (1) With rapid growth and daily innovations, Information and Communication Technology (ICT) has become the cornerstone of transforming global health care industry all around the world. Wide penetration of internet and mobile networks in many low and middle income countries (LMICs) has brought about new ideas and promises for better access, lower costs and higher quality of health services in remote areas. To make this promise come true, the ICT and global health industry along with a vast number of user and provider stakeholders have developed hundreds of transboundary mHealth ecosystems to leverage the provision and distribution of equitable health services operation, management and control through various mHealth initiatives. However, the lack of empirical evidence supporting the cost, performance and health outcomes of mHealth initiatives have impeded post pilot scale up, implementation and integration of mobile technologies in many health systems. On the same note, with limited financial and structural resources and without supporting empirical evidence the LMICs which are most likely to benefit from sustainable mHealth interventions, often do not manage to grab the attention of public and private partners to secure sustainable investments for scale up phase. Results of this study show that in agreement with the SDG17 and the comparative Net Utility equation, some elemental components for a successful business partnership, i.e.; “balance in value gain for the economic buyer and the funder”, “use of value capturing commercialization strategies with attention to stakeholders, Technology and contextual requirements, and “insurers’ contributions” need to get more concentrated attention before the sustainability of scale-up of mHealth projects can be achieved. Objective: This study is to show the necessity of ongoing market analyses to investigate the best practices for keeping mHealth initiatives sustainable for its adopters throughout its life cycle. Methods: The novel nature of our paper’s subject along with the authors’ concern to study a larger number of variables that could influence the paper’s suggested strategies, have encouraged us to use the Qualitative Exploratory Research method as the best way to address the new and undisclosed problems within the commercial scope of the mHealth industry. Results: The results of this exploratory review suggest that there are certain factors that may directly or indirectly contribute to an affordable and sustainable scale-up and adoption of mHealth initiatives especially within resource-poor contexts. Interestingly, some elemental components for a successful business partnership, i.e.; “balance in value gain for the economic buyer and the funder”, “use of value capturing commercialization strategies with attention to stakeholders, Technology and contextual requirements, and “insurers’ contributions” need to get more profound attention before the sustainability of scale-up mHealth projects could be achieved. Conclusions: Discussed as the “Technology, Context and Commercialization Triangle”, the study suggests that for mHealth projects to be sustainable, three main aspects need to be taken into consideration at the same time. The first two aspects, which have been more commonly discussed in the body of literature, are cultural norms and technical infrastructure. Designing systems that would strengthen and integrate with the pre-existing technologies would motivate LMICs’ health authorities to support new mHealth projects. Also for the LMICs to be receptive to mHealth technologies, the applications should agree with the community’s culture and believes. The third aspect however, is beyond the technical and contextual requirements and looks more carefully into mHealth projects financing and commercialization models. It seems that even in the LMICs, the era of one-way donor-receiver relationship in development projects is coming to its end and for the mHealth projects to experience sustainable scale-up phases, donor-receiver relationship should turn into more “gain” oriented business partnerships with variety of public and private investors. Choosing the right partner at different stages of the projects’ life cycle is one of the delicate moments of mHealth business which has failed to be thoroughly discussed in the context of academia and industry. This study shows that not all stages of mHealth projects’ life cycle would respond equally to a single donor-based financing model, but specific financing strategies and engagement with different types of investors, businesses and technical partners; i.e. “public, private, NGOs and foundations” at infancy, development and maturity stages of mHealth projects may increase the chances for more sustainable scale-up phases in resource-poor countries. Last but not least, similar to their movement in the developed countries, supportive financial systems such as health insurers should start to consider the LMICs’ population as a new segment. The authors suggest that further studies are needed to assess the relevance of these findings within the contextual realities that permeate the LMIC sphere.

  • Which Doctor to Trust: A Recommender System for Identifying the Right Doctors

    From: Journal of Medical Internet Research

    Date Submitted: May 22, 2016

    Open Peer Review Period: May 24, 2016 - Jun 2, 2016

    Background: In the field of medical/health informatics, it is critical to identify key opinion leaders (KOLs) on different diseases. KOLs refer to the people who have the ability in influencing public...

    Background: In the field of medical/health informatics, it is critical to identify key opinion leaders (KOLs) on different diseases. KOLs refer to the people who have the ability in influencing public opinions on the subject matter for which the opinion leaders have the authority. This is important for both health industry and patients. However, no study has tried to solve this issue systematically. Objective: We aim to develop a recommender system for identifying KOLs for any specific disease with the methods of healthcare data mining methods. Methods: In this paper, an unsupervised aggregation approach is exploited for integrating these ranking features to find the right doctors who have the reputation as KOLs on different diseases. Furthermore, we introduce the design, implementation, and deployment details of the recommender system. In this system, the professional footprints of doctors, such as articles in scientific journals, presentation activities, patient advocacy, and media exposure, are collected and used as ranking features for KOL identification. Results: We collect and exploit a large amount of public information (as much as 3,657,797 medical journal articles) related to almost all doctors (as much as 2, 381, 750 doctors) in China, including their profiles, academic publications, funding, etc. Comparative experiments have been done on the datasets and demonstrate that the proposed system outperforms several benchmark systems with similar purpose with a significant margin. Moreover, a case study is performed in real-world system to verify the reasonableness of our proposed method. Conclusions: The results suggest that doctor profile and academic publication are useful data sources for identifying key opinion leaders in the field of medical/health informatics. Moreover, the recommender system has been deployed and applied the data service for a recommender system of NetEase. Patients could obtain authority ranking lists of doctors with this system. Clinical Trial: As this was a research on method and application of doctor recommendation, no patients were involved and no intervention was performed, thus trial was not registered.

  • A feasibility study piloting a randomised controlled trial of computerised Cognitive Behavioural Therapy to treat emotional distress after stroke.

    From: Journal of Medical Internet Research

    Date Submitted: May 23, 2016

    Open Peer Review Period: May 24, 2016 - Jul 19, 2016

    Background: Depression and anxiety are common complications following stroke. Symptoms may be treatable with psychological therapy but there is little evidence-base. Aims: To investigate the accept...

    Background: Depression and anxiety are common complications following stroke. Symptoms may be treatable with psychological therapy but there is little evidence-base. Aims: To investigate the acceptability and feasibility of computerised Cognitive Behavioural Therapy (cCBT) to treat symptoms of depression and anxiety in the context of using Randomised Controlled Trial methodology as means of piloting assessment of efficacy. Method: Of 133 people screened for symptoms of depression and anxiety following stroke, 28 were cluster randomised in blocks with an allocation ratio 2:1 to cCBT (n=19) or an active comparator (n=9). Qualitative and quantitative feedback was sought on the acceptability and feasibility of the interventions, alongside measuring levels of depression, anxiety and activities of daily living (ADLs) before, after and three-months post treatment. Results: Overall, our protocol design is reasonable; both interventions were considered appropriate, accessible and useful (ranging from 50-87.5%), and participants tolerated randomisation. Drop-out rates were in line with similar trials, with only a small proportion of participants (n=3) discontinuing due to potential adverse effects. Adaptations were required to the protocol for recruiting people who are further post-stroke, and future studies may wish to control for those receiving medical interventions for mood. Descriptive statistics of the proposed outcome measures are reported and qualitative feedback about the cCBT intervention is discussed. Conclusions: A pragmatic approach is required to deliver online interventions to accommodate individual needs. We report on a protocol that should inform the development of a full RCT for testing the efficacy of cCBT for people with long-term neurological conditions; a potentially promising way of improving accessibility of psychological support.

  • A Cross-Sectional Comparison of Drugable Mutations in Primary Tumors, Metastatic Tissue, Circulating Tumor Cells and Cell-Free Circulating DNA in Patients with Metastatic Breast Cancer: The MIRROR Study Protocol

    From: JMIR Research Protocols

    Date Submitted: May 24, 2016

    Open Peer Review Period: May 24, 2016 - Jun 1, 2016

    Background: Characterization of the driver mutations in an individual metastatic breast cancer (MBC) patient is critical to selecting effective targeted therapies. Currently, it is believed that the l...

    Background: Characterization of the driver mutations in an individual metastatic breast cancer (MBC) patient is critical to selecting effective targeted therapies. Currently, it is believed that the limited efficacy of many targeted drugs may be due to the expansion of drug resistant clones with different genotypes that were already present in the primary tumor. Identifying the genomic alterations of these clones and introducing combined or sequential targeted regimens could lead to a significant increase in the efficacy of currently available targeted therapies. Objective: The primary objective of this study is to assess the concordance/discordance of mutations between the primary tumor and metastatic tissue in these patients. Secondary objectives include comparing the genomic profiles of circulating tumor cells (CTCs) and circulating free DNA (cfDNA) from peripheral blood with those of the primary tumor and metastatic tissue for each patient, evaluating these mutations in the signaling pathways that are relevant to the disease, and testing the feasibility of introducing liquid biopsy as a translational laboratory tool in clinical practice. Methods: The multicenter, transversal, observational MIRROR study is currently ongoing in 3 participating hospitals. All consecutive patients with MBC confirmed by radiologic findings, either at first relapse or with tumor regrowth while on treatment for metastatic disease, will be screened for eligibility. Results: Patient’s recruitment is currently ongoing. To date, 41 patients have a complete set of tissue samples available (plasma, CTCs, and formalin-fixed, paraffin-embedded primary tumor and metastatic tumor). However, none of these samples have undergone nucleic acids extraction and targeted deep sequencing yet. Conclusions: The results of this study might have a significant influence on the practical management of patients with MBC, as they may provide clues to clinicians towards a better stratification of patients so that they receive more selective and less toxic treatments. Additionally, if genomic mutations found in metastatic tissues are similar to those detected in CTCs and/or cfDNA, then liquid biopsy could be a more convenient, non-invasive and easily accessible source of genomic material for the analysis of mutations and other genomic aberrations in MBC. Clinical Trial: ClinicalTrials.gov: NCT02626039

  • Quantifying app store dynamics: longitudinal tracking of mental health apps

    From: Journal of Medical Internet Research

    Date Submitted: May 22, 2016

    Open Peer Review Period: May 24, 2016 - Jul 19, 2016

    Background: For many mental health conditions, mobile health apps offer the ability to deliver information, support, and intervention outside the clinical setting. However, there are difficulties with...

    Background: For many mental health conditions, mobile health apps offer the ability to deliver information, support, and intervention outside the clinical setting. However, there are difficulties with the use of a commercial app store to distribute healthcare resources, including turnover of apps, irrelevance of apps, and discordance with evidence-based practice. Objective: The primary aim of this study was to quantify the longevity and rate of turnover of mental health apps within the Android and iOS app stores. The secondary aim was to quantify the proportion of apps which are clinically relevant, and assess whether the longevity of these apps differ from non-clinically relevant apps. The third aim was to establish the proportion of clinically relevant apps which include claims of clinical effectiveness. Additional sub-group analyses were performed using additional data from the app store including search result ranking, user ratings, and number of downloads. Methods: The Google Play and iTunes app stores were searched each day over a nine-month period for apps related to depression, bipolar disorder, and suicide. Additional app-specific searches were performed if an app no longer appeared within the main search results. The time period for 50% of search results to change was calculated, along with the time period for 50% of the apps to no longer be downloadable. App store descriptions were manually screened for clinical relevance and claims of effectiveness. Results: On the Android platform, 50% of the search results changed after 130 days (depression), 195 days (bipolar disorder), and 115 days (suicide). Search results were more stable on iOS, with 50% of the search results remaining at the end of the study period. Approximately 75% of Android and 90% of iOS apps were still available to download at the end of the study. Only 35% of apps were identified as being clinically relevant, of which nine (2.6%) claimed clinical effectiveness. Only three included a full citation to a published study. Conclusions: The mental health app environment is volatile, with a clinically-relevant apps for depression becoming unavailable to download every 2.9 days. This poses challenges for consumers and clinicians seeking relevant and long-term apps, as well as researchers seeking to evaluate the evidence base for publicly available apps. Clinical Trial: n/a

  • “I always vet things”: Navigating privacy and the presentation of self on health discussion boards amongst individuals with long term conditions

    From: Journal of Medical Internet Research

    Date Submitted: May 22, 2016

    Open Peer Review Period: May 24, 2016 - Jul 19, 2016

    Background: The ethics of research into online communities is a long debated issue, with many researchers arguing that open access discussion groups are publically accessible data and do not require i...

    Background: The ethics of research into online communities is a long debated issue, with many researchers arguing that open access discussion groups are publically accessible data and do not require informed consent from participants for their use in research purposes. However, it has been suggested that there is a discrepancy between the perceived and actual privacy of user-generated online content by community members. Objective: There has been very little research regarding how privacy is experienced and enacted online. This study aims to address this gap by qualitatively exploring the expectations of privacy on internet forums among individuals with long term conditions. Methods: Semi-structured interviews were conducted with 20 participants with ME/CFS and 21 participants with type 1 and 2 diabetes and analysed using thematic analysis. Participants were recruited via online and offline routes, namely forums, email lists, newsletters, and face-to-face support groups. Results: The findings indicate that privacy online is a nebulous concept. Rather than individuals drawing a clear-cut distinction between what they would and would not be comfortable sharing online, it was evident that these situations were contextually dependent and related to a number of unique and individual factors. Conclusions: Interviewees were seen to carefully manage how they presented themselves on forums, filtering and selecting the information that they shared about themselves in order to develop and maintain a particular online persona, while maintaining and preserving an acceptable level of privacy.

  • The Effectiveness of an On-line Training Program for Improving Fire Knowledge of Healthcare Workers: A Randomized Controlled Trial

    From: Journal of Medical Internet Research

    Date Submitted: May 22, 2016

    Open Peer Review Period: May 24, 2016 - Jul 19, 2016

    Background: Fire disaster in hospitals can cause serious consequences. However, due to the busy schedule of healthcare workers, fire drills in hospitals are often difficult to achieve high attendance...

    Background: Fire disaster in hospitals can cause serious consequences. However, due to the busy schedule of healthcare workers, fire drills in hospitals are often difficult to achieve high attendance rate. Objective: We carried out and examined the effectiveness of an on-line fire knowledge training for healthcare workers in China. Methods: 128 participants were recruited between December 2014 to March 2015 by convenient sampling from five public hospitals in Chengdu, Kunming, Jingzhou, and Fuzhou in China. We built a webpage which includes the informed consent, pre-test questionnaire, video training, and post-test questionnaire. After completing the pre-test questionnaire, participants will be randomly assigned in 1:1 ratio by the webpage to watch one of the two videos. Those in the intervention group were watching a 14-min video showing the basic response to a hospital fire and patient evacuation methods, while those in the control group were watching a 6-min video introducing volcanic disasters. A questionnaire consisted of 45 items on fire knowledge was implemented before and after the video watching. The fire knowledge items can be further divided into two subscales, the first one consists of 25 items on generic knowledge of fire response, including prevention and disposal and the second one consists of 20 items on hospital-specific knowledge related to dealing with a hospital fire and selecting equipment under a fire emergency in a hospital. One point was awarded for each correct answer and no point was awarded for each wrong answer. Results: Half of the participants (n=64, 50%) was randomized into intervention group and the remaining 64 (50%) was randomized into control group. All of them complete the pre-test and pro-test questionnaire. For generic fire knowledge, those in the intervention group improved significantly (from 16.16 to 20.44, P < 0.001) while those in the control group decreased significantly (from 15.27 to 13.70, P = 0.03). For hospital-specific fire knowledge, those in the intervention group (from 10.75 to 11.33, P = 0.15) and the control group (from 10.38 to 10.16, P = 0.54) had insignificant change. For total score, those in the intervention group improved significantly (from 26.91 to 31.77, P < 0.001) while those in the control group decreased insignificantly (from 25.64 to 23.86, P = 0.07). After the intervention, the difference between intervention group and control group of all the three fire knowledge scores were significant (all Ps < 0.05). Conclusions: To conclude, on-line fire training program by watching educational video can effectively improve healthcare workers’ knowledge of fire prevention and evacuation. Clinical Trial: Clinicaltrials.gov NCT02438150; https://clinicaltrials.gov/ct2/show/NCT02438150

  • Study Protocol of Carotid Endarterectomy and Carotid Artery Stenting in Brazil: An Observational Registry

    From: JMIR Research Protocols

    Date Submitted: May 20, 2016

    Open Peer Review Period: May 20, 2016 - Jun 3, 2016

    Introdution: Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are alternative strategies for stroke prevention in patients with atherosclerotic carotid disease. CEA has been considered t...

    Introdution: Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are alternative strategies for stroke prevention in patients with atherosclerotic carotid disease. CEA has been considered the first-line treatment for carotid stenosis worldwide, and the safety and efficacy of CAS compared with CEA remain in question. The purpose of this study is to compare the practice and outcomes of CAS and CEA in a real-world setting within public university hospitals in Brazil. Methods and Analysis: This will be a prospective 5-year analysis of treatment for atherosclerotic carotid stenosis with CEA and CAS performed at 5 centres affiliated with the Vascular Study Group at public university hospitals in Brazil. The indications for the procedure will be determined by each surgeon’s individual discretion, in accordance with preoperative risk evaluation. The primary outcome measures are (1) any in-hospital stroke or death and (2) any per-procedural stroke, death, or myocardial infarction (MI). Patients undergoing CEA in conjunction with cardiac surgery will be excluded. Multivariate logistic regression will be performed to identify predictors of stroke or death in patients undergoing CEA and CAS. All tests of significance will be performed at the 0.05 level. Ethics and Dissemination: This study was approved by Committee of Ethics in Research of University Hospital of Ribeirao Preto Medical School and in all other participating institutions linked to National Research System and National Board of Health in BRAZIL (Process 15695/2011) and the recruitment is currently on-going, the last patient is expected to be included by the end of 2018. The analysis of the primary end point and all others variables of the study are expected to be published in 2019 in a peer reviewed journal and results will also be presented at scientific meetings and summary results published online. .

  • Young people, Adult worries: a randomised controlled feasibility study of the internet-based self-support method “Feel the ViBe” for adolescents and young adults exposed to family violence.

    From: Journal of Medical Internet Research

    Date Submitted: May 20, 2016

    Open Peer Review Period: May 20, 2016 - Jul 15, 2016

    Background: Children growing up in families where violence occurs are (almost) always exposed to this violence with severe consequences for physical, emotional and behavioural development. Peer suppor...

    Background: Children growing up in families where violence occurs are (almost) always exposed to this violence with severe consequences for physical, emotional and behavioural development. Peer support is recognized effective to change behaviour and the internet considered most suitable as mode of delivery. Objective: RCT and feasibility of the internet-based self-support method “Feel the ViBe (FtV)”, choosing efficacy, demand, acceptability, implementation, and practicality as focus. Feasibility studies aim to fully understand strengths and weaknesses of a new intervention, evaluating both efficacy and effectiveness. Methods: Adolescents and young adults aged 12-25 exposed to family violence, were randomized in an intervention group (access to FtV + usual care), and a control group (minimally enhanced usual care) after they self-registered themselves for participation. Between June 2012 and July 2014, participants completed the Impact of Event Scale and the Depression and Anxiety subscales of the Symptom CheckList-90R every 6 weeks. The Web Evaluation Questionnaire was completed after twelve weeks. All questionnaires were self-assessed, without face-to-face components. During the whole study period, quantitative usage data was collected using Google analytics and CMS logs and data files. UNIANOVA, Mixed Model analysis and Paired sample t-tests were used to compare groups. Feasibility measures were used to structurally address the findings. Results: 31 out of 46 participants in the Intervention group and 26 out of 47 participants in the Control group started FtV. After receiving full access 24 users used FtV for 24 weeks or longer, reporting a mean online time of 2.83 with a mean online session time of 36 minutes. Acceptability was good: FtV was rated a mean 7.47 (1-10 Likert scale) with a helpfulness score of 3.16 (1-5 Likert scale). All participants felt safe. 17 participants (I n=8, C n=9) completed all questionnaires. IES outcomes showed no significant differences between groups. Mixed model analysis showed significant differences between groups on the SCL-90 DEP (p=0.041) and ANX (p=0.049) subscales between six and twelve weeks after participation started. UNIANOVA showed no significant differences. Pre-post test paired sample t-tests for the SCL-90 DEP (p=0.034) and SCL-90 ANX (p=0.046) subscales showed significant improvements after twelve weeks. General knowledge of regular healthcare was low, but after twelve weeks, two thirds of the intervention participants started regular healthcare. Conclusions: FtV functions best as a first step for adolescents and young adults in an early stage of change and shows promising results. Preset goals for FtV have been met. No changes on the IES were found. SCL-90 DEP and ANX show promising results, however, the calculated sample size was not reached (n=18). FtV can be easily implemented without extensive resources. FtV should be implemented in the field of public healthcare or national governmental care. Clinical Trial: This randomized feasibility study is conducted in the Netherlands, registered in The Netherlands National Trial Register (NTR) and assigned the trial ID NTR3692.

  • Making Quality Health Websites a National Public Health Priority: Toward Quality Standards

    From: Journal of Medical Internet Research

    Date Submitted: May 19, 2016

    Open Peer Review Period: May 20, 2016 - Jul 15, 2016

    Background: Most U.S. adults have limited health literacy skills. They struggle to understand complex health information and services, and to make informed health decisions. The internet has quickly b...

    Background: Most U.S. adults have limited health literacy skills. They struggle to understand complex health information and services, and to make informed health decisions. The internet has quickly become one of the most popular places for people to search for information about their health, thereby making access to quality online information a priority. However, there are no standardized criteria for evaluating online health information. Every 10 years, the U.S. Department of Health and Human Services (HHS) Office of Disease Prevention and Health Promotion (ODPHP) develops a set of measurable objectives for improving the health of the nation over the coming decade, known as Healthy People. There are two objectives in Healthy People 2020 related to website quality. The first is objective HC/HIT-8.1: increase the proportion of health-related websites that meet three or more evaluation criteria for disclosing information that can be used to assess information reliability. The second is objective HC/HIT-8.2: increase the proportion of health-related websites that follow established usability principles. Objective: ODPHP conducted a nationwide assessment of the quality of online health information using the Healthy People 2020 objectives. ODPHP aimed to establish: 1) a standardized approach to defining and measuring the quality of health websites; 2) benchmarks for measurement; 3) baseline data points to capture the current status of website quality; and 4) targets to drive improvement. Methods: ODPHP developed the National Quality Health Website Survey instrument to assess the quality of health-related websites. ODPHP used this survey to review 100 top-ranked health-related websites in order to set baseline data points for these two objectives. ODPHP then set targets to drive improvement by 2020. Results: For objective HC/HIT-8.1, 58.0% (SD=4.5%) of health-related websites (n=100) met three or more out of six reliability criteria. For objective HC/HIT-8.2, 42.0% (SD=4.9%) of health-related websites (n=100) followed 10 or more out of 19 established usability principles. Based on these baseline data points, ODPHP set targets for the year 2020 that meet the minimal statistical significance (p<0.05) by the year 2020—increasing objective HC/HIT-8.1 data point to 70.5% and objective HC/HIT-8.2 data point to 55.7%. Conclusions: This research is a critical first step in evaluating the quality of online health information. The criteria proposed by ODPHP provide methods to assess website quality for professionals designing, developing, and managing health-related websites. The criteria, baseline data, and targets are valuable tools for driving quality improvement.

  • Healthcare IT utilization and penetration among physicians

    From: Journal of Medical Internet Research

    Date Submitted: May 18, 2016

    Open Peer Review Period: May 19, 2016 - Jul 14, 2016

    Background: Healthcare IT (HIT) gains more and more public attention as well as clinical relevance. A growing number of patients and physicians increasingly relies on IT services to monitor and suppor...

    Background: Healthcare IT (HIT) gains more and more public attention as well as clinical relevance. A growing number of patients and physicians increasingly relies on IT services to monitor and support wellbeing and recovery both in their private as well as in professional environment. Objective: In this study, we investigated the current status of HIT use and penetration among physicians in hospitals and private practices as well as future expectations and demands regarding HIT. Methods: Using clinical networks all over Germany, Austria and Switzerland, mainly in the cities of Nuremberg, Vienna and Munich, we addressed physicians to answer a standardized internet-based questionnaire consisting of 15 multiple choice and two open questions sent out via email. Parameters were evaluated in 5 categories: general use, frequency, acceptance, needs and future. An overall of 234 physicians (response rate 83.6%) have answered the online questionnaire. Results: Physicians with a median age of 45 (range 25 - > 60) responded and filled out the entire questionnaire. A significant correlation between parameters gender, age and level of training (resident, specialist, consultant etc.) can be proven. Whereas male physicians tend to use HIT significantly more in their professional life than their female colleagues, it is clear that this is not the case when it comes to private use of equivalent applications. Furthermore, the use of technology varies widely across age as well as level of training. Whereas increasing age among physicians is associated with a decreasing level of application of HIT, a higher training level is notably accompanied by an increasing level when it comes to a professional application of these tools. Use of data, gained with HIT is regarded as a necessary and positive standard. Most users assume the importance of HIT to grow in the future in parallel to their current use. A clear lack of trust in terms of medical data storage is recognized on both patient and physician side. In the majority of cases, physicians tend to use their own IT over the hospitals’, showing a clear need for improvement and technological innovation within the hospitals. Conclusions: The results show a clear gap between private and professional use of IT for medical purposes. HIT growth is by the majority regarded as key development driver, the future healthcare development will head towards. We conclude that the use of IT application generally depends strongly on age, gender as well as role within the hospital and type of hospital.

  • Pediatric Residents’ Perceptions of the Appropriate Use of Social Media: A National Survey

    From: JMIR Medical Education

    Date Submitted: May 18, 2016

    Open Peer Review Period: May 19, 2016 - Jul 14, 2016

    Background: The ubiquitous use of social media by physicians poses professionalism challenges. Regulatory bodies have disseminated guidelines related to physician use of social media. Objective: This...

    Background: The ubiquitous use of social media by physicians poses professionalism challenges. Regulatory bodies have disseminated guidelines related to physician use of social media. Objective: This study's objectives are to understand what residents view as appropriate social media use by physicians and to recognize the degree to which residents are exposed to postings which violate social media professionalism guidelines. Methods: An electronic survey was distributed to residents nationwide. The survey consisted of five Facebook postings from a "hypothetical" resident's personal Facebook page. Two questions were asked for each vignette: 1) opinion of the posting's appropriateness and 2) frequency they viewed similar posts. Results: The vignettes used highlighted common scenarios which challenge published social media professionalism guidelines. Residents are seeing postings that potentially violate professionalism standards frequently. For the two scenarios representing venting online about a patient interaction, residents overwhelmingly recognized the inappropriate use of social media. However, half of respondents said they see similar posts frequently or sometimes. In the vignette showing physicians drinking alcoholic beverages while in scrubs, most residents were neutral and frequently view similar posts. Of note, we found that over 50% of residents are using Facebook daily and another 30% at least once a week. Conclusions: Residents, like other of their generation, use social media sites to converse with peers without thinking about the implications on the profession. The frequent use of social media by learners needs to change the emphasis educators and regulatory bodies place on social media guidelines and teaching professionalism in the digital age.

  • Is Social Media a Threat to Patient Safety?

    From: Journal of Medical Internet Research

    Date Submitted: May 18, 2016

    Open Peer Review Period: May 19, 2016 - Jul 14, 2016

    Background: Many people are increasingly using social networking sites for health-related purposes. An increasing number of patients are using social networking sites to share their experiences with h...

    Background: Many people are increasingly using social networking sites for health-related purposes. An increasing number of patients are using social networking sites to share their experiences with health care providers or institutions. Patients also share their experiences with family members and friends via websites such as Facebook Objective: This study aims to describe the demographic characteristics of patients that demonstrate online health-seeking behavior. Second, we address how social networking affects health-seeking behavior. Third, we examine whether patients initiate or alter/discontinue their medications based on information derived from social media. Methods: We conducted a cross-sectional survey between April and June 2015 on patients attending King Abdulaziz University, Jeddah, Saudi Arabia. Patients who used social media (Facebook, WhatsApp, and Twitter) were included. A questionnaire was developed with closed-ended and multiple choice questions to assess the type of social media platforms patients used and whether information published on these websites influenced their healthcare decisions. A chi-square test was used to establish the relationship between categorical variables. An independent t-test was used to compare two group means. Results: The sample included 442 social media users aged 35.4 (11.5) years on average. The majority of respondents (89.8%) used WhatsApp, followed by Facebook (58.6%) and Twitter (42.3%). In most cases, respondents received health-related messages from WhatsApp and approximately 42.6% reported ever stopping treatment as advised on a social media platform. A significantly higher proportion of patients without heart disease (p = 0.001) and obese persons (p = 0.012) checked the authenticity of information disseminated through social medial channels. Decision-making by patients with heart disease was influenced by social media messages (p = 0.043). Respondents with heart disease (p = 0.001) and obese persons (p = 0.012) were more likely than those without these conditions to discuss health-related information published on social media channels with healthcare professional. A significant proportion of WhatsApp users reported that health-related information published on this platform influenced decisions regarding their family’s health care (p = 0.001). respondents’ decisions regarding family health care were more likely to be influenced when they used two or all three types of platforms (p = 0.003). Conclusions: Health education in the digital era needs to be accurate, evidence-based, and regulated. As technologies continue to evolve, we must be equipped to face the challenges it brings with it.

  • Satisfaction Level and Influencing Factors on Social Media Use for Neonatal and Pediatric Patient Transfer Information Systems in Chonbuk Region: A Questionnaire Study

    From: Journal of Medical Internet Research

    Date Submitted: May 17, 2016

    Open Peer Review Period: May 18, 2016 - May 27, 2016

    Background: The treatment of neonatal and pediatric patients is limited to certain medical institutions depending on treatment difficulty. Effective patient transfers are necessary in situations where...

    Background: The treatment of neonatal and pediatric patients is limited to certain medical institutions depending on treatment difficulty. Effective patient transfers are necessary in situations where there are limited medical resources. In Korea, the government has made much effort to establish patient transfer systems using various means, such as Internet sites, telephone, etc. However, in reality, the effort has not yet been effective Objective: In this study, we ran a patient transfer information system using social media for effective patient transfer. We analyzed the results, satisfaction levels, and influencing factors on satisfaction Methods: Using social media, two systems were created: one by the Neonatal Intensive Care Unit and the other by the Department of Pediatrics at Chonbuk National University Children's Hospital. The information necessary for patient transfers was provided to participating obstetricians (n = 51) and pediatricians (n = 90). We conducted a survey to evaluate the systems and reviewed the results retrospectively. Results: The number of patients transferred was reported to increase by 26/40 (65%) obstetricians and 23/57 (40%) pediatricians. The time taken for transfers was reported to decrease by 29/40 (72%) obstetricians and 34/57 (59%) pediatricians. Satisfaction was indicated by 33/40 (83%) obstetricians and 51/57 (89%) pediatricians. Regarding factors influencing satisfaction, the obstetricians reported communication with doctors in charge (P = .03) and time reduction during transfers (P = .02), while the pediatricians indicated review of the diagnosis and treatment of transferred patients (P = .01) and the time reduction during transfers (P = .007). Conclusions: The users were highly satisfied and different users indicated different factors of satisfaction. This finding implies that users’ requirements should be accommodated in future developments of patient transfer information systems.

  • The appropriateness and presentation of commonly available cardiovascular web pages.

    From: Journal of Medical Internet Research

    Date Submitted: May 14, 2016

    Open Peer Review Period: May 17, 2016 - Jul 12, 2016

    Background: The Internet is becoming the primary source that people use to retrieve general and specific health information. Cardiovascular diseases are the number one cause of death globally and it c...

    Background: The Internet is becoming the primary source that people use to retrieve general and specific health information. Cardiovascular diseases are the number one cause of death globally and it can be expected that a large amount of patients will consult the Internet for advice. However, there is still little research on the quality of web pages that are online available for patients with cardiovascular diseases. Objective: To evaluate the quality and appropriateness of commonly available cardiovascular web page(s). Methods: A descriptive design with quantitative and qualitative data. The Suitability and Comprehensibility Assessment of Material was used to evaluate web pages. Open-ended questions were added to describe the evaluators’ opinion on positive and negative aspects. The qualitative data was analyzed with a modified summative content analysis with a manifest approach. Results: 27 web pages were evaluated. Six (22%) were ranked as superior, 10 (37%) as adequate, and 11 (41%) as not suitable. The content was not suitable in 15 (56%), the literacy demands not suitable in 3 (11%), the numeric literacy in 5 (19%), the graphics in 11 (41%), the layout/typography in 5 (19%), and learning simulation/motivation in 21 (78%). Conclusions: Commonly available cardiovascular web pages in the Swedish language need to improve their content and learning simulation and motivation, in order to be suitable for cardiac patients who visit those pages.

  • The effectiveness of web-based asthma self-management: A pilot randomized clinical trial of My Asthma Portal (MAP)

    From: Journal of Medical Internet Research

    Date Submitted: May 16, 2016

    Open Peer Review Period: May 17, 2016 - Jul 12, 2016

    Background: Web-based technologies may improve self-management behaviors and outcomes. My Asthma Portal (MAP) is a web-based support system that couples evidence-based behavioral change (self- monito...

    Background: Web-based technologies may improve self-management behaviors and outcomes. My Asthma Portal (MAP) is a web-based support system that couples evidence-based behavioral change (self- monitoring of symptoms, physical activity, and medication adherence) with real-time monitoring, feedback, and support from a nurse case-manager. Objective: To compare the impact of a tailored web-based self-management asthma patient portal linked to a case-management system (MAP) over 6 months compared to usual care (UC) on asthma control and quality of life. Methods: A multi-center parallel two-arm pilot randomized controlled trial was conducted with 100 adults with confirmed diagnosis of asthma from two specialty clinics. Asthma control was measured using an algorithm based on overuse of fast-acting bronchodilators and ED visits, and asthma quality of life was assessed using the Mini-AQLQ at baseline, 3, 6, and 9 months. Secondary mediating outcomes included asthma symptoms, depressive symptoms, self-efficacy, and beliefs about medication. Process evaluation and a survey to evaluate MAP acceptance and usefulness were also carried out. Results: Forty-nine individuals were randomized to MAP and 51 to UC. As compared to UC, participants in the intervention group reported significantly higher quality of life (mean change = 0.61, 95% CI: 0.03, 1.19), and change in asthma quality of life for the intervention group between baseline and the 3 months (mean change = 0.66, 95% CI: 0.35, 0.98) not seen in the control group. No significant differences were found between the intervention and control group at 6 (mean change =.46, 95% CI:-.12, 1.05) and 9 months (mean change =.39, 95% CI:-.2, .98). There was no significant effect on poor control status. For all self-report measures, the intervention group had a significantly higher proportion of individuals demonstrating a minimal clinically meaningful improvement as compared to controls. Conclusions: This study supports the use of MAP to enhance asthma quality of life but not asthma control as measured by an administrative database. Implementation of MAP beyond 6 months with tailored protocols for monitoring symptoms and health behaviors as individuals knowledge and self-management skills improve may result in long-term gains in asthma control. Clinical Trial: Trial ID: Current Controlled Trials ISRCTN34326236.

  • The quality and accuracy of mobile applications to prevent driving after drinking alcohol

    From: JMIR mHealth and uHealth

    Date Submitted: May 10, 2016

    Open Peer Review Period: May 16, 2016 - Jul 11, 2016

    Background: Driving after the consumption of alcohol represents a significant public health problem globally. Individual prevention countermeasures such as personalised mobile applications aimed at p...

    Background: Driving after the consumption of alcohol represents a significant public health problem globally. Individual prevention countermeasures such as personalised mobile applications aimed at preventing the behaviour are widespread but there is little research on their accuracy and evidence-base. There has been no known assessment investigating the quality of such apps. Objective: This study aimed to determine the quality and accuracy of apps for drink driving prevention by conducting a review and evaluation of relevant mobile apps. Methods: A systematic app search was conducted following PRISMA guidelines. App quality was assessed using the Mobile Application Rating Scale (MARS). Apps providing blood alcohol calculators (hereafter ‘calculators’) were reviewed against current alcohol advice for accuracy. Results: A total of 58 apps (30 iOS and 28 Android) were included in the final analysis. Drink driving prevention apps had significantly lower engagement and overall quality scores than alcohol management apps. Most calculators provided conservative BAC time until sober calculations. None of the apps had been evaluated to determine efficacy in changing either drinking or driving behaviours. Conclusions: This novel study demonstrates that drink driving prevention apps lack quality as a function of low engagement. This could be improved by increasing engagement features, such as gamification. Further research should examine the context and motivations for using apps to prevent driving after drinking in at-risk populations. Development of drink driving prevention apps should incorporate evidence based information and guidance, and this is lacking in current apps.

  • The associations among individual factors, eHealth literacy and health-promoting lifestyles among college students

    From: Journal of Medical Internet Research

    Date Submitted: May 15, 2016

    Open Peer Review Period: May 16, 2016 - Jul 11, 2016

    Background: eHealth literacy is becoming important in maintaining and promoting health. Studies have shown that individual factors are associated with eHealth literacy and health-promoting lifestyles....

    Background: eHealth literacy is becoming important in maintaining and promoting health. Studies have shown that individual factors are associated with eHealth literacy and health-promoting lifestyles. Nevertheless, few studies have explored the associations among individual factors, eHealth literacy and health-promoting lifestyles among college students. Moreover, there is a lack of studies that focus on various eHealth literacy aspects as predictors of six dimensions of health-promoting lifestyles. Objective: This study examines the associations among individual factors, eHealth literacy, and health-promoting lifestyle. Methods: The eHealth Literacy Scale is a 12-item instrument designed to measure college students’ functional, interactive, and critical eHealth literacy. The Health-promoting Lifestyle Scale is a 23-item instrument developed to measure college students’ self-actualization, health responsibility, interpersonal support, exercise, nutrition and stress management. A nationally representative sample of 556 valid college students in Taiwan was surveyed. A questionnaire was administered to gather the respondents’ background information, including information about the frequency of seeking information on health issues, the frequency of eating organic food, the degree of health concern and the students’ major. We then conducted a multiple regression analysis to examine the associations among individual factors, eHealth literacy, and health-promoting lifestyles. Results: The study found that medical majors (t552=2.46-7.57, P<.001-.01) and greater concern health (t552=2.11-9.01, P<.001-.04) predicted college students’ 4-6 health-promoting lifestyle dimensions and the 3 dimensions of eHealth literacy. Moreover, critical eHealth literacy positively predicted all 6 health-promoting lifestyle dimensions (t553=4.59-8.48, P<.001), interactive eHealth literacy positively predicted all dimensions except the exercise dimension (t553=2.10-4.88, P<.001-.04), whereas functional literacy only predicted the self-actualization and interpersonal support dimensions (t553=3.44-4.11, P<.001). Conclusions: This study found that participants who majored in medical fields, had greater concern for their health and frequently sought health information exhibited better eHealth literacy and had a positive health-promoting lifestyle. Moreover, this study showed that college students with higher interactive and critical eHealth literacy engage better in health-promoting activities than those with functional literacy do.

  • Beyond the RCT: a review of alternatives in mHealth clinical trial methods.

    From: JMIR mHealth and uHealth

    Date Submitted: May 9, 2016

    Open Peer Review Period: May 13, 2016 - Jul 8, 2016

    Background: Randomized controlled trials (RCTs) have long been considered the primary research study design capable of eliciting causal relationships between health interventions and consequent outcom...

    Background: Randomized controlled trials (RCTs) have long been considered the primary research study design capable of eliciting causal relationships between health interventions and consequent outcomes. However, with a prolonged duration from recruitment to publication, high-cost trial implementation, and a rigid trial protocol, RCTs are perceived as an impractical evaluation methodology for most mHealth apps. Objective: Given the recent development of alternative evaluation methodologies and tools to automate mHealth research, we sought to determine the breadth of these methods and the extent that they were being used in clinical trials. Methods: We conducted a review of the ClinicalTrials.gov registry to identify and examine current clinical trials involving mHealth apps and retrieved relevant trials registered between November 2014 and November 2015. Results: Of the 137 trials identified, 71 were found to meet inclusion criteria. The majority used an RCT trial design (77.5%; 55/71). Alternate designs included 3 one-shot case study designs (4.2%; 3/71), 2 one-group pretest posttest designs (2.8%;2/71), and 1 static-group comparison (1.4%; 1/71). Seventeen trials included a qualitative component to their methodology (23.9%). Complete trial data collection required 20 months on average to complete (M=20.75, SD=12.49). For trials with a total duration of two years or more (30.6%; 22/71), the average time from recruitment to complete data collection (M=35.45 months, SD=9.73) was two years longer than the average time required to collect primary data (M=10.68, SD=7.95). Trials had a moderate sample size of 115 participants. Two trials automated their data collection (2.9%) and seven trials collected data continuously (10.3%); on-site study implementation was heavily favoured (69/71, 97.1%). Frequent manual data collection extended trial duration, but automated continuous data collection did not. Academic sponsorship was the most common form of trial funding (73.2%; 52/71). Only seven trials had been completed at the time this retrospective review was conducted (9.9%; 7/71). Conclusions: mHealth evaluation methodology has not deviated from common methods, despite the need for more relevant and timely evaluations. There is a need for clinical evaluation to keep pace with the level of innovation of mHealth if it is to have meaningful impact in informing payers, providers, policy makers, and patients. Clinical Trial: n/a

  • It's about me: Patients experiences of patient participation in multimodal rehabilitation in combination with the web Behaviour Change Program for Activity (web-BCPS)

    From: Journal of Medical Internet Research

    Date Submitted: May 12, 2016

    Open Peer Review Period: May 12, 2016 - Jul 7, 2016

    Background: Patients’ participation in their healthcare is recognized as a key component in high-quality healthcare. Patients with persistent pain are recommended treatments with a cognitive approac...

    Background: Patients’ participation in their healthcare is recognized as a key component in high-quality healthcare. Patients with persistent pain are recommended treatments with a cognitive approach from a biopsychosocial explanation of pain, in which a patient’s active participation in their rehabilitation is in focus. Web-based interventions for pain management have the potential to increase patient participation by enabling patients to play a more active role in rehabilitation. However, little is known about patients’ experiences of patient participation in web-based interventions. Objective: To explore patients’ experiences of patient participation in multimodal rehabilitation (MMR) in combination with a web Behaviour Change Program for Activity (the web-BCPA) among patients with persistent pain in primary healthcare. Methods: : Qualitative interviews were conducted with 14 women and 5 men, with a mean age of 45 years. Data was analyzed with qualitative content analysis. Results: One theme, “It’s about me”, and 4 categories, “Take part in a flexible framework of own priority”, “Acquire knowledge and insights”, “Ways towards change”, and “Personal and environmental conditions influencing participation”, were developed. Patient participation was depicted as being confirmed in an individualized and structured rehabilitation framework of own choice. Being confirmed was fundamental to patient participation in interactions with healthcare professionals and with the web-BCPA, and included patients’ emotions and cognitions. To acquire knowledge and insights were experienced as patient participation, and included self-reflection, self-identification, and feedback. Patients experienced patient participation as structured ways to reach their goals of behaviour change, which included analyzing their resources and restrictions, problem solving and evaluation. Patients’ emotional and cognitive resources and restrictions, as well as the healthcare professionals’ attitudes and behaviour influenced patient participation. Situations of mistrust and disrespect with one healthcare professional were perceived as temporary restrained patient participation in the rehabilitation. Also, some patients experienced difficulties to choose area of interest in the web-BCPA content and that it became a burden to complete. Conclusions: There were satisfying patient participation in MMR in combination with the web-BCPA. The patients experienced themselves as being confirmed as a whole human being. The combined treatment MMR and the web-BCPA were experienced by the patients to increase patient participation in their rehabilitation. This study adds that also acquiring knowledge and insights was a component of patient participation. Clinical Trial: The study was approved by the Regional Ethical Review Board of Umeå University, Sweden (Umu dnr 2011-383-31M).

  • MHealth to improve measles immunization in Guinea-Bissau: Study Protocol for a Randomized Controlled Trial

    From: JMIR Research Protocols

    Date Submitted: May 11, 2016

    Open Peer Review Period: May 12, 2016 - May 26, 2016

    Background: Recent studies reveal a low measles vaccination rate in Guinea-Bissau that has not increased in accordance with the increase in vaccination coverage of other vaccinations. Measles is the m...

    Background: Recent studies reveal a low measles vaccination rate in Guinea-Bissau that has not increased in accordance with the increase in vaccination coverage of other vaccinations. Measles is the most deadly of all childhood rash/fever illnesses and spreads easily so if the vaccination coverage is declining there is a significant risk of new outbreaks of measles. Meanwhile, mHealth (i.e. the use of mobile phones for health interventions) has generated much enthusiasm, and shown potential in improving health service delivery in other contexts. Objective: The aim of this study is to evaluate the efficiency of mHealth as a tool for improving measles vaccination coverage while contributing to the mHealth evidence base. Methods: The study takes place at three health centers in different regions of Guinea-Bissau. Participants will be enrolled when they arrive at the health center to receive the BCG vaccination - usually within one month of birth. Enrolment will continue until a study population of 900 children has been reached. The participants will be allocated by randomization to either a control group or one of two groups receiving intervention. Each of the three groups will have 300 participants distributed equally between health centers. Participants in the first treatment group will receive a scheduled SMS (Short Message Service) message reminding them of the measles vaccination. Participants in the second treatment group will receive a voice call in addition to the SMS message. Since measles vaccine is scheduled to be administered at 9 months of age and local policy in Guinea-Bissau prevents children aged more than 12 months from receiving the vaccination, the study will follow-up after 12 months of age. Children who have not yet received the measles vaccine will be offered vaccination by the project group. Results: The study will analyze the efficiency of the intervention by determining its overall effect on measles vaccination coverage and timeliness at 12 months of age. The main analysis will be stratified by intervention group, health center, level of education, etc. Secondary outcomes include the average number of visits with intention to obtain the measles vaccination required before successful administration. Conclusions: Despite the rapid proliferation of mHealth projects, only few of them have been evaluated in terms of direct links to health outcomes. This leaves a need for solid evidence on which policy-makers can base decisions. This study is assumed to produce significant knowledge about mHealth implementation within a Sub-Saharan context while creating data supported evidence. Clinical Trial: Clinicaltrials.gov: NCT02662595

  • Assessing the effectiveness of social media (Facebook), compared to more traditional advertising methods, in recruiting eligible participants to health research studies

    From: Journal of Medical Internet Research

    Date Submitted: May 11, 2016

    Open Peer Review Period: May 11, 2016 - Jul 6, 2016

    Background: Recruiting participants for research studies can be difficult and costly. The popularity of social media platforms (e.g., Facebook) has seen corresponding growth in the number of researche...

    Background: Recruiting participants for research studies can be difficult and costly. The popularity of social media platforms (e.g., Facebook) has seen corresponding growth in the number of researchers turning to social networking—and their embedded advertising frameworks—to locate eligible participants for their studies. Compared to traditional recruitment strategies such as print media, social media advertising has been shown to be favorable in terms of its reach (especially with hard-to-reach populations), cost effectiveness, and usability. However, to date, no studies have examined how participants recruited via social media progress through a study (compared to those recruited using more traditional recruitment strategies). Objective: (1) Examine whether visiting the study website prior to being contacted by researchers creates self-screened participants who are more likely to progress through all study phases (eligible, enrolled, completed); (2) Compare conversion rates and cost effectiveness of each recruitment method at each study phase; and, (3) Compare demographic and smoking characteristics of participants recruited through each strategy to determine if they attract similar samples. Methods: Participants recruited to a smoking cessation clinical trial were grouped by how they had become aware of the study: via social media (Facebook) or traditional media (e.g., newspaper, flyers, radio, word of mouth) strategies. Groups were compared based on throughput data (conversion rates and cost) as well as demographic and smoking characteristics. Results: Visiting the study website did not result in individuals that were more likely to be eligible for (P = .24), enroll in (P = .20), or complete (P = .25) the study. While using social media was more cost effective than traditional methods when we examined earlier endpoints of the recruitment process (cost to obtain a screened respondent: AUD$22.73 vs $29.35; cost to obtain an eligible respondent: $37.56 vs $44.77), it was less cost-effective in later endpoints (cost per enrolled participant: $56.34 vs $52.33; cost per completed participant: $103.66 vs $80.43). Participants recruited via social media were more likely to be younger (P=.001), and be less confident in their quit attempts (P=.004), compared to those recruited via traditional methods. Conclusions: Our study suggests that while social media advertising may be effective at generating interest from potential participants, this strategy’s ability to recruit conscientious recruits is more questionable. Researchers considering using online resources (e.g., social media advertising, matrix codes) should consider including pre-screening questions to promote conversion rates. Ultimately, researchers seeking to maximize their recruitment budget should consider using a combination of advertising strategies. Clinical Trial: Australian New Zealand Clinical Trials Registry: ACTRN12614000329662

  • Exploring the use of information and communication technology by people with mood disorder: A systematic review and meta-synthesis

    From: JMIR Mental Health

    Date Submitted: May 10, 2016

    Open Peer Review Period: May 11, 2016 - Jul 6, 2016

    Background: There is a growing body of evidence relating to how information and communication technology can be used to support people with physical health conditions. Less in known regarding mental...

    Background: There is a growing body of evidence relating to how information and communication technology can be used to support people with physical health conditions. Less in known regarding mental health, and in particular, mood disorder. Objective: To conduct a meta-synthesis of all qualitative studies exploring the use of information and communication technologies (ICTs) by people with mood disorder. Methods: Searches were run in eight electronic databases using a systematic search strategy. Qualitative and mixed-method studies published in English between 2007 and 2014 were included. Thematic synthesis was used to interpret and synthesis the results of the included studies. Results: Thirty-four studies were included in the synthesis. The methodological design of the studies were qualitative or mixed-methods. A global assessment of study quality identified 22 studies as strong and 12 weak with most having a typology of findings either at topical or thematic survey levels of data transformation. A typology of ICT use by people with mood disorder was created as a result of synthesis. Conclusions: The systematic review and meta-synthesis clearly identified a gap in the research literature regarding how people with mood disorder use mobile information and communication technology. Further qualitative research is recommended to understand the meaning this type of technology holds for people. Such research might provide valuable information on how people use mobile technology in their lives in general and also, more specifically, how they are being used to help with their mood disorders.

  • A Randomized Controlled Trial Comparing Web-Based Provider-initiated and Patient-Initiated Survivorship Care Planning for Cancer Patients

    From: JMIR Cancer

    Date Submitted: May 6, 2016

    Open Peer Review Period: May 7, 2016 - Jul 2, 2016

    Background: Survivorship care plans (SCPs) are intended to facilitate communication and coordination between patients, oncologists, and primary care providers (PCPs). While initial SCP approaches hav...

    Background: Survivorship care plans (SCPs) are intended to facilitate communication and coordination between patients, oncologists, and primary care providers (PCPs). While initial SCP approaches have focused on oncology providers initiating the SCP process, time and resource barriers have limited uptake. Objective: This trial compares the feasibility and value of two web-based SCP tools: provider-initiated vs. patient-initiated. Methods: This mixed-methods study recruited clinicians from two academically-affiliated community oncology practices. Eligible patients were treated by a participating oncologist, had non-metastatic cancer, completed acute treatment ≤ 2 months before enrollment, and had no evidence of disease. Patients were randomized 1:1 to either a provider-initiated or patient-initiated SCPs – both are web-based tools. We conducted qualitative interviews with providers at baseline and follow-up, and with patients 2 months after enrollment. In addition, patients were administered the Preparing for Life as a (New) Survivor (PLANS) and Cancer Survivors’ Unmet Needs (CaSUN) surveys at baseline and 2-months. Results: Of 39 providers approached, 13 (33%) enrolled. Providers/clinic staff required researcher assistance to identify eligible patients; 41 patients were randomized, of whom 25 completed follow-up (61%; 13 provider-initiated, 12 patient-initiated). Of the 25, 11 (44%) had initiated the SCP; 5 (20%) provided the SCP to their PCP. There were no statistically significant differences between study arms on the PLANS or CaSUN at baseline, follow-up, or change between baseline and follow-up. In qualitative interviews, providers and patients discussed SCPs’ value. Conclusions: Regardless of patient vs. provider initiated templates, and the web-based design of these tools, barriers to survivorship care planning persist. Further efforts should emphasize workflow functions for identifying and completing SCPs-- regardless of the SCP form used. Clinical Trial: Trial Registration: ClinicalTrials.gov NCT02405819

  • How do people suffering from psychosis use the Internet for getting information on their mental health? Literature review and recommendations

    From: Journal of Medical Internet Research

    Date Submitted: May 6, 2016

    Open Peer Review Period: May 6, 2016 - Jul 1, 2016

    Background: Studies show that the Internet has become an influential source of information for psychotic people, among which the rate of Internet users is growing, with rates ranging from 33,3% to 79,...

    Background: Studies show that the Internet has become an influential source of information for psychotic people, among which the rate of Internet users is growing, with rates ranging from 33,3% to 79,5% given the countries. Among people suffering from mental illness using the Internet on a regular basis, between 20,5% and 56,4% seek mental health information. Objective: Focusing on people suffering from psychosis’ navigation about their mental health, this paper examines what content they look for and what could be the benefits and disadvantages. Methods: We conducted a literature review through medical and psychological databases between 2000 and 2015, using the keywords “Internet”, “Web”, “Virtual”, “Health information”, “Psychosis”, “Schizophrenia”, “eMental health”, “eSupport”, “Telepsychiatry”. Results: People suffering from mental illness wish to find on the Internet trustful, non-stigmatizing information about their disease, flexibility, security standards, and positive peer-to-peer exchanges. E-mental health also appears to be desired by a substantial proportion of them. In this field, cost effectiveness and clinical efficiency have been demonstrated, and the existing developments for intervention and early prevention in the areas of depression, bipolar and anxiety disorders become also operational for schizophrenia. The many benefits of the Internet as a source of information and support, such as empowerment, enhancement of self-esteem, relief from peer information, better social interactions and more available care, seem to overcome the difficulties. Conclusions: In our paper, after having discussed the challenges related to the various aspects of the emergence of the Internet into the life of people suffering from psychosis, we propose areas of future research and practical recommendations for this major transition.

  • Possible Biases of Researchers' Attitudes towards Video Games: Publication Trends Analysis of the Medical Literature (1980-2013)

    From: Journal of Medical Internet Research

    Date Submitted: May 4, 2016

    Open Peer Review Period: May 5, 2016 - Jun 30, 2016

    Background: The study of video-games is expanding, and so is the debate regarding their possible positive and deleterious effect. As controversies continue, several researchers have expressed their co...

    Background: The study of video-games is expanding, and so is the debate regarding their possible positive and deleterious effect. As controversies continue, several researchers have expressed their concerns about substantial biases existing in the field, which might lead to the creation of a skewed picture, both in professional and in lay literature. However, no study has tried to examine this issue quantitatively. Objective: The current study is set to examine possible systematic biases in the literature, by analyzing the publication trends of the medical and life-sciences literature regarding video-games. Methods: A complete and systematic PubMed search till December 2013 was performed. All 1927 articles deemed relevant were assessed for their attitude towards video-games according to the focus, hypothesis and authors' interpretation of the study results, using a three-category outcome (Positive, Negative, Neutral). Prevalence of different attitudes was assessed for possible association with year of publication, location of researchers, academic discipline, methodological research and centrality of publishing journals. Results: The attitude towards video-games presented in publications varies by year of publication, location, academic discipline and methodological research applied (P<.001 for all). Moreover, representation of different attitudes differs according to centrality of journals, as measured by Impact Factor (P<.001). Conclusions: The results suggest that context, whether scientific or social, is related to researchers' attitudes toward video-games. Weighing in these contextual variables may contribute to the debate and to the interpretation of studies' results, both in the professional community, as well as the public domain. Funding: No funding was received for the current study. Clinical Trial: As this was a publication trends analysis, no patients were involved and no intervention was performed, thus trial was not registered.

  • How do you #relax when you're #stressed? A content analysis and infodemiology study of stress-related tweets

    From: Journal of Medical Internet Research

    Date Submitted: May 5, 2016

    Open Peer Review Period: May 5, 2016 - Jun 30, 2016

    Background: Stress is a contributing factor to many major health problems in the United States, such as heart disease, depression and autoimmune diseases. Relaxation is often recommended in mental hea...

    Background: Stress is a contributing factor to many major health problems in the United States, such as heart disease, depression and autoimmune diseases. Relaxation is often recommended in mental health treatment as a frontline strategy to reduce stress, thereby improving health conditions. Twitter is a micro-blog platform that allows users to post their own personal messages (tweets), including their expressions about feelings and actions related to stress and stress management (e.g., relaxing). While Twitter is increasingly used as a source of data for understanding mental health from a population perspective, the specific issue of stress – as manifested on Twitter – has not yet been the focus of any systematic study. Objective: To understand how and in what way people express their feelings of stress and relaxation through Twitter messages. In addition, we investigate automated natural language processing (NLP) methods to (1) classify stress vs. non-stress and relaxation vs. non-relaxation tweets and (2) identify first-hand experience – i.e., who is the experiencer – in stress and relaxation tweets. Furthermore, we apply the automated classification methods we have developed to rank stress and relaxation levels at the city level, and compare the results to United States national stress surveys. Methods: We first performed a qualitative content analysis of 814 first-person tweets containing stress and relaxation related keywords, resulting in a manually annotated (coded) data set of 479 first-person stress-related tweets and 335 first-person relaxation-related tweets. We then investigated the use of machine learning algorithms – in particular naïve Bayes and Support Vector Machines (SVMs) – to automatically classify tweets as stress vs. non-stress and relaxation vs. non-relaxation. Finally, we applied these classifiers to sample data sets drawn from four cities (Los Angeles, New York, San Diego, and San Francisco) obtained from Twitter’s Streaming Application Programming Interface (API), with the goal of evaluating the extent of any correlation between our automatic classification of tweets and results from public stress surveys. Results: Content analysis showed that the most frequent topic of stress tweets was education (15%), followed by work (9%) and social relationships (8%). The most frequent topic of relaxation tweets was rest and vacation (36%), followed by nature (22%) and water (20%). Evaluations using 10-fold cross-validation showed that SVM outperformed naïve Bayes in classifying stress vs. non-stress and relaxation vs. non-relaxation tweets. However, naïve Bayes is better in identifying first-hand experience in both stress and relaxation tweets. When applied to the city dataset, we found that the proportion of stress tweets in New York and San Diego is substantially higher than in Los Angeles and San Francisco. In addition, we found that characteristic expressions of stress and relaxation vary for each city based on its geo-location. Conclusions: This content analysis and infodemiology study revealed that Twitter, when used in conjunction with NLP techniques, is a useful data source for understanding stress and stress management strategies, and can potentially serve as a supplement to infrequently collected survey-based stress data.

  • Evaluating the Accuracy of Google Translate Website for Diabetes Education Material

    From: Journal of Medical Internet Research

    Date Submitted: May 3, 2016

    Open Peer Review Period: May 4, 2016 - Jun 29, 2016

    Background: Approximately 21% of the US population speaks a language other than English at home, of which a large number cannot effectively communicate in English. Hispanics and Chinese Americans, in...

    Background: Approximately 21% of the US population speaks a language other than English at home, of which a large number cannot effectively communicate in English. Hispanics and Chinese Americans, in particular, are the two largest minority groups having low health literacy in the United States. Fortunately, machine-generated translations represent a novel tool non-English speakers can utilize to receive and relay health education information when human interpreters are not available. Objective: The purpose of this study is to evaluate the accuracy of the Google Translate website when translating health information from English to Spanish and English to Chinese. Methods: The pamphlet, “You are the heart of your family…take care of it”, is a health education sheet for diabetes patients which outlines six tips for behavior change. Two professional translators translated the original English sentences into Spanish and Chinese. We recruited six certified translators (three Spanish and three Chinese) to conduct blinded evaluations of the following versions: (1) sentences translated by Google Translate; and (2) sentences translated by a professional human translator. Evaluators rated the provided sentences on four scales: fluency, adequacy, meaning, and severity. We performed descriptive analysis to examine differences between these two versions. Results: The Cronbach’s alpha values were exhibiting high degrees of agreement on the rating outcome of both evaluator groups: 0.919 for the Spanish evaluators and 0.972 for the Chinese evaluators. The readability of the sentences in this study ranged from 2.8 to 9.0 (M=5.4, SD=2.7). The correlation coefficients between the Grade Level and translation accuracy for all the sentences translated by Google were negative (e.g., rMeaning=-.660), which indicates Google provided accurate translation for simple sentences; however, the likelihood of incorrect translation increased when the original English sentences required higher grade levels to comprehend. The Chinese human translator provided more accurate translation compared to Google. The Spanish human translator, on the other hand, did not provide a significantly better translation compared to Google. Conclusions: Google produced a more accurate translation from English to Spanish than English to Chinese. Some sentences translated by Google from English to Chinese exhibit the potential to result in delayed patient care. We recommend continuous training and credential practice standards for professional medical translators to enhance patient safety as well as providing health education information in multiple languages.

  • A national neighborhood dataset from geotagged Twitter data

    From: Journal of Medical Internet Research

    Date Submitted: May 1, 2016

    Open Peer Review Period: May 2, 2016 - Jun 27, 2016

    Background: Studies suggest that where people live, play and work can influence health and well-being. However, the dearth of neighborhood data, especially data that is timely and consistent across ge...

    Background: Studies suggest that where people live, play and work can influence health and well-being. However, the dearth of neighborhood data, especially data that is timely and consistent across geographies, hinders understanding of the effects of neighborhoods on health. Social media data represents a possible new data resource for neighborhood research. Objective: The aim of this study is to build, from geotagged Twitter data, a national neighborhood database with area-level indicators of well-being and health behaviors. Methods: We utilized Twitter’s Streaming Application Programming Interface (API) to continuously collect a random 1% subset of publicly available geo-located tweets over a period of 12 months (April 2015– March 2016). We collected 80 million geotagged tweets from 603,363 unique Twitter users across the contiguous United States. We validated our machine learning algorithms for constructing indicators of happiness, food, and physical activity by comparing predicted values to those generated by human coders. Geotagged tweets were spatially mapped to the 2010 census tract and zip code areas they fall within, which enabled further assessment of the associations between Twitter-derived neighborhood variables and neighborhood demographic, economic, and business characteristics. Results: Machine-labeled and manually-labeled tweets had a high level of agreement: 80% for happiness, 83% for food and 85% for physical activity. About 20% of tweets were classified as happy. Relatively few terms (less than 25) were necessary to characterize the majority of tweets on food and physical activity. Data from over 70,000 census tracts from the United States suggest that percent African American and economic disadvantage were associated with lower happiness levels. Urbanicity was related to higher frequency of fast food tweets. Greater numbers of fast food restaurants predicted higher frequency of fast food mentions. Surprisingly, fitness centers and nature parks were only modestly associated with higher frequency of physical activity tweets. Conclusions: Machine learning algorithms can be built with relatively high accuracy to characterize sentiment, food and physical activity mentions on social media. Such data can be utilized to construct neighborhood indicators consistently and cost-effectively for small areas across the United States. Access to neighborhood data, in turn, can be leveraged to better understand neighborhood effects and address social determinants of health. We find that neighborhoods with social and economic disadvantage, high urbanicity, as well as those with more fast food restaurants may exhibit lower happiness and fewer healthy behaviors.

  • Engaging Gatekeeper-stakeholders in Development of a Mobile Health Intervention to Improve Medication Adherence among African American and Pacific Islander Elderly Patients with Hypertension

    From: JMIR mHealth and uHealth

    Date Submitted: Apr 25, 2016

    Open Peer Review Period: Apr 29, 2016 - Jun 24, 2016

    Background: Approximately 70 million people in the US have hypertension. While antihypertensive therapy can reduce the morbidity and mortality associated with hypertension, often patients do not take...

    Background: Approximately 70 million people in the US have hypertension. While antihypertensive therapy can reduce the morbidity and mortality associated with hypertension, often patients do not take their medication as prescribed. Objective: The goal of this study was to better understand issues affecting the acceptability and usability of mobile health technology (mHealth) to improve medication adherence for elderly African American (AA) and Native Hawaiian and Pacific Islander (NHPI) patients with hypertension. Methods: In-depth interviews were conducted with 20 Gatekeeper-stakeholders using targeted open-ended questions. Interviews were de-identified, transcribed, organized and coded manually by two independent coders. Analysis of patient interviews used largely a deductive approach because the targeted open-ended interview questions were designed to explore issues specific to the design and acceptability of a mHealth intervention for seniors. Results: A number of similar themes regarding elements of a successful intervention emerged from our two groups of AA and NHPI Gatekeeper-stakeholders. First was the need to teach participants both about the importance of adherence to antihypertensive medications; second, the use of smart/cell phones for messaging and patients need to be able to access ongoing technical support; third, messaging needs to be short and simple, but personalized, and to come from someone the participant trusts and with whom they have a connection. There were some differences between groups. For instance, there was a strong sentiment among AA that the church be involved and that the intervention begin with group workshops, while NHPI seemed to believe that the teaching could occur on a one-to-one basis with the health care provider. Conclusions: Information from our Gatekeeper-stakeholder (key informant) interviews suggests that the design of the mHealth intervention to improve adherence to antihypertensives among the elderly could be very similar between AAs and NHPIs. The main difference might be in the way in which the program is initiated (possibly through church-based workshops for AA and by individual providers for NHPIs). Another difference might be who sends the messages with AA wanting someone outside the health care system, but NHPI preferring a provider.

  • Influence of Pedometers Position on their Accuracy at Various Walking Speeds: a Comparative Study

    From: Journal of Medical Internet Research

    Date Submitted: Apr 28, 2016

    Open Peer Review Period: Apr 28, 2016 - Jun 23, 2016

    Background: Demographic changes and the rise of chronic diseases increase the pressure on the healthcare systems of most OECD countries. Physical activity has been demonstrated to be an essential fact...

    Background: Demographic changes and the rise of chronic diseases increase the pressure on the healthcare systems of most OECD countries. Physical activity has been demonstrated to be an essential factor to maintain elderly health. The walk is especially recommended as it is a simple activity that can be performed by most people without constraints. Pedometers have been heavily used as an incentive to motivate people to perform more activity. A recognized problem of these devices is the loss of accuracy going along with a decrease of walking speed. The introduction, on the consumer market, of new devices that can be worn indifferently at the waist, wrist or as a necklace opens interrogations about the accuracy of these devices regarding these different positions. Objective: In this study, we assess the performance of four pedometers and compare their accuracy according to their position at various walking speed. Methods: The study was conducted on a controlled environment with 21 healthy adults walking 100 meters, constrained to adopt 3 different paces (0.4 m/s, 0.6 m/s, 0.8 m/s) by a string attached between their legs and a metronome giving the cadence. Baseline for each participant is measured with a 200 meters walk at their own pace. Results: The results confirm a decrease of accuracy correlated with the speed (12% mean error at self-selected pace, 27% mean error at 0.8 m/s, 52% mean error at 0.6m/s and 76 % mean error at 0.4 m/s). The position did not have a significant influence on the accuracy of the pedometer, except 1) at speed higher than 0.8 m/s positioning the pedometer at the waist or as a necklace tend to produce lower mean error compare to the wrist and 2) for slow walk (0.4 m/s) pedometers worn at the wrist tend to produce lower mean error compared to the other positions. Conclusions: At all positions, all tested pedometers generated significant errors at slow speed and cannot be used reliably to evaluate the walk of people walking slower than 0.6 m/s (2.16 km/h, or 1.24 mp/h). At slow speed, the better accuracy observed when pedometers are worn at the wrist can be a valuable lines of inquiry for the future development of devices adapted to elderly people.

  • Self-reported psychosomatic health in Swedish children, adolescents and young adults living in rural and urban areas An Internet-based survey

    From: Journal of Medical Internet Research

    Date Submitted: Apr 25, 2016

    Open Peer Review Period: Apr 25, 2016 - Jun 20, 2016

    Background: Frequencies in reported psychosomatic ill health have increased in Sweden among children, adolescents and young adults. Objective: Little is known about demographic differences in self-rep...

    Background: Frequencies in reported psychosomatic ill health have increased in Sweden among children, adolescents and young adults. Objective: Little is known about demographic differences in self-reported psychosomatic health (SPH) in this population such as between urban and rural areas, and whether surveys launched on the Internet could be a useful method in sampling such data. Methods: A cross-sectional study using 7 validated questions about psychosomatic health, were launched in a controlled way onto a recognized Swedish internet community site which targeted users 10 to 24 years of age. The subjects were able to answer the items whilst they were logged in to their personal domain. The results were analyzed cross-geographically within Sweden. Results: In total we received 100 000–130 000 individual answers per question. Subjects of both sexes generally reported significantly higher levels of SPH complaints in major city areas as compared to minor city/rural areas, even though the differences between the areas were small. Females reported significantly higher frequencies of SPH complaints than males (p<0.0001). Conclusions: In subjects aged 10-24 years of age, higher levels of SPH complaints appear to correlate with living in major city areas in comparison to minor city/rural areas. Surveys launched on the Internet could be a useful method in sampling SPH data for this age group.

  • Investigating the Perceptions of Care Coordinators on Using Behavior Theory-Based Mobile Health Technology with Medicaid Populations: A Grounded Theory Study

    From: JMIR mHealth and uHealth

    Date Submitted: Apr 20, 2016

    Open Peer Review Period: Apr 22, 2016 - Jun 17, 2016

    Background: Medicaid populations are less engaged in their healthcare than the rest of the population, translating to worse health outcomes and increased healthcare costs. Since theory-based mobile he...

    Background: Medicaid populations are less engaged in their healthcare than the rest of the population, translating to worse health outcomes and increased healthcare costs. Since theory-based mobile health (mHealth) interventions have been shown to increase patient engagement, mobile phones may be an optimal strategy to reach this population. There is a deep disconnect between developers of mHealth technology and health behavior researchers, so there is a lack of data on what components of theory-based mHealth increase patient engagement. Objective: This study aims to address this gap between academia and practice by conducting research using the health behavior-theory based patient-provider text-messaging platform, Sense Health, which integrates Transtheoretical Model and Stages of Change (TTM), Social Cognitive Theory (SCT), Supportive Accountability, and Motivational Interviewing. Methods: Interviews based in grounded-theory methodology were conducted with 10 care managers to triangulate the findings of internal user activity data and to further understand perceptions of the relationship between mHealth and patient engagement. Results: The interviews with care managers yield a grounded theory model including four intertwined relationships revolving around patient engagement: between Sense Health, client-care manager relationships, and communication; Sense Health, literacy, and access to care; support, Sense Health, and communication; and Sense Health, patient accountability, and patient motivation. Conclusions: Sense Health features tied to health behavior theory appear to be effective in improving patient engagement. Two-way communication (Supportive Accountability), trusted relationships (Supportive Accountability, SCT), personalized messages (TTM), and patient input (TTM, SCT, Motivational Interviewing) appeared as the most relevant components in achieving desired outcomes. Additionally, reminder messages were noted as especially useful in making Medicaid patients accountable, and in turn engaging them in their health and healthcare. These findings expose how this theory-centered platform drives engagement, allowing Sense Health, and future mHealth interventions that aim to improvement patient engagement in Medicaid populations, to improve their technology. Clinical Trial: Columbia University Medical Center Institutional Review Board (IRB-AAAQ5254)

  • Gamification of cognitive assessment and cognitive training: A systematic review of applications and efficacy

    From: JMIR Serious Games

    Date Submitted: Apr 21, 2016

    Open Peer Review Period: Apr 22, 2016 - Jun 17, 2016

    Background: Cognitive tasks are typically viewed as effortful, frustrating and repetitive, which often leads to participant disengagement. This, in turn, may negatively impact data quality and/or redu...

    Background: Cognitive tasks are typically viewed as effortful, frustrating and repetitive, which often leads to participant disengagement. This, in turn, may negatively impact data quality and/or reduce intervention effects. However, gamification may provide a possible solution. If game design features can be incorporated into cognitive tasks without undermining their scientific value, then data quality, intervention effects and participant engagement may be improved. Objective: This systematic review aims to explore and evaluate the ways in which gamification has already been used for cognitive training and assessment purposes. We hope to answer three questions: 1) Why have researchers opted to use gamification? 2) What domains has gamification been applied in? 3) How successful has gamification been in cognitive research thus far? Methods: We systematically searched several online databases, searching the titles, abstracts and keywords of database entries using the search strategy (gamif* OR game OR games) AND (cognit* OR engag* OR behavi* OR health* OR attention OR motiv*). Searches included articles published in English between January 2007 and October 2015. Results: Our review identified 31 relevant studies, covering 30 gamified cognitive tasks used across a range of disorders and cognitive domains. We identified seven reasons for researchers opting to gamify their cognitive training and testing. We found that working memory and general executive functions were common targets for both gamified assessment and training. Gamified tests were typically validated successfully, although mixed-domain measurement was a problem. Gamified training appears to be highly engaging and does boost participant motivation, but mixed effects of gamification on task performance were reported. Conclusions: Heterogeneous study designs and typically small sample sizes highlight the need for further research in both gamified training and testing. Nevertheless, careful application of gamification can provide a way to develop engaging and yet scientifically valid cognitive assessments and it is likely worthwhile to continue to develop gamified cognitive tasks in the future.

  • Are online patient ratings of hospitals influenced by enhanced supervision by healthcare inspectorates? A multilevel approach of more than 43.000 online ratings

    From: Journal of Medical Internet Research

    Date Submitted: Apr 19, 2016

    Open Peer Review Period: Apr 19, 2016 - Jun 14, 2016

    Background: Patient rating sites are an upcoming phenomenon in healthcare. Patient reviews might be influenced by the media coverage of healthcare providers when the healthcare inspectorate imposes en...

    Background: Patient rating sites are an upcoming phenomenon in healthcare. Patient reviews might be influenced by the media coverage of healthcare providers when the healthcare inspectorate imposes enhanced supervision. Objective: The aim of this study was to investigate whether being under enhanced supervision by the healthcare inspectorate influences online patient ratings of hospitals. Methods: We used data of patient rating site Zorgkaart Nederland, from January 1st 2010 until December 31st 2015. We compared data of seven hospitals with enhanced supervision with a control group of 28 hospitals. The dataset contained 43.856 ratings. We performed a multilevel logistic regression analysis to account for clustering of ratings within hospitals. Fixed effects in our analysis were hospital type, time and the period of enhanced supervision. Random effect was the hospital. The outcome variable was the dichotomised rating score. Results: The period of enhanced supervision was associated with a low rating score for hospitals compared to control group hospitals: both one year prior to enhanced supervision (OR 1.67: 95% BI (1.06-2.63)) and one year after (OR 1.79: 95% BI (1.14-2.81)) the differences are significant. For all periods the odds on a low rating score for hospitals under enhances supervision are higher than for the control group hospitals, corrected for time. Time is also associated with low rating scores, with descending odds ratio's over time since 2010. Conclusions: Hospitals that are confronted with enhanced supervision by the healthcare inspectorate have lower ratings on patient rating sites. The scores are independent of the period: before, during or just after the intervention by the healthcare inspectorate. Healthcare inspectorates might learn from these results since they indicate that the inspectorate identifies the same hospitals as ‘at risk’ as patients rate hospitals as underperformers.

  • Methods of Sentiment Analysis of Healthcare Tweets: A Review of the Literature

    From: Journal of Medical Internet Research

    Date Submitted: Apr 18, 2016

    Open Peer Review Period: Apr 18, 2016 - Jun 13, 2016

    Background: Twitter is mobile micro blogging service, where users are able to send and read short 140-character messages called “tweets”. There is a large amount of unstructured, free-text tweets...

    Background: Twitter is mobile micro blogging service, where users are able to send and read short 140-character messages called “tweets”. There is a large amount of unstructured, free-text tweets relating to healthcare being shared on Twitter, which is becoming a popular area for healthcare research. Sentiment is a metric commonly used to investigate the positive or negative opinion within these messages. Exploring the methods used for sentiment analysis in twitter healthcare research may allow us to better understand the options available for future research in this growing field. Objective: The first objective was to understand which tools would be available for sentiment analysis of healthcare Twitter research, by reviewing existing studies in this area, and the methods they used. The second objective was to determine which methods would work best in healthcare, by anlaysing how the methods were use to answer specific healthcare questions, their production, and how their accuracy was validated. Methods: We conducted a review of the literature pertaining to Twitter and healthcare research which used a quantitative method of sentiment analysis for the free text messages (tweets). We compared the types of tools used in each case and examined methods for tool production, tool training and validation. Results: 11 papers were found studying the quantitative measurement of sentiment in the healthcare setting. Half of these studies produced tools specifically for their research, 3 used open source tools available freely, and two used commercially available software. Four out of the eleven tools were trained using a smaller sample of the study’s final data. The sentiment method was trained against, on average, 4% of the total sample data. None of the 11 papers commented on the validation of accuracy of the tools used. Conclusions: There are multiple methods used for sentiment analysis of tweets in the healthcare setting. These range from self-produced basic categorisations, to more complex and expensive commercial software. The open source and commercial methods are developed on product reviews and generic social media messages. None of these methods have been extensively validated against a corpus of healthcare messages to check their accuracy. This study suggests there is a need for an accurate and validated tool for sentiment analysis of tweets, within the healthcare setting.

  • Stride with the tide of new media era: a combination of benefiting patients and supporting needy students

    From: interactive Journal of Medical Research

    Date Submitted: Apr 14, 2016

    Open Peer Review Period: Apr 15, 2016 - Jun 10, 2016

    With the development of web and smart cell phones, new media era approaches. Bearing these thoughts in mind, we have been the leader in domestic academic media via DXY Orthopaedic channel. The rapid e...

    With the development of web and smart cell phones, new media era approaches. Bearing these thoughts in mind, we have been the leader in domestic academic media via DXY Orthopaedic channel. The rapid expansion of WeChat has been narrowing the distance of the public, linking not only scientific community, but physicians and patients. Therefore, we registered a WeChat public platform as Spine Truth (WeChat ID: jzglyl) on Sep 17th, 2015. Motivated by benefiting patients suffering pain, we have been dedicated to release evidence-based medicine articles per day. We distilled the essence of medical scientific knowledge into light and acceptable essays with funny images. Thereafter, we gained Originality certification and Appreciation function by Tecent as the Operator. The Appreciation funds were donated to needy students via a network. Collectively, we achieve success to some extent on academic transmission and popularization of medical knowledge and preventive treatment of diseases in new media era via network and public platforms. Furthermore, we practice the goal of scientific research, from bench to bedside, from beside to public. Unexpectedly, we could combine benefiting patients and supporting needy students in the practice of scientific popularization.

  • SMS-Based Intervention Targeting Alcohol Consumption Among University Students: Findings from a Formative Development Study

    From: JMIR mHealth and uHealth

    Date Submitted: Apr 12, 2016

    Open Peer Review Period: Apr 12, 2016 - Jun 7, 2016

    Background: Drinking of alcohol among university students is a global phenomenon with heavy episodic drinking being accepted despite several potential negative consequences. Half of all young adults i...

    Background: Drinking of alcohol among university students is a global phenomenon with heavy episodic drinking being accepted despite several potential negative consequences. Half of all young adults in Sweden attend university making the health and well-being of this group a public health concern. There is emerging evidence that text messaging (SMS) interventions are effective to promote behaviour change among students. However, it is still unclear how effectiveness can be optimized through intervention design or how user interest and adherence can be maximised. Objective: To develop an SMS-based intervention targeting alcohol drinking among university students using formative research. Methods: A formative research design was used including an iterative revision process based on input from end users and experts. Data were collected via focus groups (n=7) with students and a panel evaluation involving students (n=15) and experts (n=5). Student participants were recruited from five universities in Sweden. A semi-structured interview guide was used in the focus groups and included questions on alcohol culture, message content and intervention format. The panel evaluation asked participants to rate to what degree preliminary messages were understandable, usable and had a good tone on a scale from 1 to 4 (1 = very low degree; 4 = very high degree). Participants could also write their own comments for each message. Qualitative data were analysed using qualitative descriptive analysis. Quantitative data were analysed using descriptive statistics. The SMS messages and the intervention format were revised continuously, in parallel with data collection. A behaviour change technique analysis was conducted on the final version of the program. Results: The focus group data showed that, overall, students were positive towards the SMS intervention. Messages that were neutral, motivated, clear and tangible engaged students. Students expressed that they preferred short, concise messages and confirmed that a 6-week intervention was an appropriate duration. However, there was limited consensus regarding SMS frequency, personalization of messages and timing. Overall, messages scored high on understanding (3.86, SD 0.43), usability (3.70, SD 0.61) and tone (3.78, SD 0.53). Participants added comments to 67 of 70 messages, including suggestions for change in wording, order of messages, and feedback on why a message was unclear or needed major revision. Comments also included positive feedback that confirmed the value of the messages. Twenty-three behaviour change techniques, aimed at, for example, addressing self-regulatory skills, were identified in the final program. Conclusions: The formative research design was valuable and resulted in significant changes to the intervention. All the original SMS messages were changed and new messages were added. The findings showed that, overall, students were positive towards receiving support through SMS and that neutral, motivated, clear and tangible messages promoted engagement. However, limited consensus was found on the timing, frequency and tailoring of messages.

  • Electronic communication between patient and provider: Assessing the attitudes and perspectives of 624 primary health care patients from Southwestern Ontario

    From: Journal of Medical Internet Research

    Date Submitted: Apr 11, 2016

    Open Peer Review Period: Apr 12, 2016 - Jun 7, 2016

    Background: Electronic communication (or “email”) between patients and their health care providers can serve as an ongoing and collaborative forum to improve access to care, enhance convenience of...

    Background: Electronic communication (or “email”) between patients and their health care providers can serve as an ongoing and collaborative forum to improve access to care, enhance convenience of communication, reduce administrative costs and missed appointments and improve satisfaction with the patient-provider relationship. Objective: The main objective of this study was to investigate the attitudes of patients aged 16 years and older towards receiving email communication for health-related purposes from an academic inner-city family health team in Southern Ontario. In addition to exploring the proportion of patients with a functioning email address and interest in email communication with their health care provider, patient-level predictors of interest in email communication were also examined. Methods: A cross-sectional study was conducted using a self-administered, one-page survey of attitudes towards electronic communication for health purposes. Participants were recruited from attending patients at the McMaster Family Practice in Hamilton, Ontario, Canada. These patients were aged 16 years and older and were approached consecutively to complete the survey (N = 624). Descriptive analyses were conducted using the Pearson chi-square test to examine correlations between variables. A logistic regression analysis was conducted to determine statistically significant predictors of interest in email communication (yes or no). Results: The majority of respondents (73.2%) reported that they would be willing to have the McMaster Family Practice contact them via email to communicate health-related information. Those respondents who checked their personal email more frequently were more likely to want to engage in this electronic communication. Among respondents who check their email less frequently (fewer than every three days), 45% preferred to communicate with the McMaster Family Practice via email. Conclusions: Electronic communication (e.g., email) is becoming a prominent method to transfer health information between members of health care teams, as well as between patients and health care providers. With increasing utility of mobile devices in the general population, the proportion of patients interested in email communication with their health care providers will continue to increase.

  • Crowdsourced Identification of Possible Allergy Associated Factors: Automated Hypothesis Generation and Validation using a Crowdsourcing Services

    From: Journal of Medical Internet Research

    Date Submitted: Apr 8, 2016

    Open Peer Review Period: Apr 8, 2016 - Jun 3, 2016

    Background: Hypothesis generation is an essential task for clinical research, and it can require years of research experience to formulate a meaningful hypothesis. Recent studies have endeavored to ap...

    Background: Hypothesis generation is an essential task for clinical research, and it can require years of research experience to formulate a meaningful hypothesis. Recent studies have endeavored to apply crowdsourcing to generate novel hypotheses for research. In this study, we apply crowdsourcing to explore previously unknown allergy associated factors. Objective: In this study, we aimed to collect and test hypotheses of unknown allergy associated factors using a crowdsourcing service. Methods: Using a series of questionnaires, we asked crowdsourcing participants to provide hypotheses on associated factors for 7 different allergies, and validated the candidate hypotheses with odds ratios calculated for each associated factors. We repeated this abductive validation process to identify a set of reliable hypotheses. Results: We obtained 2 primary findings: first, crowdsourcing showed that 8 of the 13 already known hypothesized allergy risks were statically significant. Second, among the total of 157 hypotheses generated by the crowdsourcing service, 75 hypotheses were statistically significant allergy-associated factors, comprising the 8 known risks and 53 previously unknown allergy-associated factors. These findings suggest that there are still many topics to be examined in future allergy studies. Conclusions: Crowdsourcing was able to generate new hypotheses on allergy-associated factors. In the near future, clinical trials should be conducted to validate the hypotheses generated in this study. Clinical Trial: No

  • The State of Open Source Electronic Health Record Projects: A Software Anthropology Study

    From: JMIR Medical Informatics

    Date Submitted: Apr 6, 2016

    Open Peer Review Period: Apr 7, 2016 - Jun 2, 2016

    Background: Electronic health records are key tools in managing and storing patients’ illness information. Several open source EHR applications are available at SourceForge, the largest repository o...

    Background: Electronic health records are key tools in managing and storing patients’ illness information. Several open source EHR applications are available at SourceForge, the largest repository of open source projects. However, few published studies that focused on the characteristics of F/OSS electronic health record software and none to date has been published on the motivation, knowledge background, and demographic characteristics of the developers involved in open source electronic health records (EHR) projects. Functionality and usability are important success factors for any system. These are often a direct reflection of the domain knowledge and motivations of the developers. This is particularly true in open source development, where it is often said the genesis of many open source projects is “scratching one’s own itch”. Objective: This study analyzes the characteristics of F/OSS electronic health record software and aims to provide an understanding of the motivation, knowledge background, and characteristics of the developers involved in open source electronic health records (EHR) projects. Methods: The research identified F/OSS electronic health record projects on SourceForge and other websites starting in May 2014. Projects were classified and characterized by :license type , downloads, programming languages, spoken languages, project age, development status, supporting materials, top downloads according to countries, and certified open EHR. Healthcare F/OSS developers were also surveyed using an online survey website (SurveyGizmo). Results: There are 54 open source EHR projects, but only four of them are CMS certified applications. The majority of the projects, 44.5%, have been downloaded by users in the United States, which reveals a significant interest in EHR open source applications in the U.S. A total of 103 responses were successfully collected showing the reasons to contribute to a healthcare open source project. The top motivation factor (56.5%) is intrinsic enjoyment. The majority of users are paid for participation in F/OSS projects. Only twenty-five percent of healthcare F/OSS developers are, of have been, healthcare providers in their careers, and 45.9% of developers do not work in the healthcare field. Conclusions: Open source software seems to be important to many healthcare organizations in general; however, given that only four F/OSS EHR systems are U.S. ONC certified, this highlights a challenge for the U.S. adoption of F/OSS healthcare systems. Healthcare open source software currently lacks the governmental support for sustainability and growth of these software programs. This research highlights some challenges that may be hindering the future of healthcare F/OSS.

  • Linguistic and cultural adaption of a computerized counseling program (CARE+ Spanish) to support HIV treatment adherence and risk reduction for PLHA: A randomized controlled trial

    From: Journal of Medical Internet Research

    Date Submitted: Apr 4, 2016

    Open Peer Review Period: Apr 6, 2016 - Jun 1, 2016

    Background: HIV disease in the United States disproportionately affects minorities including Latinos. Barriers including language are associated with lower antiretroviral therapy (ART) adherence seen...

    Background: HIV disease in the United States disproportionately affects minorities including Latinos. Barriers including language are associated with lower antiretroviral therapy (ART) adherence seen among Latinos, yet ART and clinic visit adherence interventions are rarely developed or delivered in Spanish. Objective: A computerized counseling tool, demonstrated to reduce HIV-1 viral load and sexual risk transmission in a population of English-speaking adults, was adapted for use during routine clinical visits for an HIV positive Spanish-speaking population (CARE+ Spanish); the Technology Acceptance Model (TAM) was the theoretical framework guiding program development. Methods: A longitudinal randomized controlled trial (RCT) was conducted from June 4, 2010 to March 29, 2012. Participants were recruited from a comprehensive HIV treatment center comprising three clinics in New York City. Eligibility criteria were (1) adults (≥18 years old), (2) Latino birth or ancestry, (3) speaks Spanish (mono- or multi-lingual), and (4) on anti-retrovirals (ARVs). Linear and generalized mixed linear effects models were used to analyze primary outcomes which included ART adherence, sexual transmission risk behaviors, and HIV-1 viral loads. Exit interviews were offered to purposively-selected intervention participants to explore cultural acceptability of the tool among participants, and focus groups explored the acceptability and system efficiency issues among clinic providers, using the TAM framework. Results: A total of 494 Spanish speaking HIV clinic attendees were enrolled and randomly assigned to intervention (Arm A, n=253) or risk-assessment only control (Arm B, n=241) and followed up at 3-month intervals for one year. Gender distribution was 296 (68.4%) male, 110 (25.4%) female, and 10 (2.3%) transgender. Four hundred thirty-three (87.7%) were retained by study end. Although intervention participants had reduced viral loads, increased ART adherence and decreased sexual transmission risk behaviors over time, these findings were not statistically significant. We also conducted 61 qualitative exit interviews with participants and two focus groups with a total of 16 providers. Conclusions: A computerized counseling tool grounded in the TAM theoretical model and delivered in Spanish was acceptable and feasible to implement in a high-volume HIV clinic setting. It was able to provide evidence-based, linguistically-appropriate ART adherence support without requiring additional staff time, bilingual status, or translation services. We found that language preferences and cultural acceptability of a computerized counseling tool exist on a continuum in our urban Spanish-speaking population. Theoretical frameworks of technology’s usefulness for behavioral modification need further exploration in other languages and cultures. Clinical Trial: ClinicalTrials.gov identifier: NCT01013935

  • Comparison of Face-to-Face versus Telemedicine Respiratory Assessment in a Pediatric Intensive Care Unit

    From: Journal of Medical Internet Research

    Date Submitted: Apr 4, 2016

    Open Peer Review Period: Apr 4, 2016 - May 30, 2016

    Background: Telemedicine is the use of electronic communication and information technologies to provide or support clinical care at a distance. Much has been written about the potential for telemedic...

    Background: Telemedicine is the use of electronic communication and information technologies to provide or support clinical care at a distance. Much has been written about the potential for telemedicine to increase access to care, but applications in pediatrics are sparse and few studies have been done to measure the reliability of the physical assessment obtained via telemedicine. The use of telemedicine to help manage critically ill pediatric patients in an ICU setting is a particularly attractive application given current and anticipated pediatric critical care medicine subspecialty workforce challenges. Objective: To test the hypothesis that many aspects of the respiratory examinations of patients admitted to a pediatric intensive care unit can be reliably obtained via telemedicine. Methods: Prospective, randomized study comparing telemedicine versus face-to-face assessments of 55 pediatric intensive care unit patients. Study providers included six pediatric intensivists and seven critical care fellows. For each study patient, two providers were randomly assigned to perform an examination in-person or via telemedicine. Findings were recorded on a standardized data collection form and compared. Results: One hundred and ten comparisons were completed. There agreement, as measured by the Kappa coeficient, on elements of the respiratory examination ranged from 0.02 to 0.34. Telemedicine assessment of respiratory findings was highly sensitive and specific. Providers identified equipment-related difficulties and environmental influences that limited their ability to obtain a reliable pulmonary assessment via telemedicine. Conclusions: Telemedicine is a powerful tool to aid in assessment of critically ill patients. Its utility in assessment of several pulmonary variables is limited by equipment-related issues, lack of training of bedside assistants and poor cooperation of some patients. Clinical Trial: This was not a randomized clinical trial. There was no randomization process as this was a prospective study which enrolled eligible patients as they were admitted to the ICU. All patients underwent the same physical examination, no randomization to different arms of the study or different treatment or observation occurred.

  • Content Analysis of Responses to Tobacco-Free Campaign on Twitter

    From: Journal of Medical Internet Research

    Date Submitted: Mar 31, 2016

    Open Peer Review Period: Apr 1, 2016 - May 27, 2016

    Background: Smoking has been proved harmful for human health in previous studies. To address the health issues and advocate a tobacco-free lifestyle, many government and nongovernmental organizations...

    Background: Smoking has been proved harmful for human health in previous studies. To address the health issues and advocate a tobacco-free lifestyle, many government and nongovernmental organizations have put a lot of efforts, such as social media campaigns. Since social media spread messages quickly and powerfully, whether a social media campaign is effective or not is a vital consideration for these organizations. Objective: Due to this need, an analysis for the public responses to the campaign on social media is required. This study aims to analyze the content of responses to a tobacco-free campaign. Methods: 6968 public tweets over two years responding to “The Real Cost” campaign, FDA’s first tobacco-free campaign, were collected. We analyzed the topics under positive and negative sentiment over two years and constructed a topic network to study the leading topics and their connections. We further analyzed the content characteristics for the posts, and used content features to propose two predictive models for retweetability and likability. Results: Of the 6968 tweets, 44.37% are positive, 38.46% are negative, and the remaining 17.17% are neutral. The volume of responses to the campaign was larger in the first six months compared to the later months, but then dropped in 2015. The negative responses increased for a three-month period in 2015, due to ill-received videos. Health concerns are prevalent in positive responses, while campaign content topics are widespread in negative responses. Topic analysis showed that the leading positive topic is “cigarette is harmful” and the leading negative topic is “doubt the tweet”. The topic “doubt the tweet” has the highest centrality in the topic network. The positive tweets are generally longer, less complex, more informative and more readable than the negative tweets (P < .001). Readability, informativeness, etc. are significant predictors for the likelihood that other users will retweet a post (retweetability). Complexity, informativeness, readability, etc., are significant predictors for the likelihood that other users will like a post (likability). Social features are found to influence likability more significantly, while content features affect retweetability to a larger extent. Conclusions: Social media users respond sensitively to tobacco-free campaigns. The problem is that there exits a large number of negative responses, which turn against the goal of the campaign. This paper showed the topics in positive and negative posts respectively, and found out that the campaign content is the main reason for negative responses. The campaign official account should be careful of these negative topics in the future. We also showed that content and social features, such as complexity, readability and informativess can predict retweetability and likability. To make future tweets be retweeted and liked, official accounts should pay more attention to the content features.

  • Mixed Method Evaluation of Adolescent and Young Adult Cancer Survivorship Educational Programming

    From: JMIR Cancer

    Date Submitted: Mar 30, 2016

    Open Peer Review Period: Apr 1, 2016 - May 27, 2016

    Background: This mixed method evaluation considers the need for increased professional and patient education for Adolescent and Young Adult (AYA) cancer survivorship. Due to the high incidence of late...

    Background: This mixed method evaluation considers the need for increased professional and patient education for Adolescent and Young Adult (AYA) cancer survivorship. Due to the high incidence of late effects of cancer treatment among AYA cancer survivors, knowledge sharing and communications are needed throughout the transition from cancer care into community care. AYA survivors are likely to need developmentally appropriate psychosocial care as well as extensive follow-on surveillance by physicians who are educated and aware of the likely chronic conditions and late effects that may occur in these patients. Digital technology including mobile apps, videos, and podcasts are important tools to support both AYA survivor and provider education. Objective: The objective of this mixed methods research was to evaluate the outcomes of the After Cancer Care Ends, Survivorship Starts for Adolescent and Young Adults (ACCESS AYA) programming. The intent of the ACCESS AYA program was to build health literacy around AYA survivorship issues and to stimulate improved communications between survivors and healthcare providers. The paper addresses the central research question of “How did the ACCESS AYA program increase health literacy, communications, and understanding among AYA survivors and providers?” Included in the evaluation were use of an iPhone app “AYA Healthy Survivorship” and a companion website with digital media developed for the project. Methods: This mixed methods evaluation included a brief quantitative survey of participants’ awareness and effectiveness of the ACCESS AYA project combined with in-depth qualitative interviews based on a general interview guide tailored to the different types of evaluation participants. The evaluation used the Atlas Ti™ qualitative database and software for coding and key word analyses. Inter-rater reliability analyses were assessed using Cohen’s Kappa analysis using Stata 12.1 software Results: Using a scale of 1 to 5, with 5 as high, there were 22 respondents who rated their level of awareness of the project with a mean 3.2 (CI 3.02:3.45). Participants rated effectiveness with a mean of 4 (CI 3.72:4.27). In the qualitative evaluation, key coding themes included survivor wellbeing, healthcare professional education, cancer advocates role and education, Seton hospital and community-based resources and the role of societal support. The inter-rater reliability scores (ranging from 1 to minus 1) for the First Cycle coding was .893, and .784 for the Second Cycle. The Cohen kappa scores were derived using Stata 12.1 statistical analysis software. Conclusions: This case study offers a substantive contribution to understanding the AYA survivor community and to the healthcare professionals and advocates who aid them in their efforts to a new “normal” life and wellbeing in their survivorship. The results of the evaluation highlight the need to continue to build both survivor and professional resources to address the unique impact of cancer on AYA cancer survivors.

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