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JMIR Preprints

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Journal Description

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

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

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

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

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

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

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

 

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

    Authors List:

    Abstract:

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

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Latest Submissions Open for Peer-Review:

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  • A Behavioral Lifestyle Intervention Enhanced with Multiple-Behavior Self-Monitoring Using Mobile and Connected Tools: A Pilot Comparative Effectiveness Trial among Underserved Individuals with Type 2 Diabetes

    From: Journal of Medical Internet Research

    Date Submitted: Dec 9, 2017

    Open Peer Review Period: Dec 9, 2017 - Dec 21, 2017

    Background: Self-monitoring is a cornerstone of behavioral lifestyle interventions for obesity and type 2 diabetes mellitus (T2DM). Previous studies found that mobile technology has potential to impro...

    Background: Self-monitoring is a cornerstone of behavioral lifestyle interventions for obesity and type 2 diabetes mellitus (T2DM). Previous studies found that mobile technology has potential to improve adherence to self-monitoring and patient outcomes. However, no study has tested the use of a smartphone to facilitate self-monitoring in low-literate overweight or obese adults with T2DM living in the underserved community. Objective: To examine the feasibility of and compare preliminary efficacy of a behavioral lifestyle intervention using smart phone or paper-based self-monitoring of multiple behaviors on weight loss and glycemic control in a sample of overweight or obese adults with T2DM living in underserved communities Methods: We conducted a randomized controlled trial to examine the feasibility and preliminary efficacy of a behavioral lifestyle intervention among underserved individuals. A total of 26 overweight or obese patients with T2DM were recruited from an underserved minority community health center in Houston, TX. They were randomly assigned to one of the three groups: 1) behavior intervention with smart phone based self-monitoring, 2) Behavior intervention with paper diary based self-monitoring, and 3) Usual care group. Both the mobile and paper groups received a total of 11 group sessions in a 6-month intervention. The mobile group received an android-based smart phone with two applications loaded to help them record their diet, physical activity, weight, and blood glucose, along with a connected glucometer, while the paper group used paper diaries for these recordings. Treatment fidelity was assessed using a checklist for each intervention session. Primary outcomes of the study included % weight loss and glycolated hemoglobin (HbA1c) changes over 6 months of the study. Results: We had 96% retention rate at 6 months. The sample is predominantly African Americans with an average age of 56.4 years and BMI of 29.6. Participants lost an average of 2.73% (mobile group), 0.13% (paper group) weight at 6 months, while the control group had an average .49% weight gain. Their HbA1c changed from 8% to 7 % in mobile group, 10% to 9% in paper group, and maintained at 9% for the control group. We found a significant difference on HbA1c at 6 months among the 3 groups (P=.01). We did not find statistical significance on % weight loss (P=.20) and HbA1c changes (P=.44) among the 3 groups overtime, however, we found a large effect size of .40 for weight loss and a medium effect size of .28 for glycemic control. Conclusions: Delivering a simplified behavioral lifestyle intervention using mHealth-based self-monitoring in an underserved community is feasible and acceptable, and shows higher preliminary efficacy, as compared to paper-based self-monitoring. A full-scale randomized controlled trial is needed to confirm the findings in this pilot study. Clinical Trial: Clinicaltrials.gov NCT02858648; https://clinicaltrials.gov/ct2/show/NCT02858648

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

    From: Journal of Medical Internet Research

    Date Submitted: Dec 6, 2017

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

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

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

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

    From: JMIR Preprints

    Date Submitted: Sep 15, 2017

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

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

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

  • Applying Persuasive Design Techniques to Change Data Entry Behaviour in Primary Care

    From: Journal of Medical Internet Research

    Date Submitted: Nov 4, 2017

    Open Peer Review Period: Nov 6, 2017 - Jan 1, 2018

    Background: Persuasive design (PD) is an approach that seeks to change the behaviours of users by using design and social influence. In primary care, clinician behaviours and attitudes are important p...

    Background: Persuasive design (PD) is an approach that seeks to change the behaviours of users by using design and social influence. In primary care, clinician behaviours and attitudes are important precursors to structured data entry, and there is an impact on overall data quality. This research hypothesizes that PD could change data entry behaviours in clinicians and improve data quality. Objective: Our objective was to use PD principles to change clinician data-entry behaviours in a primary care environment and to increase data quality within a registry system. Methods: We performed a detailed systems analysis of the data-entry task by using cognitive work analysis (CWA). We used the results of this analysis with the Persuasive Systems Design (PSD) framework to describe the persuasion context. We identified several PD principles to be introduced in a new summary screen, which became part of the data entry workflow. As part of our experimental design, we defined three data quality measures (same-day entry, record completeness, and data validity) to measure changes in data quality and entry behaviour. We measured the impacts of the new screen with a paired pre/post t-test and generated XmR charts to contextualize the results. Results: 53 users were shown the new screen during their data entry over the course of 10 weeks. Based on a pre-post analysis, the new summary screen successfully encouraged users to enter more of their data on the same day as their encounter. The percentage of same-day entries increased by 10.34% (P < 0.001). During the first month of the new screen, users compensated by sacrificing aspects of data completeness, before returning to normal in the second month. Improvements to record validity were marginal over the study period (P = 0.045). Statistical process control techniques allowed us to study the XmR charts to contextualize our results and understand trends throughout the study period. Conclusions: By conducting a detailed systems analysis and introducing new PD elements into a data entry system, we demonstrated it was possible to change data-entry behavior and influence data quality in a reporting system. The results show that using PD concepts may be effective at influencing data entry behaviours in clinicians. There may be opportunities to continue improving this approach, and further work is required to perfect and test additional designs. Persuasive design is a viable approach to encourage clinician user change and could support better data capture in the field of medical informatics.

  • Are Turkish University Students Text-Message Dependent?Validity and Reliability of Turkish Self-Perception of Text-Message Dependency Scale

    From: Journal of Medical Internet Research

    Date Submitted: Oct 17, 2017

    Open Peer Review Period: Oct 18, 2017 - Dec 13, 2017

    Background: Text messaging is a fast and efficient means of communication among people. Text messaging (especially via SMS, Facebook, Twitter, Whatsapp) is quite common in developed and developing cou...

    Background: Text messaging is a fast and efficient means of communication among people. Text messaging (especially via SMS, Facebook, Twitter, Whatsapp) is quite common in developed and developing countries. Objective: We aimed to do validity and reliability of Self-perception of Text-message Dependency Scale among Turkish university students and show their text-message dependency level Methods: Between January 2016 and March 2016, Self-perception of Text-message Dependency Scale were administered to 221 students selected with a simple random selection method, from the Faculty of Social Sciences of Çankırı Karatekin University along with a sociodemographic data form. Internal reliability coefficient (Chronbach α), Pearson correlation analysis, confirmatory factor analysis, and goodness of fit indexes were calculated. P<0.05 is considered significant. Results: The mean age of the participants was 21 ± 1.72. The Internal Consistency Coefficient of the self-perception of text-message dependency scale was found to be Cronbach α 0.85. GFI=1, CFI=1, NFI=1, RMSEA=0,000. The total item correlation (rit) is between 0.329 and 0.663, indicating that the construct validity is strong.The theoretical model proposed by Igarashi et al. consists of 3 latent variables (factors) that are influenced by extroversion and neuroticism: 1) excessive use of messaging, 2) relationship maintenance, and 3) emotional reactions (5). These factors have an impact on the psychological or behavioral patterns by affecting the frequency of message writing. Conclusions: In our study, the internal reliability and goodness of fit indexes values were similar to the original study inciting that the Message Dependence Perception Scale can reliably be used in Turkey.

  • MIROR, An automated modular MRI clinical decision support system: an application in paediatric cancer diagnosis

    From: JMIR Medical Informatics

    Date Submitted: Oct 25, 2017

    Open Peer Review Period: Oct 26, 2017 - Dec 21, 2017

    Background: Advances in magnetic resonance imaging (MRI) and the introduction of clinical decision support systems has underlined the need for an analysis tool to extract and analyse relevant informat...

    Background: Advances in magnetic resonance imaging (MRI) and the introduction of clinical decision support systems has underlined the need for an analysis tool to extract and analyse relevant information from MRI data to aid decision-making, prevent errors and enhance health care. Objective: The aim of this study was to design and develop a modular Medical Image Region of interest analysis tool and Repository (MIROR) for automatic processing, classification, evaluation and representation of advanced MRI data. Methods: The clinical decision support system was developed and evaluated for diffusion-weighted imaging of body tumours in children (cohort of 48 children, with 37 malignant and 11 benign tumours). Mevislab software and Python have been used for development of MIROR. Regions of interests were drawn around benign and malignant body tumours on different diffusion parametric maps and extracted information was used to discriminate the malignant from benign tumours. Results: Using MIROR, the various histogram parameters derived for each tumour case when compared with the information in the repository, provided additional information for tumour characterization and facilitated the discrimination between benign and malignant tumours. Clinical decision support system cross validation showed high sensitivity and specificity in discriminating between these tumour groups for various histogram parameters, 100 % for kurtosis and entropy 85% and 78% respectively over all parameters. Conclusions: MIROR as a diagnostic tool and repository allowed the interpretation and analysis of MRI images to be more accessible and comprehensive for clinicians. It aims to increase clinicians’ skillset by introducing newer techniques and up-to-date findings to their repertoire and make information from previous cases available to aid decision-making. The modular-based format of the tool allowed integration of analyses which are not readily available clinically and streamlines future developments. Clinical Trial: N/A

  • Qualitative exploration of patient and health professional requirements for an e-health behavioural change intervention to self-manage cardiovascular disease.

    From: Journal of Medical Internet Research

    Date Submitted: Oct 16, 2017

    Open Peer Review Period: Oct 17, 2017 - Dec 12, 2017

    Background: Cardiovascular diseases (CVD) are a leading cause of premature death worldwide. International guidelines recommend routine delivery of all phases of cardiac rehabilitation (CR). Uptake of...

    Background: Cardiovascular diseases (CVD) are a leading cause of premature death worldwide. International guidelines recommend routine delivery of all phases of cardiac rehabilitation (CR). Uptake of traditional cardiac rehabilitation remains suboptimal, as attendance at formal hospital-based CR programmes is low, with community-based CR rates and individual long-term exercise maintenance even lower. Home-based CR programs have been shown to be equally effective in clinical and health-related quality of life outcomes, and yet are not readily available. Objective: Given the potential that home-based CR programs have it is important to explore how to appropriately design any such intervention in conjunction with key stakeholders. The aim of the current study was to engage with individuals with cardiovascular disease and other professionals within the health eco-system to 1) understand the personal, social and physical factors that inhibit or promote their capacity to engage with physical activity and 2) explore their technology competencies, needs and wants in relation to an eHealth intervention. Methods: Fifty-four semi-structured interviews were conducted across two countries. Interviews were audiotaped, transcribed verbatim, and analysed using thematic analysis and further mapped onto the COM-B model for future intervention design. Results: Key recommendations included collection of patient data and use of measurements, harnessing hospital based social connections, and advice to utilize a patient-centered approach with personalization and tailoring to facilitate optimal engagement. Barriers to the implementation of PATHway were also explored specifically in relation to physical capability and safety as well as technology readiness. Conclusions: In summary, a multi-faceted, personalisable intervention with an inclusively designed interface was deemed desirable for use among CVD patients both by end-users and key stakeholders. In depth understanding of core needs of the population can aid intervention development and acceptability.

  • Satisfaction with the newly-implemented Electronic System for Integrated Health Information among Pediatricians at a University Hospital

    From: Journal of Medical Internet Research

    Date Submitted: Oct 18, 2017

    Open Peer Review Period: Oct 21, 2017 - Dec 16, 2017

    Background: Electronic Health Records (EHR) are becoming the standard of care in healthcare settings, with their great potentials to reduce operational costs, improve healthcare quality, and patient...

    Background: Electronic Health Records (EHR) are becoming the standard of care in healthcare settings, with their great potentials to reduce operational costs, improve healthcare quality, and patient’s safety. Various factors may influence physicians’ satisfaction, and there is a need to address them according to healthcare workers’ needs in Saudi Arabia. Objective: The objective of this study was to explore factors that may have influenced satisfaction with a newly-implemented EHR system (namely: eSiHi or Electronic System for Integrated Health Information) among Physicians in the Pediatric Department at King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia Methods: Methods: A cross-sectional survey was conducted on the physicians of Pediatric Department, KSUMC, between July-August 2015, after two months of launching the EHR system (eSiHi). Results: A total of 150 physicians enrolled in the survey, only (120, 80%) responded to the survey in a timely manner. Tentative analysis of missing values, however, revealed that 112 surveys were complete and suitable for inclusion in the analysis. As such, response rate was 74.6%. 60% of the physicians were males and 40% were females. 27.6% of them were consultants, 43% specialists, followed by 28% who were residents. Almost half of the physicians had no previous experience with Electronic Medical Records (51.8%). 86.7% of the respondents have attended the workshops and the training courses before the implementation of the new EHR system. On average, they rated their satisfaction levels with the EHR (eSiHi) at 5.2 out of 10, and for the usefulness for the patient's care it was rated on average (6.4 out of 10). 82.2% of respondents believed that the EHR improves the Quality of care and reduces errors and 73% of the respondents agreed that EHR's Improve the quality of the clinical practice environment. 55.8% indicated that EHR increased the practice productivity. Conclusions: There is a global and national transition toward an EHR system in the hospitals and the physicians have the willing to support this transition and they appreciate the potential benefits of this system over the paper-based system. In order to increase the like hood of a successful transition, an ongoing technical support must be considere

  • Engaging Vulnerable Patients through Health Information Transparency: How important is reading notes to different patient populations?

    From: Journal of Medical Internet Research

    Date Submitted: Oct 23, 2017

    Open Peer Review Period: Oct 24, 2017 - Dec 19, 2017

    Background: OpenNotes is a national initiative to share clinicians’ visit notes with patients. Studies suggest that transparent notes can improve care, but little is known about their effect on care...

    Background: OpenNotes is a national initiative to share clinicians’ visit notes with patients. Studies suggest that transparent notes can improve care, but little is known about their effect on care for vulnerable populations. Objective: To examine the importance of online visit notes to vulnerable patients. Methods: Patients at an urban academic medical center with an active patient portal account and at least one available ambulatory visit note over the prior year were surveyed during June-Sep 2016. The survey assessed importance of reading notes for: 1) understanding health conditions, 2) feeling informed about care, 3) understanding how patients’ providers are thinking about their medical conditions, 4) remembering the plan of care, and 5) making decisions about care. Response options ranged from 0 to 10. We compared the proportion of patients reporting 9-10 (“extremely important”) for each item across three sociodemographic factors: education level, race/ethnicity, and self-reported health. Results: 6,913/24,722 (28%) patients completed the survey. Non-white patients and those with a high school education or less were more likely to report that notes are “extremely important” for all 5 items than white and more educated respondents, respectively (p< 0.01 for all comparisons). Patients with poorer self-reported health were as or more likely to indicate that notes are "extremely important" for all items. Conclusions: Patients who are non-white, less educated, and sicker each assigned higher importance to reading open notes for several health behaviors than white, highly educated and healthier patients. Some vulnerable patients who use the portal may find OpenNotes especially valuable for understanding their health and engaging in their care. Facilitating access to notes may improve engagement in health care for some vulnerable populations who have historically been more challenging to reach.

  • Development and feasibility testing of internet-delivered Acceptance and Commitment Therapy (iACT) for severe health anxiety

    From: JMIR Mental Health

    Date Submitted: Nov 5, 2017

    Open Peer Review Period: Nov 7, 2017 - Jan 2, 2018

    Background: Severe health anxiety (hypochondriasis), or illness anxiety disorder according to the DSM-5, is characterised by preoccupation with fear of suffering from a serious illness in spite of med...

    Background: Severe health anxiety (hypochondriasis), or illness anxiety disorder according to the DSM-5, is characterised by preoccupation with fear of suffering from a serious illness in spite of medical reassurance. It is a debilitating, prevalent disorder associated with increased health care utilisation. Still, there is a lack of easily accessible specialised treatment for severe health anxiety. Objective: The present paper has two objectives; 1) to describe the development and setup of a new internet-delivered Acceptance and Commitment Therapy (iACT) programme for patients with severe health anxiety using self-referral and a video-based assessment, and 2) to examine the feasibility and potential clinical efficacy of iACT for severe health anxiety. Methods: Fifteen self-referred patients with severe health anxiety were diagnostically assessed by a video-based interview. They received 7 sessions of clinician-supported iACT comprising self-help texts, video clips, audio files and worksheets over 12 weeks. Self-report questionnaires were obtained at baseline, post-treatment and at 3-month follow-up (3MFU). The primary outcome was Whiteley-7 index measuring health anxiety severity. Depressive symptoms, health-related quality of life (HRQoL), life satisfaction and psychological flexibility were also assessed. A within-group design was employed. Means, standard deviations (SD) and effect sizes using the Standardized Response Mean were estimated. Post-treatment interviews were conducted to evaluate the patient experience of the usability and acceptability of the treatment setup and programme. Results: Self-referral and video-based assessment were well received. Most patients 12/15 (80%) completed the treatment, and only one patient dropped out. Post-treatment data were available for almost all patients 14/15 (93%) and 3MFU data for 12/15 (80%). Paired t-tests showed significant improvements on all outcome measures both at post-treatment and 3MFU except on one physical component subscale of HRQoL. Health anxiety symptoms decreased with 33.9 points at 3MFU (95% CI 13.6 to 54.3, t(11) = 3.66, P=0.004) with a large within-group effect size measured by the standardised response mean (SRM=1.06). Conclusions: Treatment adherence and potential efficacy suggest that iACT may be a feasible treatment for health anxiety. The uncontrolled design and small sample size limit the robustness of the findings. Therefore, the findings should be replicated in a randomised controlled trial. Potentially, iACT may increase availability and accessibility of specialised treatment for health anxiety. Clinical Trial: The study was approved by the Danish Data Protection Agency, Central Denmark Region (ID no. 1-16-02-427-14). URL: https://www.datatilsynet.dk/forside/

  • New-Onset Diabetes Educator to Educate Children and their Caregivers about Diabetes at the Time of Diagnosis: a Pragmatic Trial

    From: JMIR mHealth and uHealth

    Date Submitted: Oct 17, 2017

    Open Peer Review Period: Oct 18, 2017 - Dec 13, 2017

    Background: Background Diabetes self-management education (DSME) is essential at the time of diagnosis. We developed the New Onset Diabetes Educator (NODE), an animation-based educational web applicat...

    Background: Background Diabetes self-management education (DSME) is essential at the time of diagnosis. We developed the New Onset Diabetes Educator (NODE), an animation-based educational web application for Type 1 Diabetes Mellitus patients. Objective: Objective: Our hypothesis is that NODE is a feasible, effective and user-friendly intervention in improving DSME delivery to child/caregiver-dyads at the time of diagnosis. Methods: Methods: We used a pragmatic parallel randomized trial design. Dyads were recruited within 48 hours of diagnosis and randomized into a NODE-enhanced DSME or a standard DSME group. Dyads randomized in the NODE group received the intervention on an iPad before receiving the standard DSME with a nurse educator. The Diabetes Knowledge Test 2 (DKT2) assessed disease-specific knowledge pre- and post-intervention in both groups, and was compared using t-tests. Usability of the NODE mobile health intervention was assessed in the NODE group. Results: Results: We recruited 16 dyads (Mean child age=10.75, SD=3.44). Mean DKT2 scores were 14.25 (SD=4.17) and 18.13 (SD=2.17) pre- and post- intervention in the NODE group, and 15.50 (SD=2.67) and 17.38 (SD=2.26) in the standard DSME group. The effect size was medium (Δ = 0.56). Usability ratings of NODE were excellent. Conclusions: Conclusion: NODE is a feasible mobile health strategy for type 1 diabetes education. It has the potential to be an effective and scalable tool to enhance DSME at time of diagnosis, and consequently, could lead to improved long-term clinical outcomes for patients living with the disease.

  • Integration of a technology-based mental health screening into routine practices of primary health care services in Peru: The Allillanchu Project

    From: Journal of Medical Internet Research

    Date Submitted: Nov 6, 2017

    Open Peer Review Period: Nov 7, 2017 - Jan 2, 2018

    Background: Despite their high prevalence and significant burden, common mental disorders (CMD) are largely underdiagnosed and undertreated. Objective: The Allillanchu Project aimed to design, develop...

    Background: Despite their high prevalence and significant burden, common mental disorders (CMD) are largely underdiagnosed and undertreated. Objective: The Allillanchu Project aimed to design, develop, and test an intervention to promote early detection, opportune referral and access to treatment of patients with CMD attending public primary health care services in Lima, Peru. Methods: The project had a multi-phase design: formative study, development of intervention components and implementation. The intervention combined three strategies: training of primary health care providers (PHCP), task shifting of CMD detection and referral, and a mHealth component comprising a CMD screening app followed by motivational and reminder SMS to identify at-risk patients. The intervention was routinely implemented by 22 PHCP working in ten public health care services including prenatal control, tuberculosis, chronic diseases and HIV/AIDS clinics. Results: During the 9-week implementation phase, 733 patients were screened by the 22 PHCP during routine consultations. The chronic diseases (49.9%) and prenatal care services (36.7%) had the higher number of screenings. Time constraint and workload were the main barriers to screening, while the use of technology, training and supervision were facilitators. Out of the 733 patients, 21.7% screened positively for CMD and were advised to seek specialized care. During a follow-up interview, 72.4% of positively screened patients reported seeking specialized care and 55.1% stated seeing a specialist. Both patients and PHCP recognized the utility of the screening and identified some key challenges to its wider and successful implementation. Conclusions: The use of a CMD screening app supported by training and supervision is feasible and uncovers a high prevalence of unidentified psychological symptoms in primary care. To increase its sustainability and utility, this procedure can be tailored to the resources and features of each service but need to be incorporated into the routine health care system. The early detection of psychological symptoms by a PHCP within a regular consultation, followed by adequate advice and support, can lead to a significant percentage of patients accessing specialized care and reducing the treatment gap of CMD.

  • Development of a family-based intervention for BRCA carriers and their close biological relatives: Focus groups, feasibility, and usability testing

    From: Journal of Medical Internet Research

    Date Submitted: Oct 18, 2017

    Open Peer Review Period: Oct 21, 2017 - Dec 16, 2017

    Background: Carriers of BRCA mutations are asked to communicate genetic test results to their close biological relatives and advocate for genetic services. This process is highly variable from family...

    Background: Carriers of BRCA mutations are asked to communicate genetic test results to their close biological relatives and advocate for genetic services. This process is highly variable from family to family. Interventions that support communication of genetic test results, coping, and offer decision support in families that harbor a pathogenic variant may contribute to more effective management of hereditary cancer. Objective: This paper describes the development of the Family Gene Toolkit©, a web-based intervention targeting BRCA carriers and untested biological relatives, designed to enhance coping, family communication, and decision-support. Methods: We present findings from focus groups regarding intervention acceptability and participant satisfaction, and findings from a pre-post pilot study with random allocation to a wait listed control group regarding intervention feasibility and usability. Results: The Family Gene Toolkit© was developed by a multidisciplinary team as a psycho-educational and skills-building intervention, including two live webinar sessions and a follow-up phone call guided by a certified genetic counselor and a Master’s prepared oncology nurse. Each live webinar includes two modules (total four modules) presenting information about BRCA mutations, a decision-aid for genetic testing, and two skills-building modules for effective coping and family communication. Participants in focus groups (n=11) were highly satisfied with the intervention, reporting it was useful and illustrative of pertinent issues. From the n=12 dyads recruited in the pre-post pilot study (response rate 23%), completion rate was 71% and 20% for the intervention and wait-listed control group, respectively. Conclusions: Acceptability and satisfaction with the Family Gene Toolkit© is high. Based on usability and feasibility testing, modifications on timing, delivery mode, and recruitment methods are planned. Clinical Trial: NCT02154633

  • Changes in anxiety following participation in BRAVE Self-Help: an open-access online Cognitive-Behaviour Therapy Program for anxiety

    From: Journal of Medical Internet Research

    Date Submitted: Oct 19, 2017

    Open Peer Review Period: Oct 21, 2017 - Dec 16, 2017

    Background: Internet-based CBT (iCBT) for child and adolescent anxiety has demonstrated efficacy in randomized controlled trials, but has not yet been examined when disseminated as a public health int...

    Background: Internet-based CBT (iCBT) for child and adolescent anxiety has demonstrated efficacy in randomized controlled trials, but has not yet been examined when disseminated as a public health intervention. If effective, iCBT programs may offer promise as a first-step, low-intensity intervention that can be easily accessed by young people. Objective: The aim of this study was to examine changes in anxiety severity in young people enrolling in a publicly available online, self-help iCBT program (BRAVE Self-Help). Methods: This study conducted an open trial, involving the analysis of data collected from 1094 children and adolescents aged 7-17 years who presented with elevated anxiety at baseline and commenced the program during the data collection period. The iCBT program was delivered through an open-access portal with no professional support. Anxiety severity was assessed via scores on the Children’s Anxiety Scale, 8-item (CAS-8) at four time points; baseline, Session 4, Session 7 and Session 10. Results: Statistically significant reductions in anxiety were evident across all time points for both children and adolescents. For users who completed 6 or more sessions, there was an average 4-point improvement in CAS-8 scores (d=0.87 for children, d=0.81 for adolescents) indicative of a moderate to large effect size. For participants who completed 9 sessions, 58.3% (95 out of 163) achieved clinically meaningful, and 54.6% (89 out of 163) achieved statistically reliable reductions in anxiety. Conclusions: Substantial and meaningful reductions in anxiety symptoms were achieved by many children and adolescents taking part in a completely open-access and self-directed iCBT program. Online self-help CBT may offer an effective and viable first step for service delivery with children and adolescents with anxiety. Clinical Trial: n/a

  • Towards replicable evaluations of privacy for mobile health apps

    From: JMIR mHealth and uHealth

    Date Submitted: Oct 24, 2017

    Open Peer Review Period: Oct 24, 2017 - Dec 19, 2017

    Background: The increasing sophistication of self-tracking technologies allows individuals to generate significant quantities of timely and accurate data about their lifestyle, biology, and environmen...

    Background: The increasing sophistication of self-tracking technologies allows individuals to generate significant quantities of timely and accurate data about their lifestyle, biology, and environment, which can be used to support health interventions and measure outcomes. However, such user-generated data is often not treated with the sensitivity of other medical data, with data stored and processed by vendors with commercial motivations, such as enabling targeted advertising and making inferences from linked data. As the sensors and applications which enable these technologies continue to become more sophisticated, the privacy implications may become more severe. Methods for systematically identifying and investigating privacy issues in such applications are required, but currently lacking. Objective: In this paper, we introduce a set of heuristics for assessing key privacy characteristics of such services, rooted in US and EU data privacy regulations, and usability best practice from the human-computer interaction literature. By applying these heuristics to existing services, we aim to identify and characterise common privacy issues, and suggest how designers can avoid exposing their users to them. Methods: We conduct an analysis of 64 popular services to determine the extent to which they satisfy various dimensions of privacy captured by the heuristics, including regulatory compliance, suitability of consent processes, and the usability of interfaces for controlling disclosures. We also investigate non-health related self-tracking services, to determine whether the current generation of mobile health applications exhibit stronger privacy protections, or reveal unique weaknesses. Results: We found that the majority of services examined fail to (a) provide users with full access to their own data, (b) acquire sufficient consent, or (c) extend controls over disclosures to third parties. We demonstrate a number of best and worst-practice usability patterns, and make recommendations for how designers can avoid such pitfalls. Conclusions: Our findings are of interest to clinicians looking to incorporate self-tracking technologies into care; privacy researchers for whom we provide a robust and reproducible method for investigating the state of privacy in self-tracking applications; developers of mHealth applications who seek guidance to incorporate best practice into the design of their services; and end-users looking for assurance that services meet their privacy requirements. We provide the documentation and tools needed to replicate our work, allowing the state of privacy in mHealth services to be monitored over time.

  • Long-Term Effectiveness of a Smartphone Application for Improving Healthy Lifestyles in general population in Primary Care: A Randomized Controlled Trial (EVIDENT II study)

    From: Journal of Medical Internet Research

    Date Submitted: Oct 21, 2017

    Open Peer Review Period: Oct 22, 2017 - Dec 17, 2017

    Background: Information and communication technologies are currently one of the supporting elements that may contribute to improving health and changing lifestyles. Objective: To evaluate the long-ter...

    Background: Information and communication technologies are currently one of the supporting elements that may contribute to improving health and changing lifestyles. Objective: To evaluate the long-term effectiveness of adding an app to standardized counselling in order to increase physical activity (PA) and adherence to the Mediterranean diet (MD) and to analyze the effects of app adherence in lifestyles changes. Methods: Randomized, multicenter clinical trial with 12 month-follow up, including 833 participants, recruited by random sampling in six primary Spanish care centers (415 versus 418). Interventions: Counseling on PA and MD was given to both groups by a nurse research. The counseling+app group (IG) received additional training in the use of an app that was designed to promote MD and PA over a 3-month period. Main Outcomes and Measures: PA by accelerometer and the 7-day Physical Activity Recall (PAR) questionnaire and adherence to the MD by an adherence screener questionnaire. We considered adherence to the app to be high when it was used for >60 days. Results: The mean age was 51 years (SD 12) in the IG and 52.3 (SD 12.0) in the counseling only group (CG); females predominated in both groups (60.0% and 64.1%, respectively). PA by accelerometer declined in both groups at 12 months (p for tendency in moderate-vigorous PA [MVPA]=0.146).The subgroup of IG with high app adherence had better behavior than the low adherence subgroup (p for tendency in MVPA=0.001). The PA analyzed by 7-day PAR did not show changes at 12 months in any of the groups (p for tendency=0.245). In MD, an increase in adherence was observed in both groups at 12 months with no differences between them (p for tendency=0.465). In these two cases the group with high app adherence also had better behavior although without reaching significance for the tendency (p >0.05). Conclusions: In subjects with high app adherence, better results in healthy lifestyle improvements were observed. Overall, however, no differences were found between the IG group and CG in PA increase and adherence to the MD in the long-term. Clinical Trial: Clinical Trials.gov Identifier: NCT02016014 (https://clinicaltrials.gov/ct2/show/NCT02016014)

  • Adoption of Stroke Rehabilitation Technologies bu the User Community

    From: JMIR Rehabilitation and Assistive Technologies

    Date Submitted: Oct 19, 2017

    Open Peer Review Period: Oct 21, 2017 - Dec 16, 2017

    Background: Using technology in stroke rehabilitation is attractive. Devices from robots to smart phone apps can help deliver evidence-based levels of practice intensity and automated feedback without...

    Background: Using technology in stroke rehabilitation is attractive. Devices from robots to smart phone apps can help deliver evidence-based levels of practice intensity and automated feedback without additional labour costs. Currently, however, few technologies have been adopted into everyday rehabilitation. Objective: This project aimed to identify the priorities for users (therapists/patients and carers) and generate user centred solutions to enhance technology adoption. Methods: Stakeholders (n=60), including stroke survivors (33%), therapists (33%), carers, technologists and researchers (33%), were invited to attend three workshops facilitated by the Scottish Universities Insight Institute. Workshop 1 was preceded by a survey of stroke survivors and therapists (n=177) to generate an initial list of priorities. Subsequent workshops focused on generating practical solutions to enhance adoption. Results: Twenty-four priorities were generated from the survey, these were reduced to ten, non-ranked, priorities through discussion, consensus activities and voting at workshop 1. These were: access to technologies, ease of use, awareness of available technologies, technologies focused on function, supports self-management, user training, evidence of effectiveness, value for money, knowledgeable staff and performance/progress feedback. Follow-up workshops set out user benefits for walking technologies and provided recommendations for improve technology adoption: an annual exhibition of commercially available and developing technologies, an online consumer-rating website of available technologies and a user network to inspire and test new technologies. Conclusions: The key outcomes from this series of stakeholder workshops provides a starting point for an integrated approach to promoting greater adoption of technologies in stroke rehabilitation. Bringing technology developers and users together to shape future and evaluate current technologies is critical to achieving evidence based stroke rehabilitation Clinical Trial: None

  • Evaluation of a Diabetes Self-Management Program on Type II Diabetes Patients’ Comorbid Illnesses, Healthcare Utilization, and Cost

    From: Journal of Medical Internet Research

    Date Submitted: Oct 31, 2017

    Open Peer Review Period: Oct 31, 2017 - Dec 26, 2017

    Background: An estimated 30.3 million Americans have diabetes mellitus (DM). The US Department of Health and Human Services created national objectives via its Healthy People 2020 initiative to impro...

    Background: An estimated 30.3 million Americans have diabetes mellitus (DM). The US Department of Health and Human Services created national objectives via its Healthy People 2020 initiative to improve the quality-of-life for people who either have, or are at risk, for DM and, hence, lower the personal and national economic burden of this debilitating chronic disease. Diabetes self-management education interventions are a primary focus of this initiative. Objective: To evaluate the impact of the Better Choices Better Health Diabetes (BCBH-D) self-management program on comorbid illness related to DM, healthcare utilization, and cost. Methods: A propensity score matched, two-group, pre-post design was used for this study. Retrospective administrative medical and pharmacy claims data from the HealthCore Integrated Research Environment (HIRE) were used for outcome variables. The Intervention cohort included DM patients who were recruited to a diabetes self-management program offered both on-line and via in-person workshops. Control cohort subjects were identified from the HIRE by at least two diabetes associated claims (ICD-9 250.xx) within two years prior to the program launch date (10/01/2011-09/30/2013), and received usual care but did not participate in BCBH-D. Controls were matched to cases in a 3:1 propensity score match. Outcome measures included pre- and post-intervention all-cause and diabetes-related utilization and costs recorded in the HIRE claims database. Cost outcomes are reported as least squares means. Repeated measures analyses (Generalized Estimating Equation approach) were conducted for utilization, comorbid conditions, and costs. Results: The program participants who were identified in HIRE claims (N=558) were matched to a Control Cohort of 1,669 patients. Following the intervention, the self-management cohort experienced significant reductions in claims for DM associated comorbid conditions, with the post-intervention disease burden being significantly lower (mean 1.78 (SD=1.6)) compared to the Control cohort (mean 2.13 (SD=1.73)); P=.001. Post-intervention all-cause utilization was decreased in the Intervention cohort compared to controls with -40/1000 Emergency department visits vs +70/1000; P=.004 and -2,790 outpatient visits per 1000 vs. -440/1000; P=.001. Unadjusted total all-cause medical cost was decreased by $2,207 in the Intervention cohort compared to a $338 increase in the Controls, P=.001. After adjustment for other variables through structural equation analysis, the direct effect of the BCBH-D was -$815. Conclusions: Patients in the BCBH-D program experienced reduced all-cause healthcare utilization and costs. Direct cost savings were $815. While encouraging, given the complexity of the patient population, further study is needed to cross-validate the results. Clinical Trial: N/A

  • Virtual Reality and Well-being: A systematic review of behaviour change and virtual reality systems.

    From: JMIR Serious Games

    Date Submitted: Oct 20, 2017

    Open Peer Review Period: Oct 21, 2017 - Dec 16, 2017

    Background: E-health interventions are becoming increasingly used in public health. Computer generated environments viewed through virtual reality (VR) have demonstrated endless possibilities to adap...

    Background: E-health interventions are becoming increasingly used in public health. Computer generated environments viewed through virtual reality (VR) have demonstrated endless possibilities to adapt problematic behaviours that affect well-being. VR is no longer unaffordable for individuals, and with smartphone technology able to track movements and project 3D images, VR is now a mobile tool that can be used at work, home or on the move. Objective: This systematic review aims to explore in what context VR can be an applicable tool for the improvement of well-being, what conditions interventions are aimed it and what forms of VR are commonly being used in research. Methods: A systematic review was carried out that included studies whose interventions were relevant to well-being. Thematic analysis was incorporated to find themes that assist us in answering the objectives set out for this review. Several web-based databases were searched for papers that were published between January 2012 and July 2017. Results: 102 studies were identified, they were concerned with areas of anxiety (n = 76), depression/stress (n = 5), addiction (n = 9), eating disorders/body image (n = 10) and sleep disorders (n = 3). In these papers 22 different virtual reality systems were found, the most common VR HMD (Head-Mounted Display) was the eMagin z800 (n=28). VR exposure therapies that incorporated traditional treatments such as cognitive behaviour therapy (CBT) proved to be effective across conditions, particularly for anxiety and post-traumatic stress disorder (PTSD). Cue exposure therapy (CET) reduced addiction cravings and full body images viewed in VR could revolutionise treatment for anorexia. VR has proven itself to be an applicable platform for behaviour change. Conclusions: With reactions to feared stimuli proving effective in VR, increasingly immersive environments that promote positive stimuli combined with health knowledge could prove to be a valuable tool for public health and well-being. The current state of research highlights the importance of the content within VR programs for improved well-being. Future research should look to incorporate more accessible forms of VR

  • Improving prediction of risk of hospital admission in chronic obstructive pulmonary disease: application of machine learning to telemonitoring data

    From: Journal of Medical Internet Research

    Date Submitted: Oct 30, 2017

    Open Peer Review Period: Oct 31, 2017 - Dec 26, 2017

    Background: Telemonitoring of symptoms and physiological signs has been suggested as a means of early detection of exacerbations of chronic obstructive pulmonary disease (COPD) with a view to institut...

    Background: Telemonitoring of symptoms and physiological signs has been suggested as a means of early detection of exacerbations of chronic obstructive pulmonary disease (COPD) with a view to instituting timely treatment. However, current algorithms to identify exacerbations result in frequent false positive results and increased workload. Machine learning, when applied to predictive modelling, can determine patterns of risk factors useful for improving quality of predictions. Objective: To establish if machine learning techniques applied to telemonitoring datasets improve prediction of hospital admissions, decisions to start steroids, and to determine if the addition of weather data further improves such predictions. Methods: We used daily symptoms, physiological measures and medication data, with baseline demography, COPD severity, quality of life, and hospital admissions from a pilot and large randomised controlled trial of telemonitoring in COPD. In addition, we linked weather data from the UK Meteorological Office. We used feature selection and extraction techniques for time-series to construct up to 153 predictive patterns (features) from symptom, medication, and physiological measurements. The resulting variables were used for the construction of predictive models fitted to training sets of patients and compared to common algorithms. Results: We had a mean 363 days of telemonitoring data from 135 patients. The two most practical traditional score-counting algorithms, restricted to cases with complete data resulted in AUC estimates of 0.60 [CI 95% 0.51, 0.69] and 0.58 [0.50, 0.67] for predicting admissions based on a single day’s readings. However, in a real-world scenario allowing for missing data, with greater numbers of patient daily data and hospitalisations (N = 57,150, N+=17), the performance of all the traditional algorithms fell, including those based on two days data. One of the most frequently used algorithms performed no better than chance. Machine learning models demonstrated significant improvements; the best machine learning algorithm based on 57,150 episodes resulted in an aggregated AUC = 0.73 [0.67, 0.79]. Addition of weather data measurements resulted in a negligible improvement in the predictive performance of the best model (AUC = 0.74 [0.69, 0.79]). In order to achieve an 80% true positive rate (sensitivity), the traditional algorithms were associated with an 80% false positive rate: our algorithm halved this rate to approximately 40% (specificity approximately 60%). The machine learning algorithm was moderately superior to the best standard algorithm (AUC = 0.77 [0.74, 0.79] v AUC = 0.66 [0.63, 0.68]) at predicting the need for steroids. Conclusions: The early detection and management of COPD remains an important goal given the huge personal and economic costs of the condition. Machine learning approaches, which can be tailored to an individual’s baseline profile and can learn from experience of the individual patient are superior to existing predictive algorithms show promise in achieving this goal. Clinical Trial: NA

  • Ontology-based cloud computing approach implements on mobile healthcare and management

    From: JMIR mHealth and uHealth

    Date Submitted: Oct 20, 2017

    Open Peer Review Period: Oct 22, 2017 - Dec 17, 2017

    Background: Healthcare involves the maintenance or improvement of health via diagnosis, treatment, and prevention of disease, illness, injury, or other physical and mental impairments. During the past...

    Background: Healthcare involves the maintenance or improvement of health via diagnosis, treatment, and prevention of disease, illness, injury, or other physical and mental impairments. During the past decade, there has been a proliferation of research on health information technology (HIT), which shows that HIT is essential for improving the quality of mobile healthcare and management. Objective: The smart-healthcare industry is a growing market that uses new technologies for the mobile healthcare and management field. The provision of more precise service solutions will allow smart healthcare and management strategies to be deployed in the healthcare industry. Methods: Thus, this study gives theoretical and practical insights into an ontology-based cloud computing approach in the mobile healthcare and management context. Results: Depending on the characteristics of the variable content, these data formats are defined as category data variable and numerical data variable (Table 1). These health evaluation factors also have a threshold value for each factor in Table 2, which determines the health status. Conclusions: This increases the understanding of the creation of value using a cloud computing business model and opens new paths for the development of a business case for healthcare providers.

  • Mobile Technology in E-Learning for Undergraduate Medical Education on Emergent Otorhinolaryngology-Head and Neck Surgery Disorders: A Pilot Randomized Controlled Trial

    From: Journal of Medical Internet Research

    Date Submitted: Nov 13, 2017

    Open Peer Review Period: Nov 13, 2017 - Jan 8, 2018

    Background: The use of mobile technology in e-learning (M-TEL) can add new levels of experience and significantly increase the attractiveness of e-learning in medical education. Whether an innovative...

    Background: The use of mobile technology in e-learning (M-TEL) can add new levels of experience and significantly increase the attractiveness of e-learning in medical education. Whether an innovative interactive e-learning multimedia (IM) module using M-TEL to teach emergent otorhinolaryngology-head and neck surgery (ORL-HNS) disorders is feasible and efficient in undergraduate medical students is unknown. Objective: The aim of this study was to compare the impact of a novel IM module using M-TEL to a conventional PowerPoint show (PPS) module for emergent ORL-HNS disorders with regards to learning outcomes, satisfaction, and learning experience. Methods: This pilot randomized controlled trial was conducted at an academic teaching hospital and included 24 undergraduate medical students who were novices in ORL-HNS. The cognitive style was determined using the Group Embedded Figures Test. The participants were randomly allocated (1:1) to one of two groups matched by age, sex, and cognitive style: the IM group, and the PPS group. The content for the gamified IM module and the PPS video module was derived from the textbook-based learning material. During the 100-minute learning period, the participants were unblinded to use the IM or PPS courseware on a 7-inch tablet. Pretests and posttests using multiple choice questions to evaluate knowledge and multimedia situational tests to evaluate competence were administered. The global satisfaction scale and AttrakDiff2 learning experience questionnaire were also given to each participant, who also provided feedback about the modules. Data were expressed as median (95% confidence interval [CI]). Results: Overall, the participants had significant gains in knowledge (71% [95% CI, 1–100%], P<.001) and competence (25% [95% CI, 0–33%], P=.007) after 100 minutes of learning. Although there was no significant difference in knowledge gain between the two groups (difference, -24% [95% CI, -75–36%]; P=.55), competence gain was significantly lower in the IM group compared to the PPS group (-41% [95% CI, -67–-20%]; P=.008). However, the IM group had significantly higher scores of satisfaction (difference, 2 [95% CI, 2–4]; P=.01), pragmatic quality (1.7 [95% CI, 0.1–2.7]; P=.03), and hedonic stimulation (1.9 [95% CI, 0.3–3.1]; P=.01) compared with the PPS group. Qualitative feedback indicated that the various games in the IM module attracted the participants’ attention, but that the nonlinearly arranged materials affected their learning. Conclusions: Using M-TEL for undergraduate medical education on emergent ORL-HNS disorders, an IM module seems to be useful for gaining knowledge, but competency may need to occur elsewhere. While the small sample size reduces the statistical power of our results, its design seems to be appropriate to determine the effects of M-TEL using a larger group. Clinical Trial: ClinicalTrials.gov NCT02971735, (http://clinicaltrials.gov/show/NCT02971735)

  • The Mediating Effect of Internet Addiction in the Relationship between Individualism and Cyberbullying

    From: Journal of Medical Internet Research

    Date Submitted: Oct 22, 2017

    Open Peer Review Period: Oct 22, 2017 - Dec 17, 2017

    Background: Among a variety of dynamics that may have an effect in Internet-related behaviors, cultural orientation is particularly important. Previous studies suggest that individualism is a strong d...

    Background: Among a variety of dynamics that may have an effect in Internet-related behaviors, cultural orientation is particularly important. Previous studies suggest that individualism is a strong determinant of aggressive behavior. In addition, findings suggest that vertical individualism may lead to the development of more tolerance for addiction and aggression. Objective: The study aimed to test whether vertical individualism has significant positive effects on cyberbullying and Internet addiction and whether horizontal individualism has significant negative effects on cyberbullying and Internet addiction. A theoretical model was specified to test the relationships among vertical versus horizontal individualism, cyberbullying, and Internet addiction. Methods: A total of 665 college students were selected using convenience sampling method and willingly participated in the study. Participants’ ages ranged from 17 years old to 19 years old (mean age=17.94, SD=1.12). Of the group, 462 were women (69.5 %) and 203 were men (30.5%). Study majors represented are mathematics (n=113, 17%), science (n=102, 15.3%), instructional technology (n=99, 14.9%), psychology (n=98, 14.7%), and others (n=253, 38.1%). Self-report instruments were used to measure vertical/horizontal individualism, cyberbullying, and Internet addiction. Results: Results show significant positive effect of vertical individualism (.10) and significant negative effect of horizontal individualism (-.12) on cyberbullying. In addition, the direct effect of vertical individualism on Internet addiction was significant (.28) but the direct effect of horizontal individualism was not (-.05). Finally, Internet addiction had a significant direct effect on cyberbullying (.39) as well as an intervening effect in the relationship between vertical individualism and cyberbullying. Results also indicate significant gender differences in cultural patterns and Internet addiction. Conclusions: Points raised in the current study should be valuable to researchers and taken into account by practitioners who design and implement prevention or treatment programs in dealing with Internet addiction or cyberbullying.

  • Barriers and facilitators when implementing online monitoring and management as a substitution for traditional outpatient care in children with asthma

    From: Journal of Medical Internet Research

    Date Submitted: Nov 7, 2017

    Open Peer Review Period: Nov 8, 2017 - Jan 3, 2018

    Background: Despite their potential benefits many eHealth innovations studied in major studies fail to integrate into organizational routines and implementation of these innovations remains problemati...

    Background: Despite their potential benefits many eHealth innovations studied in major studies fail to integrate into organizational routines and implementation of these innovations remains problematic. Objective: The purpose of this study was to describe health care professionals’ self-identified perceived barriers and facilitators for the implementation of a web-based portal to monitor asthmatic children online as a substitution for routine outpatient care. Also, we assessed patient (and/or their parents) satisfaction with this eHealth innovation. Methods: Between April and November 2015, 76 healthcare professionals were recruited to participate. During a period of six months, participants received three questionnaires to identify factors that facilitate or impede the use of this eHealth innovation. Questionnaires for patients (and/or parents) were sent once after a period of 6 months. Results: perceived barriers included concerns about the lack of structural financial reimbursement for online monitoring, lack of integration of this eHealth innovation with electronic medical records, the burden of web-based portal use on clinician workload and altered patient-professional relationship (due to fewer face-to-face contacts). Major perceived facilitators included enthusiastic and active initiators, a positive attitude of professionals towards eHealth, the possibility to tailor care to the individual patient (so-called ‘personalized eHealth’) and to easily deliver care according to current guidelines by using the virtual asthma clinic (VAC) and long-term profit and efficiency. Conclusions: Implementation of an eHealth innovation is complex, dynamic and influenced by multiple factors at the levels of the innovation itself, individual professionals, patients, social context, organizational context and economic and political context. Understanding and defining the barriers and facilitators that influence the context appears to be important for successful implementation and sustainability of eHealth innovations.

  • Prescription and use of inhaled medication in patients with asthma and COPD: Baseline-data of an adherence-Intervention-study

    From: Journal of Medical Internet Research

    Date Submitted: Oct 27, 2017

    Open Peer Review Period: Oct 27, 2017 - Dec 22, 2017

    Background: In Swiss adults, prevalence of asthma and COPD is around 7%. To date, asthma and COPD are not curable but treatable respiratory diseases. The burden of each disease among patients is high...

    Background: In Swiss adults, prevalence of asthma and COPD is around 7%. To date, asthma and COPD are not curable but treatable respiratory diseases. The burden of each disease among patients is high and people affected are frequently hospitalised due to exacerbations. This is associated with accelerated lung function decline, increased mortality and reduced health-related quality of life (HRQoL). However, there are numerous reasons for the lack of disease control in asthma and COPD patients. It is repeatedly associated with non-adherence to guidelines regarding treatment recommendation on the part of the health care provider and with poor inhalation technique and/or non-adherence to the prescribed treatment plan by the patient. Objective: This study aims at presenting data on compliance in accordance with current treatment guidelines. Moreover, we provide baseline data on inhaler application and its impact on quality of life and symptom control in a typical population with chronic lung disease from the Adherence-Trial. Methods: For this cross-sectional analysis, 169 in- and out-patients with asthma and COPD were recruited. Correct application of inhaler devices was tested using pre-defined checklists. Quality of life and symptom control were investigated using COPD Assessment Test (CAT) and Asthma Control Test (ACT). Spirometry was used to measure forced vital capacity (FVC) and forced expiratory volume in one second (FEV1). Results: Overall, correct inhalation technique ranged from 55% to 100% depending on the type of inhaler. 112 participants (68%) participants were treated according to global guidelines. COPD patients with incorrect device application had a higher CAT sum score compared to those with a correct device application (P=.02). Moreover, COPD patients with incorrect device application had more often cough (P=.03) and were more breathless while walking up hills or one flight of stairs (P=.02). While there was no significance found in asthma patients, COPD patients who used their devices correctly had a significantly better mean FEV1% predicted at baseline compared to those who applied their devices incorrectly (P=.04). Conclusions: Regular and comprehensive training of correct an inhalation technique is recommended in patients with chronic lung disease, in particular COPD. Correct inhalation of prescribed medication is associated with improved health status and lung function. These findings should encourage physicians and pharmacists to provide instructions on correct inhalation technique and to re-evaluate the patients’ inhalation technique on a regular basis. Clinical Trial: Trial registration: ClinicalTrials.gov: NCT02386722

  • Development and validity of physiotherapy questionnaires: An app with the main musculoskeletal assessment questionnaires

    From: JMIR Rehabilitation and Assistive Technologies

    Date Submitted: Oct 23, 2017

    Open Peer Review Period: Oct 24, 2017 - Dec 19, 2017

    Background: Patient-reported outcomes (PROs) translate subjective outcomes into objective data that can be quantified and analyzed. Nevertheless, the use of PROs in their traditional paper format is n...

    Background: Patient-reported outcomes (PROs) translate subjective outcomes into objective data that can be quantified and analyzed. Nevertheless, the use of PROs in their traditional paper format is not practical for clinical practice due to limitations associated with the analysis and management of the data. To address the need for a viable way to group and utilize the main functioning assessment tools in the field of musculoskeletal disorders, a physiotherapy questionnaires (PQ) app was developed. Objective: This study aims to explain the development of the PQ app, to validate it using two questionnaires, and to analyze whether participants prefer to use the app or the paper version of the questionnaires. Methods: In the first stage, the PQ app for an Android operational system was developed. In the second stage, the aim was to select questionnaires that were most often used in musculoskeletal clinical practice and research. The Foot and Ankle Outcome Score (FAOS) and American Orthopaedic Foot and Ankle Society (AOFAS) questionnaires were selected to validate the PQ. 50 participants completed the paper and app versions of the AOFAS and 50 completed the FAOS. The study’s outcomes were the correlation of the data between the paper and app versions as well as the preference of the participants between the two versions. Results: The PQ was approved by the experts after the adaptations of the layout for mobile phones and a total of 18 questionnaires were included in the app. Moreover, the app allows the generation of PDF and Excel files with the patients' data. In regards to validity, the mean of the total scores of the FAOS were 91.54% ± 8.86 for the paper version and 91.74% ± 9.20 for the app. There was no statistically significant difference in the means of the total scores or the subscales (P=.11-.94). The mean total scores for the AOFAS were 93.94 ± 8.47 for the paper version and 93.96 ± 8.48 for the app. No statistically significant difference was found for the total scores for the AOFAS or the subscales (P=1.00). The PQ app showed excellent agreement with the paper version of the FAOS, with an ICC value of .98 for the total score (CI 95%, 0.98–0.99) which was also found for the AOFAS with the ICC for the total score of .99 (IC 95%, 0.98–0.99). In regards to compliance, 72% of the participants in the FAOS and 94% in the AOFAS opted for the application as their preferred version. Conclusions: The PQ app showed validity and high levels of compliance for the FAOS and AOFAS, which means that it is not inferior to the paper version of these two questionnaires, thus confirming its viability and feasibility for use in clinical practice.

  • Modeling and Predicting European Physicians’ eHealth Usage Outcomes: A Multidimensional Approach from a Survey of 9,196 General Practitioners

    From: Journal of Medical Internet Research

    Date Submitted: Oct 24, 2017

    Open Peer Review Period: Oct 24, 2017 - Dec 19, 2017

    Background: In the shared healthcare model that eHealth proposes, the literature has noted the need to use more advanced methods and models to evaluate physicians’ eHealth usage outcomes. Objective:...

    Background: In the shared healthcare model that eHealth proposes, the literature has noted the need to use more advanced methods and models to evaluate physicians’ eHealth usage outcomes. Objective: The goal of our study was to design and evaluate a predictive multidimensional model of European general practitioners’ eHealth usage outcomes. Methods: We used data from a 2012-2013 survey of a sample of 9,196 European general practitioners. We proposed and tested two composite indicators of eHealth usage outcomes (internal practices [IP] and practices with patients [PP]) by means of two-stage structural equation modeling with latent variables and measurement errors. Logistic regression (odds ratios, OR) to model the predictors of eHealth usage outcomes indicators was performed using independent variables corresponding to sociodemographic circumstances, attitudes towards ICT impact, and working conditions. Results: The dimensions with more explanatory power of eHealth usage outcomes in internal practices were ICT usage, electronic health records_data, electronic health records_decision support systems, personal health records and Telehealth. In contrast, the eHealth usage outcomes in practices with patients were only explained by the composite indicator of eHealth usage outcomes in the internal practices and by Telehealth usage. For 54.8% (5,035/9,196) and for 55.8% (5,133/9,196) of European general practitioners, the eHealth usage outcomes in internal practices and in practices with patients were more favorable (greater than the mean). European general practitioners who were female (IP OR 1.15, 95% CI 1.10–1.20; PP OR 1.19, 95% CI 1.14–1.24) and younger –aged < 35 years (IP OR 1.14, 95% CI 1.02–1.26; PP OR 1.32, 95% CI 1.13–1.54) and aged 36-45 years (IP OR 1.16, 95% CI 1.06–1.28; PP OR 1.21, 95% CI 1.10–1.33) – had a higher propensity towards favorable eHealth usage outcomes in internal practices (IP) and in practices with patients (PP). European general practitioners who positively valued the effect of ICT on their personal work processes (IP OR 5.30, 95% CI 4.73–5.93; PP OR 4.83, 95% CI 4.32–5.40), teamwork processes (IP OR 4.19, 95% CI 3.78–4.65; PP OR 3.38, 95% CI 3.05–3.74) and relations with patients (IP OR 3.97, 95% CI 3.60–4.37; PP OR 6.02, 95% CI 5.43–6.67) showed a high propensity towards the favorable results of eHealth uses (IP and PP). European general practitioners who had used 2.0 applications in their personal lives frequently (IP OR 1.77, 95% CI 1.60–1.97; PP OR 1.94, 95% CI 1.74–2.15) or occasionally (IP OR 1.16, 95% CI 1.06–1.28; PP OR 1.19, 95% CI 1.08–1.31) also had a high propensity towards favorable eHealth usage outcomes. Self-employed European general practitioners (IP OR 1.33, 95% CI 1.22–1.45; PP OR 1.10, 95% CI 1.03–1.28) also showed more favorable results in eHealth usage. Lastly, general practitioners who reported that the number of patients treated had remained constant (IP OR 1.08, 95% CI 1.01–1.17) or had increased in the last two years (PP OR 1.12, 95% CI 1.03–1.22) had a greater predisposition towards favorable eHealth usage outcomes. Conclusions: We provide new evidence of predictors (sociodemographic issues, attitudes towards ICT impacts, and working conditions) explaining favorable eHealth usage outcomes. The results highlight the need to develop more specific policies for general practitioners’ eHealth usage to address different realities. Clinical Trial: NONE

  • Cost-effectiveness of facilitated access to a self-management website (HeLP-Diabetes) compared to usual care for patients with Type 2 Diabetes: a randomised-control trial

    From: Journal of Medical Internet Research

    Date Submitted: Nov 25, 2017

    Open Peer Review Period: Nov 25, 2017 - Jan 20, 2018

    Background: Type 2 Diabetes Mellitus is one of the commonest long-term conditions, and costs health services approximately 10% of their total budget. Active self-management by patients improves outco...

    Background: Type 2 Diabetes Mellitus is one of the commonest long-term conditions, and costs health services approximately 10% of their total budget. Active self-management by patients improves outcomes and reduces health service costs. While the existing evidence suggested that uptake of self-management education was low, the development of internet-based technology might improve the situation. Objective: To establish the cost-effectiveness of a web-based self-management programme for people with type 2 Diabetes (HeLP-Diabetes) compared to usual care. Methods: An incremental cost-effectiveness analysis was conducted, from a National Health Service and personal and social services perspective, based on data collected from a multi-centre, two-arm individually randomised controlled trial over 12 months. Adults aged 18 or over with a diagnosis of type 2 diabetes and registered with the 21 participating general practices (primary care) in England, UK, were approached. People who were unable to provide informed consent or to use the intervention, terminally ill, or currently participating in a trial of an alternative self-management intervention, were excluded. The participants were then randomised to either usual care plus HeLP-Diabetes, an interactive, theoretically-informed web-based self-management programme, or to usual care plus access to a comparator website containing basic information only. The participants’ intervention costs and wider health care resource use were collected as well as two health-related quality of life measures: the Problem Areas in Diabetes (PAID) Scale and EQ-5D-3L. EQ-5D-3L was then used to calculate quality-adjusted life years (QALYs). The primary analysis was based on intention-to-treat, using multiple imputation to deal with the missing data. Results: In total, 374 participants were randomised, with 185 in the intervention group and 189 in the control group. The primary analysis showed incremental cost-effectiveness ratios (ICERs) of £58 (-£268 to £742) per unit improvement on PAID scale and £5,550 (-£15,515 to £59,275) per QALY gained by HeLP-Diabetes, compared to the control. The complete case analysis showed less cost-effectiveness and higher uncertainty with ICERs of £116 (95% CI -£1,299 to £1,690) per unit improvement on PAID scale and £18,500 (95%CI -£203,949 to £190,267) per QALY. The cost-effectiveness acceptability curve showed an 87% probability of cost-effectiveness at £20,000 per QALY willingness-to-pay threshold. The one-way sensitivity analyses estimated 363 users would be needed to use the intervention for it to become less costly than usual care. Conclusions: Facilitated access to HeLP-Diabetes is cost-effective, compared to usual care, under the recommended threshold of £20,000 to £30,000 per QALY by National Institute of Health and Care Excellence. Clinical Trial: ISRCTN02123133

  • E-Health as the Next Generation Obstetric Care: a Review of the Literature

    From: JMIR mHealth and uHealth

    Date Submitted: Nov 2, 2017

    Open Peer Review Period: Nov 3, 2017 - Dec 29, 2017

    Rapid development in digital technology has provided healthcare with numerous devices, systems and services to support daily care by e-health. In the reproductive age, women are particularly frequent...

    Rapid development in digital technology has provided healthcare with numerous devices, systems and services to support daily care by e-health. In the reproductive age, women are particularly frequent users of Internet, social media and smartphone apps. This makes the obstetric patient a prime candidate for e-health supported health care. This review describes the current state of affairs on e-health developments in obstetrical care. We evaluate the effect on healthcare quality, discuss legal and privacy barriers and identify possibilities for future directions. Several studies show that e-health applications in gestational diabetes and mental health are good alternatives to standard practice. Examples are interactive blood glucose management with remote care using smartphones, telephone screening for postnatal depression and web-based cognitive behavioral therapy. A number of applications and exercise programs show a direction towards less gestational weight gain, increase in step count and increase in smoking abstinence. Multiple studies describe novel systems to enable home fetal monitoring with cardiotocography and uterine activity. However, only few studies assess outcomes in terms of fetal monitoring safety and efficacy in high risk pregnancy. Patients and clinicians report good overall satisfaction with new strategies that enable the shift from hospital-centered to patient-centered care. This active involvement of patients to their health has been widely acknowledged to improve commitment to treatment and thus health outcomes. In general, the combination of increased patient empowerment and home pregnancy care could lead to more efficiency and reduction of costs. E-health will continue to grow and this will not be limited to the obstetric department. We accentuate the need for evidence for health outcomes, patient satisfaction and the impact on costs of the possibilities of e-health interventions in obstetric care. The link between this specific group of patients and their digital mindset cannot be ignored.

  • Depression is predicted by emotional instability on Facebook, but by reduced emotion variability on Twitter

    From: Journal of Medical Internet Research

    Date Submitted: Oct 25, 2017

    Open Peer Review Period: Oct 26, 2017 - Dec 21, 2017

    Background: Frequent expression of negative emotion words on social media has been linked to depression. However, metrics have relied on average values, not dynamic measures of emotional volatility. O...

    Background: Frequent expression of negative emotion words on social media has been linked to depression. However, metrics have relied on average values, not dynamic measures of emotional volatility. Objective: This study reports on the associations between depression severity and the variability (time-unstructured) and instability (time-structured) in emotion word expression on Facebook and Twitter across status updates. Methods: Status updates and depression severity ratings of 29 Facebook users and 49 Twitter users were collected through the app MoodPrism. The average proportion of positive and negative emotion words used, within-person variability, and instability were computed. Results: Negative emotion word instability was a significant predictor of greater depression severity on Facebook (rs(29) =.44, p = .017, 95% CI [.09, .69]), even after controlling for the average proportion of negative emotion words used (partial rs(26)= .51, p = .006) and within-person variability (partial rs(26) = .49, p = .009). A different pattern emerged on Twitter where greater negative emotion word variability indicated lower depression severity (rs(49) = -.34, p = .011, 95% CI [-.58, .09]). Differences between Facebook and Twitter users in their emotion word patterns and psychological characteristics were explored. Conclusions: The findings suggest that negative emotion word instability may be a simple yet sensitive measure of time-structured variability useful when screening for depression through social media, though this may only be the case for Facebook.

  • Higher efficacy ratings for self-medication with psychedelics than offered treatment for psychopathologies

    From: Journal of Medical Internet Research

    Date Submitted: Oct 26, 2017

    Open Peer Review Period: Oct 27, 2017 - Dec 22, 2017

    Background: A substantial number of people worldwide suffer from mental health problems during their lifetime. Current first-line treatments are not efficacious for a considerable number of patients a...

    Background: A substantial number of people worldwide suffer from mental health problems during their lifetime. Current first-line treatments are not efficacious for a considerable number of patients and the need for alternative treatments is high. Recent scientific studies suggest that psychedelic drugs have high therapeutic potential for a variety of difficult to treat mental disorders. Objective: To the best of our knowledge the present survey study is the first to assess the tendency of psychedelic users to self-medicate with psychedelics and to compare the efficacy of self-administered psychedelics to treat their disorder, and the treatment offered by a medical professional. Methods: In total 2319 (47.4%) participants completed the survey of which 1967 consented and were 18 years or older. The mean (±SD) age of this final set was 25.9 (8.7); 78.7% were males, 19.9% females, and 1.3% classified themselves as ‘other’. Results: Almost half of the final set (45.7%) indicated to have suffered or to be currently suffering from a mental disorder; 77.5% of those were diagnosed by a medical professional. In 92.5% of the diagnosed cases some kind of treatment was offered; 77.3% of them searched for treatments outside a medical professional’s recommendation and 15% of those had used or were using psychedelics to treat or cure symptoms. Self-administered psychedelic treatment had a higher likelihood of being efficacious, with higher symptoms reduction and larger quality of life improvement compared to treatment offered by a medical professional. Conclusions: Lifetime prevalence of psychopathologies in the current sample of psychedelic drug users seemed to be higher than in the general population. Self-medication with psychedelics was not highly frequent, though when it occurred it was rated as significantly more effective as treatment offered by a medical professional. Current findings support research exploring the potential of psychedelics in the treatment of psychopathologies. Clinical Trial: na

  • The effectiveness of a computer-tailored e-learning program for practice nurses to improve their adherence to smoking cessation counseling guidelines: a randomized controlled trial

    From: Journal of Medical Internet Research

    Date Submitted: Oct 27, 2017

    Open Peer Review Period: Oct 27, 2017 - Dec 22, 2017

    Background: Improving practice nurses’ adherence to smoking cessation counseling guidelines will benefit the quality of smoking cessation care and will potentially lead to higher smoking abstinence...

    Background: Improving practice nurses’ adherence to smoking cessation counseling guidelines will benefit the quality of smoking cessation care and will potentially lead to higher smoking abstinence rates. However, support programs to aid practice nurses in improving their guideline uptake and adherence do not exist yet. Objective: To assess the effects of a novel computer-tailored e-learning program on practice nurses’ smoking cessation guideline adherence. Methods: A web-based randomized controlled trial was conducted in which an intervention group (N = 147) with full access to the e-learning program for six months was compared to a control group (N = 122) without access. Data collection was fully automated at baseline and six-month follow-up via online questionnaires, assessing practice nurses’ demographics, work-related factors, potential behavioral predictors based on the I-Change model and guideline adherence. Practice nurses also completed counseling checklists to retrieve self-reported counseling activities for each consultation with a smoker (N = 1,175). To assess the program’s effectiveness in improving practice nurses’ guideline adherence (i.e. overall adherence and adherence to individual counseling guideline steps), mixed linear and logistic regression analyses were conducted, thus accommodating for the smokers being nested within practice nurses. Potential effect moderation by work-related factors and behavioral predictors was also examined. Results: After six months, 121 practice nurses in the intervention group (43.4%) and 103 in the control group (36.9%) completed the follow-up questionnaire. Mixed linear regression analysis revealed that counseling experience moderated the program’s effect on practice nurses’ overall guideline adherence (β = 0.610; 95% CI 0.132 – 1.089; P = .013), indicating a positive program effect on adherence for practice nurses with a more than average level of counseling experience. Mixed logistic regression analyses regarding adherence to individual guideline steps revealed a trend towards moderating effects of baseline levels of behavioral predictors and counseling experience. More specifically, for practice nurses with less favorable scores on behavioral predictors (e.g. low baseline self-efficacy) and high levels of counseling experience the program significantly increased adherence. Conclusions: Results from our randomized controlled trial showed that among practice nurses with more than average counseling experience the e-learning program resulted in significantly better smoking cessation guideline adherence. Experienced practice nurses might have been better able to translate the content of our e-learning program into practically applicable counseling strategies compared to less experienced colleagues. Less favorable baseline levels of behavioral predictors among practice nurses possibly contributed to this effect, as there was more room for improvement by consulting the tailored content of the e-learning program. To further substantiate the effectiveness of e-learning programs on guideline adherence by healthcare professionals, it is important to assess how to support a wider range of healthcare professionals. Clinical Trial: No medical ethical clearance for this study was needed according to the Medical Ethics Committee Atrium-Orbis-Zuyd (14-N-17). The study is registered with the Dutch Trial Register (NTR4436).

  • A Community Based Participatory Approach to Training Young Adults to Design and Implement a Social Marketing Framed Lifestyle Intervention on their College Campus

    From: Journal of Medical Internet Research

    Date Submitted: Oct 26, 2017

    Open Peer Review Period: Oct 27, 2017 - Dec 22, 2017

    Background: Using a Community-Based Participatory Research (CBPR) approach may increase the likelihood of relevance and acceptability of the designed intervention, especially on a college campus. Furt...

    Background: Using a Community-Based Participatory Research (CBPR) approach may increase the likelihood of relevance and acceptability of the designed intervention, especially on a college campus. Furthermore, recruiting and training college students to design and implement a social marketing framed healthy lifestyle intervention for their peers will allow the intervention to be tailored to the needs of the campus Objective: To describe the process of training college students to develop a campus-based, social marketing health promotion intervention Methods: Four universities recruited current college students (18+ y.o.) to develop a social marketing and environmental intervention (SMEI), which was completed during a 16-week semester course. Researchers and Extension professionals trained students to design 24 weeks of intervention events that would be implemented the upcoming year. Results: Seventy-eight students enrolled in the study and SMEI course among the four intervention states (FL=30, SD=8, TN=13, WV=27); students were predominately Caucasian (65.8%), females (84.0%), and sophomore status in college (64.9%). Throughout the semester, students assessed their campus environments, set priorities, and developed weekly events and resources needed to implement the intervention on their campuses. By the end of the semester, the students had designed 24 weeks of intervention events focusing on nutrition/food/diet, physical activity, stress management, sleep, and time management. SMEI students designed interactive events, advertisements, artwork, and social media posts for the intervention. These events and resources were catalogued into a digital toolkit of instructions and activities for each week of intervention events. Conclusions: Training students to be social marketing and environmental interventionists via the CBPR process allows for the development of an intervention that stems from grass roots efforts and is tailored to the acceptability and needs of their peers. Clinical Trial: This study was prospectively registered in October 2016 on clinicaltrials.gov, NCT 02941497.

  • An mHealth Intervention to Improve Young Gay and Bisexual Men’s Sexual, Behavioral, and Mental Health in a Structurally Stigmatizing National Context

    From: JMIR mHealth and uHealth

    Date Submitted: Oct 26, 2017

    Open Peer Review Period: Oct 27, 2017 - Dec 22, 2017

    Background: Young gay and bisexual men (YGBM) in Eastern European countries like Romania face high stigma and discrimination, including in healthcare. Increasing HIV transmission is a concern given in...

    Background: Young gay and bisexual men (YGBM) in Eastern European countries like Romania face high stigma and discrimination, including in healthcare. Increasing HIV transmission is a concern given inadequate prevention, travel to high-prevalence countries, and popularity of sexual networking technologies. Objective: An efficacious mobile health (mHealth) HIV-prevention intervention created in the United States was adapted and pilot-tested in Romania to reduce YGBM’s HIV risk. Methods: After an intervention formative phase, 43 YGBM (M age = 23.2, SD=3.6) who reported condomless sex with a male partner and at least five days of heavy drinking in the past three months were enrolled and completed up to eight 60-minute counseling sessions based on motivational interviewing and cognitive behavioral skills training with trained counselors. Pre-post intervention assessments of sexual (e.g., HIV-risk behavior), behavioral (e.g., alcohol use), and mental health (e.g., depression) outcomes were conducted to evaluate intervention impact. Results: From baseline to follow-up, participants reported significant: 1) increases in HIV-related knowledge (M=4.6 vs. M=4.8, P < 0.001) and recent HIV testing (M=2.8 vs. M=3.3, P < 0.05); 2) reductions in heavy alcohol consumption (M=12.8 vs. M=6.9, P < 0.01), and 3) increases in self-efficacy of condom use (M=3.3 vs. M=4.0, P < 0.01). Participants also reported significant reductions in depression symptoms (M=1.5 vs. M=1.0, P < 0.01). Conclusions: This first mHealth HIV risk-reduction pilot intervention for YGBM in Eastern Europe indicated preliminary efficacy and strong acceptability and feasibility. This mobile prevention tool lends itself to broad dissemination pending future efficacy testing, especially in contexts where stigma keeps GBM out of reach of affirmative health interventions.

  • The use and effects of ehealth tools for patient self-monitoring and reporting of outcomes following medication use: A systematic review

    From: Journal of Medical Internet Research

    Date Submitted: Nov 2, 2017

    Open Peer Review Period: Nov 3, 2017 - Dec 29, 2017

    Background: eHealth tools are becoming increasingly popular for helping patients self-manage chronic conditions. Little research has examined the effect of ehealth tools for patient self-reporting on...

    Background: eHealth tools are becoming increasingly popular for helping patients self-manage chronic conditions. Little research has examined the effect of ehealth tools for patient self-reporting on medication management. This review aims to determine whether ehealth tools featuring patient self-reporting of symptoms, adverse effects and drug therapy problems are effective at prompting medication changes and improving patient outcomes. Objective: The primary objective is to determine how patient self-reporting of symptoms and adverse effects via ehealth tools influences medication use and changes made to medications. Secondary objectives are to investigate how patient use of ehealth tools influences identification of adverse events, patient self-management of disease and self-efficacy, medication use behaviour, medication reconciliation and recommendations for drug changes, changes in patient signs and symptoms, health services utilization, quality of life, and patient satisfaction with health care. Methods: MEDLINE, EMBASE and CINAHL were searched from Jan 1, 2000 through to January 4, 2016. References were also searched. Title, abstract and full text review, as well as data abstraction and risk of bias assessment were performed in duplicate. Due to high heterogeneity, results were not meta-analyzed, and instead presented as a narrative synthesis. Results: 13 studies, including 10 randomized controlled trials (RCTs) and 3 single-arm cohort studies were included, from which 10 unique ehealth tools were identified. Here six of seven RCTs found improvement in patient symptoms following ehealth tool use, especially in adolescent asthma patients. Four of six RCTs reported that ehealth tools may have potential to initiate changes to medications based on patient self-reports. Two of four RCTs showed that ehealth tools may improve patient self-efficacy and self-management of chronic disease. Little or no evidence was found to support the effectiveness of ehealth tools at improving medication recommendations and reconciliation by clinicians, medication-use behaviour, health service utilization, quality of life, or patient satisfaction. eHealth tools with multifaceted functionalities and those allowing direct patient-provider communication may be more effective at improving patient self-management and self-efficacy. Conclusions: Initial evidence showing ehealth tools may improve patient symptoms and lead to medication changes is promising. Patients generally found ehealth tools useful in improving communication with health care providers. Implementation issues such as poor patient engagement and poor clinician workflow integration were identified. More high-quality research is needed to explore how ehealth tools can be used to effectively manage use of medications to improve patient outcomes.

  • TaskExchange: Facilitating online collaboration in evidence synthesis

    From: Journal of Medical Internet Research

    Date Submitted: Oct 26, 2017

    Open Peer Review Period: Oct 27, 2017 - Dec 22, 2017

    Background: The conduct and publication of scientific research is increasingly open and collaborative. There is growing interest in online platforms that can effectively enable global, multidisciplina...

    Background: The conduct and publication of scientific research is increasingly open and collaborative. There is growing interest in online platforms that can effectively enable global, multidisciplinary scientific teams, and create networks of scientists in areas of shared research interest. Designed to facilitate online collaboration in research evidence synthesis, TaskExchange highlights the potential of these kinds of platforms. Objective: This paper describes the development, growth and future for TaskExchange, an online platform facilitating collaboration in research evidence synthesis. Methods: The original aim for the development of TaskExchange was to create a platform that connected people who needed help with their Cochrane Systematic Reviews (rigorous syntheses of health research) with people who had the time and expertise to help. The scope of TaskExchange has now been expanded to include other evidence synthesis tasks, including guideline development. The development of TaskExchange was undertaken in four agile development phases with substantial user engagement. In each phase, software was iteratively deployed as it was developed and tested, enabling close cycles of development and refinement. Results: TaskExchange enables users to browse and search tasks and members by key word or nested filters, post and respond to tasks, sign up to notification emails and acknowledge the work of TaskExchange members. The pilot platform has been open access since August 2016, has almost 1500 members and has hosted more than 400 tasks, covering a wide range of research synthesis-related tasks. Response rates are consistently over 70% and user feedback has been positive. Conclusions: TaskExchange demonstrates the potential for new technologies to support online collaboration in health research. Development of a relatively simple platform for peer-to-peer exchange has provided opportunities for systematic reviewers to get their reviews completed more quickly, and provides an effective pathway for people to join the global health evidence community.

  • Empirical Study of Wearable and Social App in Social Care

    From: JMIR mHealth and uHealth

    Date Submitted: Oct 27, 2017

    Open Peer Review Period: Oct 28, 2017 - Dec 23, 2017

    Background: The amount of mobile self-tracking devices connected to the web has exploded in today’s society. With these mobile wearables related to Web 2.0 apps and social media has followed new way...

    Background: The amount of mobile self-tracking devices connected to the web has exploded in today’s society. With these mobile wearables related to Web 2.0 apps and social media has followed new ways of monitoring, measuring, representing and sharing experiences of the human body. New opportunities related to health, and new areas of implementation for professionals have appeared. One identified area that can benefit from mHealth technologies is social work. Objective: There are still few publications presenting experiences of applying wearables and social apps in social work. To contribute to this area it was started a research project targeting wearables and social apps for youths in need of social care. The project was framed by the overarching questions: What improved physical and sleeping effects did the youths and the professional staff experience as a result of using the wearables and the social apps? Methods: To answer the question a field study was performed were wearables and social apps were tried out and studied in the context of vulnerable youths in need of social care, living at a Swedish municipalities care and accommodation home. Results: : The study confirmed earlier reported mHealth research results claiming that instant graphical feedback, sharing information, and being part in social community can have positive impact on life style changes. In addition, the present study identified that the most important factor for positive health related life style changes for youths was the establishment of own long-term goals. The professional social workers identified that the studied wearable and social app could function as a valuable counseling tool opening up for life style talks that otherwise were hard to accomplish. Conclusions: This study demonstrate how wearables and social apps can help vulnerable youths to change bad life style patterns, and also suggests that they can be used as counseling tools for professionals in social work.

  • Serious games in the context of people with cognitive disabilities: a case study

    From: JMIR Serious Games

    Date Submitted: Oct 27, 2017

    Open Peer Review Period: Oct 28, 2017 - Dec 23, 2017

    Background: While traditional video games provide amusement, with the advent of serious games (SG), it has raised the potential and the results that can be achieved from the games, these artifacts, wh...

    Background: While traditional video games provide amusement, with the advent of serious games (SG), it has raised the potential and the results that can be achieved from the games, these artifacts, whose main differentials are the fact that they are naturally playful and motivators. While in the 1990s, the games aimed only at entertainment, nowadays teaching and learning combine with entertainment and become the main goals to be achieved through the SG. A strong example of SG application is for motivation and help in the formal or special teaching-learning process acting as a pedagogical tool. In this sense, the following question arises: What are the characteristics and interface resources considered adequate to compose the interface of a serious game that have educational objectives directed to people with Williams-Beuren Syndrome? Here's the motivation guide for this article. Objective: Elementary mathematics education for people with Williams Syndrome Methods: An exploratory and descriptive study,using qualitative and quantitative approaches. Results: The results portfolio obtained from the WBS user experience assessment presents the confidence rectangle within the "desirable" quadrant. This is what a project program is, since scientifically this is one of the biggest difficulties reported by unlock authors, it is not possible to teach content and maintain playfulness. Conclusions: The prototype of the game here called SoundMath, was intended to meet a demand for learning elementary arithmetic for people with WBS, from a playful and immersive process. Through the results of the evaluations carried out, this work provides relevant information that can encourage the development of this game, as well as help companies in the educational segment, and contribute to the improvement of the quality of the applications targeted to this type of public. Other important point to be highlighted from this work is with regard to the social aspect that this work encompasses, because it is the development of a solution applied to a daily problem of this public. But we did not just develop; we decided to go beyond and document the entire process of engineering and gamification, based on data obtained throughout this study of design and design of a serious educational game prototype that contained in its layout the ideal characteristics to mediate a teaching-learning process from its use, as well as document and outline a methodological process that may serve as the basis for further studies. Thus, we believe that the results and reflections raised from this study may, in the future, broaden the knowledge about the design of serious games for people with cognitive disabilities. The prototype of the game here called SoundMath, was intended to meet a demand for learning elementary arithmetic for people with WBS, from a playful and immersive process. Through the results of the evaluations carried out, this work provides relevant information that can encourage the development of this game, as well as help companies in the educational segment, and contribute to the improvement of the quality of the applications targeted to this type of public. Other important point to be highlighted from this work is with regard to the social aspect that this work encompasses, because it is the development of a solution applied to a daily problem of this public.

  • Information Technology-Assisted Treatment Planning and Performance Assessment For Severe Thalassemia Care in a resource-limited setting

    From: JMIR Medical Informatics

    Date Submitted: Oct 27, 2017

    Open Peer Review Period: Oct 28, 2017 - Dec 23, 2017

    Background: Successful models of information and communication technology (ICT) applied to cost-effective delivery of quality care in low- and middle-income countries (LMIC) are an increasing necessit...

    Background: Successful models of information and communication technology (ICT) applied to cost-effective delivery of quality care in low- and middle-income countries (LMIC) are an increasing necessity. Severe thalassemia (ST) is one of the most common life-threatening non-communicable diseases of children globally. Objective: To study the impact of ICT on quality of care for ST patients in LMIC. Methods: A total of 1110 patients with ST from 5 centers in India were followed over a one-year period. The impact of consistent use of a web-based application platform designed to assist comprehensive management of ST (ThalcareTM) on key indicators of quality of care such as minimum (pre-transfusion) hemoglobin, serum ferritin, liver size and spleen size was assessed. Results: For four centers, the improvement in mean pre-transfusion hemoglobin level was statistically very significant (P<0.001). Four out of five centers achieved reduction in mean ferritin levels with two displaying a highly significant drop in ferritin (P=0.003 and P=0.0002). One of the five centers did not record liver and spleen size on palpation, but out of the remaining 4 centers, 2 witnessed a strongly significant drop in liver and spleen size (P <0.01), 1 witnessed moderate drop (P= 0.05 for liver P =0.03 for spleen size) while the fourth witnessed a moderately increase in liver size (P =0.08) and insignificant change in spleen size (P=0.12). Conclusions: Implementation of Computer-Assisted Treatment Planning and Performance Assessment positively impacted on indices reflecting effective delivery of care to patients suffering from ST in LMIC consistently.

  • Effectiveness of an Internet- and App-based intervention for college students with elevated stress: results of a randomized controlled trial.

    From: Journal of Medical Internet Research

    Date Submitted: Oct 30, 2017

    Open Peer Review Period: Oct 31, 2017 - Dec 26, 2017

    Background: Mental health problems are highly prevalent among college students. The majority of students with poor mental health, however, does not receive professional help. Internet-based self-help...

    Background: Mental health problems are highly prevalent among college students. The majority of students with poor mental health, however, does not receive professional help. Internet-based self-help formats may increase the utilization of treatment. Objective: This randomized controlled trial evaluated the efficacy of an Internet-based, App-supported stress-management intervention for college students. Methods: 150 college students with elevated levels of stress (Perceived Stress Scale; PSS-4≥ 8) were randomly assigned to either an Internet- and mobile-based stress intervention group (IG) or a control group (CG). Self-report data were assessed at baseline, post-treatment (7 weeks) and 3-month follow-up. The primary outcome was perceived stress (Perceived Stress Scale; PSS-4). Secondary outcomes included mental health outcomes, modifiable risk and protective factors, and college-related outcomes. Subgroup analyses were conducted in students with clinical relevant symptoms of depression (CES-D>17). Results: Findings indicated significant effects of the intervention compared to the CG for stress (d=0.69; 95%CI:0.36-1.02), anxiety (d=0.76; 95%CI:0.43-1.09), depression (d=0.63; 95%CI:0.30-0.96), college-related productivity (d=0.33; 95%CI:0.01-0.65), academic work impairment (d=0.34; 95%CI:0.01-0.66) and other outcomes at post-treatment. Effects were sustained at follow-up and similar findings emerged in students with symptoms of depression. Conclusions: Internet- and mobile-based interventions could be an effective and cost-effective approach to reduce consequences of college-related stress. Clinical Trial: German Clinical Trial Register; DRKS00010212

  • Spatial variation of harmful traditional practices and associated factors among under five children in Dabat District, Northwest Ethiopia

    From: JMIR Public Health and Surveillance

    Date Submitted: Oct 28, 2017

    Open Peer Review Period: Oct 30, 2017 - Dec 25, 2017

    Background: In Ethiopia, evidences show that there are about 140 harmful traditional practices affecting mothers and children. Knowledge of the spatial distribution and characteristics of harmful trad...

    Background: In Ethiopia, evidences show that there are about 140 harmful traditional practices affecting mothers and children. Knowledge of the spatial distribution and characteristics of harmful traditional practices are important for planning effective mitigation activities. Objective: The aim of this study was to identify spatial variations of harmful traditional practices and associated factors among children under age of 5 years at Dabat health and demographic surveillance site (HDSS), in northwest Ethiopia. Methods: A total of 7240 under five children on follow-up in Dabat Health and demographic surveillance site were included in the study. A spatial scan test using SaTScan Version 9.4 was used to identify spatial clusters of harmful traditional practice using a Bernoulli probability model. Results: Nine from ten mothers reported at least one harmful traditional practice on their children. Of harmful traditional practice, Uvelectomy (83.6%) accounted the highest. The frequent practice was found high at Arebur (93%) and Doka (95%) Kebeles. Nine most likely clusters (LLR=17.3, p = .002) of harmful traditional practice were identified. Age and educational level of mothers, access to television and tel-ephone of the household were significantly associated with occurrence of HTPs on children before age of five years. Conclusions: In this study we found out that harmful traditional practice remains one of the major public health problem and have spatial variations in rural community. The younger aged and less educated mothers, and no access to television and telephone in the household were significant predictors of harmful tradi-tional practices to be undergone on children.

  • An Ordinal Regression based Approach to Doctor Performance Evaluation in EHealth

    From: Journal of Medical Internet Research

    Date Submitted: Oct 30, 2017

    Open Peer Review Period: Oct 30, 2017 - Dec 25, 2017

    Background: Doctor performance evaluation (DPE) is an important task in eHealth, which aims to evaluate the overall quality of online diagnosis and patient outcomes so that high customer satisfaction...

    Background: Doctor performance evaluation (DPE) is an important task in eHealth, which aims to evaluate the overall quality of online diagnosis and patient outcomes so that high customer satisfaction and loyalty can be attained. However in reality most of customers trend not to give ratings to doctor performance. Therefore it is imperative to develop a model to make DPE automatically. When making auto-evaluation of doctor performance, we expect to rate the doctor performance into a score label that is as close as possible to the true one. Objective: This study aims to do DPE automatically from online textual consultation contents between doctors and customers by a novel machine learning method. Methods: We propose a solution which models DPE as an ordinal regression problem. In doing so, a combined SVM and Ordinal Partitioning model, namely SVMOP, along with an innovative prediction function is developed to capture the ordering labels hidden in preferences over DPE. Specifically, when conducting feature engineering, in addition to the basic text features, eight handcrafted features extracted from over 70,000 medical entries, are added and then further boosted by Gradient Boosting Decision Tree. Results: Real data sets from one of the largest mobile doctor-patient communication platforms in China are used in our study. In according with the statistics, 64% of data on eHealth platforms loss the evaluation labels from customers. Experimental results reveal that our approach can well support doctor performance evaluation automatically. Specifically, compared with other auto-evaluation models, SVMOP improve the MAE by up to 0.1, MSE by up to 0.5, PAcc by up to 5%; the handcrafted features that we suggest, improve the MAE by up to 0.1, MSE by 0.2, PAcc by up to 3%. After boosting, the performance can be further improved. Furthermore, based on OR-DPE model, we could also mine some predictive features like some useful polite expressions and sentiment words, which can be further applied to guide the development of eHealth platforms. Conclusions: It is the first time to model the problem of doctor performance evaluation on eHealth platforms as an ordinal regression problem. Apart from the basic text features, we use eight handcrafted features suggested by domain experts as important features to improve our model’s performance. Additionally, we propose a more reasonable and effective prediction function in SVMOP model. Experiments show that the performance of the model with revised prediction function is better than many other machine learning methods on MAE, MSE as well as Pairwise Accuracy. In summary, with this model the eHealth platform could not only make an auto-evaluation of doctor performance online but also mine the most effective features which could guide the promotion and development of doctors and platforms.

  • The Rise and Need for Mobile Apps for Maternal and Child Health Care in China- a survey based on App markets

    From: Journal of Medical Internet Research

    Date Submitted: Oct 31, 2017

    Open Peer Review Period: Oct 31, 2017 - Dec 26, 2017

    Background: The mobile health (mHealth) services are booming in maternal and child health (MCH) in China, due to the expansion of e-health and the introduction of the ‘two child policy’ Countless...

    Background: The mobile health (mHealth) services are booming in maternal and child health (MCH) in China, due to the expansion of e-health and the introduction of the ‘two child policy’ Countless MCH apps can be found in computer stores, but the exact number, downloads and functional features of such apps are not clear. Objective: To explore the use of MCH apps in Android and iOS app stores and describe the key functional features of the most popular ones with the purpose of providing insight for further research and development of MCH mobile health products. Methods: The researchers searched the three most popular Android app stores (Tencent MyApp, Baidu Mobile Assistant and 360 Mobile Assistant) and the iTunes App Store in China. All apps on family planning (contraception and preparing for pregnancy), pregnancy and perinatal care, neonatal care and health, and development for children under 6 years were counted. Any apps focusing on MCH product marketing, children's songs, animation and games were excluded from the study. The 50 most used apps in each of the Android and iTunes stores (78 de-duplicated apps in total) were downloaded for in-depth analysis. Results: A total of 5276 Android apps and 877 iOS apps were identified for MCH care. Of the 78 most popular ones, 43 (55.1%) apps focused on only one stage of MCH care, mainly targeting child care (25 apps) and pre-pregnancy (11 apps), while 35 (44.9%) apps covered two or more stages, with most of these (32 apps) related to both pregnancy and child care. The functions mostly covered by the popular apps were health education/promotion, communication, data collection and management, diary, reminder and counseling. Among the functions of ‘data collection and management’, the researchers found 47 independent tools, including pregnancy preparation, fetal heart monitoring, blood glucose and blood pressure monitoring, as well as some that prompted an action, such as visiting the doctor. A few apps were equipped with external devices (n=3) or cellphone-based measurement technology (n=1). No app was found having intelligent decision-support functions to support disease management such as gestational diabetes and pregnancy-induced hypertension. Only a small amount of apps (n=5) had a web connection with hospital information systems to support appointment scheduling, payments, hospital service guidance or to check on laboratory test results. Conclusions: There are thousands of MCH apps on the China market. The most popular apps tend to cover both pregnancy and child care, or child care or pre-pregnancy separately. They are usually equipped with various functions and tools. However, internet of things, intelligent decision-support and docking with existing hospital information systems are still being developed and need more research.

  • Internet and Social Media Access Among Youth Experiencing Homelessness

    From: Journal of Medical Internet Research

    Date Submitted: Oct 30, 2017

    Open Peer Review Period: Oct 31, 2017 - Dec 26, 2017

    Background: Youth experiencing homelessness are at risk for a variety of adverse outcomes. Given the widespread use of internet and social media, these new technologies may be used to address their ne...

    Background: Youth experiencing homelessness are at risk for a variety of adverse outcomes. Given the widespread use of internet and social media, these new technologies may be used to address their needs and for outreach purposes. However, little is known about how this group uses these resources. Objective: This study investigated how homeless adolescents use these technologies for general and health related purposes, whether the scope of their use changes with housing status, and their interest in a website dedicated to youth experiencing homelessness. Methods: A convenience sample of youth ages 18-21 were recruited from a youth specific homeless shelter. All participants completed a 47-item survey, with 10 individuals completing a semi-structured interview. Descriptive statistics, exact testing, and GEE modeling was performed for quantitative data analysis. Interviews were transcribed verbatim, and NVivo 10 was employed to facilitate double coding and thematic analysis. Results: 87 participants completed the survey with a mean age of 19.4 ±1.1 years. 56.3% accessed the internet at least once/day, with 86.1% accessing once/week. Access to a smartphone was associated with a 2.76 greater odds of getting online, and was the most frequently used device (65.5% of participants). While experiencing homelessness, subjects were less likely to access the internet at least once a day (79.3% vs. 56.3%, P < .001), spend more than 2 hours/day on the internet (56.3% vs. 24.1%, P < 0.001), use social media (97.0% vs. 85.1%, P = .006), and have access to a smartphone (85.1% vs. 65.5%, P = .006). Ten participants completed the semi-structured interview. Several themes were identified including, (1) changes in internet behaviors while experiencing homelessness, (2) health status as a major concern and reason for internet use, and (3) interest in a website dedicated to youth experiencing homelessness. While experiencing homelessness, participants indicated their behaviors were more goal oriented and less focused on leisure or entertainment activities. Conclusions: While homeless youth experience changes in the frequency, amount of time, and specific uses of the internet and social media, study participants were able to access the internet regularly. The internet was used to search health related topics. Given the importance of smartphones in accessing the internet, mobile-optimized websites may be an effective method for reach this group.

  • RCGP Research and Surveillance Centre Annual Report 2015-2016: Boys and young male adults have a higher incidence of lower respiratory tract infections and atopic conditions

    From: JMIR Public Health and Surveillance

    Date Submitted: Nov 1, 2017

    Open Peer Review Period: Nov 3, 2017 - Dec 29, 2017

    Background: The Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) comprises >150 general practices, with a combined population of >1.5 million, contributing to UK an...

    Background: The Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) comprises >150 general practices, with a combined population of >1.5 million, contributing to UK and European public health surveillance and research. Objective: To report gender differences in the presentation of infectious and respiratory conditions in children and young adults Methods: Disease incidence data testing the hypothesis that boys up to puberty present more with lower respiratory tract infection (LRTI) and asthma. Incidence rates were reported for infectious conditions in children and young adults, by gender. We controlled for ethnicity, deprivation, and consultation rates. We report odds ratios (OR) with 95%CI, p-values and probability of presenting. Results: Boys presented more with LRTI, largely due to acute bronchitis. The OR of males consulting was greater across the youngest three age bands (OR 1.59 95%CI 1.35-1.87; OR 1.13 95%CI 1.05-1.21; OR 1.20 95% CI 1.09-1.32). Allergic rhinitis and asthma had a higher OR of presenting in 5-14 year old boys (OR 1.52 95%CI 1.37-1.68; OR 1.31, 95%CI 1.17-1.48). Upper respiratory infection (URTI) and urinary tract infection (UTI) had lower odds of presenting in boys, especially over 15years old. The probability of presenting showed different patterns for LRTI, URTI and atopic conditions. Conclusions: Boys under 15 years old have greater odds of presenting with LRTI and atopic conditions; whereas girls may present more with URTI and UTI. These differences may provide insights into disease mechanisms and for health service planning. Clinical Trial: Not applicable

  • Potential application of connected tuberculosis diagnostics for real-time surveillance of drug resistant TB transmission

    From: JMIR Medical Informatics

    Date Submitted: Nov 1, 2017

    Open Peer Review Period: Nov 2, 2017 - Dec 28, 2017

    Background: Tuberculosis (TB) is the top killer infectious disease in the world, and yet the surveillance of this disease is still paper-based. Rifampicin resistant TB (RR-TB) is an urgent public heal...

    Background: Tuberculosis (TB) is the top killer infectious disease in the world, and yet the surveillance of this disease is still paper-based. Rifampicin resistant TB (RR-TB) is an urgent public health crisis, and the World Health Organization has endorsed since 2010 a series of rapid diagnostic tests (RDTs) that allowed rapid detection of drug resistant strains and produced large volumes of data. In parallel, most high burden countries have adopted connectivity solutions that allow linking of diagnostics, real-time capture and shared repository of these test results. However, these connected diagnostics and readily available test results are not utilised to their full capacity as we have yet to capitalize on fully understanding the relationship between test results and specific rpoB mutations to elucidate its potential application on real-time surveillance. Objective: We aimed to validate and analyse RDT data in detail, and propose the potential use of connected diagnostics and associated test results for real-time evaluation of RR-TB transmission. Methods: From the Belgian Coordinated Collections of Microorganisms at the Institute of Tropical Medicine, 107 RR-TB strains harbouring 34 unique rpoB mutations, including 30 within the Rifampicin Resistance Determining Region (RRDR), were selected. These strains were subjected to XpertMTB/RIF (Cepheid), GenoTypeMTBDRplusv2.0 (Hain LifeScience GmbH), and GenoscholarNTM+MDRTBII (Nipro), the results of which were validated against the strains’ available rpoB gene sequences. The reproducibility of the results was determined, and the probe reactions were analysed and visualised, and proposed for potential use in evaluating transmission. Results: TB diagnostic test results, particularly the RDT probe reactions detected the majority of RRDR mutations tested, although a few critical discrepancies between observed probe reactions and manufacturer claims were found. Based on published frequencies of probe reactions and RRDR mutations, we found specific probe reactions with high potential use in transmission studies namely XpertMTB/RIF probes A, Bdelayed, C, Edelayed; GenotypeMTBDRplusv2.0 WT2, WT5, WT6; and GenoscholarNTM+MDRTBII S1, S3. Additionally, inspection of probe reactions of disputed mutations may potentially resolve discordance between genotypic and phenotypic test results. Conclusions: We propose a novel approach for potential real-time detection of RR-TB transmission through fully utilizing connected TB diagnostics and shared repository of test results. To our knowledge, this is the first pragmatic and scalable work in response to the consensus of world-renowned TB experts in 2016 on the potential of diagnostic connectivity for accelerated efforts toward TB elimination. This is evidenced by the ability of our proposed approach to facilitate comparison of probe reactions between and among different RDTs used in the same setting. Integrating this proposed approach as a plug-in module to a connectivity platform will increase usefulness of connected TB diagnostics for RR-TB outbreak detection through real-time investigation of suspected RR-TB transmission cases based on epidemiological linking.

  • Increasing Physical Activity in Mothers Using Video Exercise Groups and Exercise Mobile Apps: A Randomized Controlled Trial

    From: Journal of Medical Internet Research

    Date Submitted: Nov 13, 2017

    Open Peer Review Period: Nov 14, 2017 - Jan 9, 2018

    Background: Women significantly decrease their activity levels in the transition to motherhood. Digital health technologies are low cost, scalable, and can provide an effective delivery mechanism for...

    Background: Women significantly decrease their activity levels in the transition to motherhood. Digital health technologies are low cost, scalable, and can provide an effective delivery mechanism for behavior change. This is the first study that examines the use of videoconferencing and mobile apps to create exercise groups for mothers. Objective: We tested the feasibility, acceptability, and effectiveness of an individually adaptive and socially supportive physical activity intervention incorporating videoconferencing and mobile apps in mothers. Methods: The Moms Online Video Exercise (MOVE) Study was an 8-week, two-armed, web-based randomized trial comparing the effectiveness of a group exercise intervention to a waitlist control. Healthy mothers with at least one child under age 12 were recruited online, through Facebook and email listservs. Intervention participants joined exercise groups using videoconferencing (Google Hangouts) every weekday morning and exercised together in real time guided by exercise mobile apps (e.g. Nike+, Sworkit, etc.) of their choosing. Waitlist control participants had access to the list of recommended mobile apps and an invitation to join an exercise group after an 8-week period. The main outcomes assessed were self-reported moderate, vigorous, and moderate-to-vigorous physical activity (MVPA) minutes per week in aggregate and stratified by whether women met Centers for Disease Control and Prevention (CDC) guidelines for sufficient aerobic activity at baseline. Outcomes were measured through self-assessed online questionnaires at baseline and 8 weeks. Results: The intervention was effective at increasing exercise for inactive women, and proved to be feasible and acceptable to all participants. 64 women were randomized, 30 to intervention and 34 to control. Women attended 2.8 sessions per week. There was a strong, but not statistically significant, trend toward increasing moderate and vigorous minutes of physical activity for all women. As hypothesized, women in the pre-specified strata who were inactive at baseline (n=51) significantly increased their activity by an average of 56 MVPA minutes per week more in the intervention group (95% CI: 10.8, 100.7, P=.02). A corresponding statistically significant net increase of 21 (95% CI: 5.2, 36.8, P=.01) minutes of vigorous activity drove the difference in increased MVPA minutes for this stratum of inactive women. Inactive women in the intervention group reported promising reductions in depression, a statistically significant net decrease in their depression score, -4.1 (95% CI: -7.3, -0.8, P=.02).  Conclusions: We found that a group exercise intervention using videoconferencing and mobile apps was a feasible and acceptable way to deliver a physical activity intervention to mothers with young children. The intervention significantly increased physical activity in inactive mothers. Further studies are needed to better establish how long these changes in physical activity can be maintained and whether these findings can be reproduced in a more diverse population. Clinical Trial: ClinicalTrials.gov NCT02805140

  • Women’s Perceptions on a Mobile Application of Breast Cancer e-Support Program: The process evaluation

    From: Journal of Medical Internet Research

    Date Submitted: Nov 19, 2017

    Open Peer Review Period: Nov 20, 2017 - Jan 15, 2018

    Background: Women with breast cancer undergoing chemotherapy experience difficulty in accessing to adequate cancer care in China. Mobile applications (apps) have the potential to provide easily access...

    Background: Women with breast cancer undergoing chemotherapy experience difficulty in accessing to adequate cancer care in China. Mobile applications (apps) have the potential to provide easily accessible support for these women. However, there remains a paucity of Randomized Controlled Trials (RCTs) to evaluate the effectiveness of the app-based program targeting specifically at women with breast cancer undergoing chemotherapy. Moreover, women’s perceptions and experiences related to using and interacting within the app-based program have rarely been reported. Therefore, an app-based Breast Cancer e-Support (BCS) program was developed and evaluated using a randomized controlled trial (RCT). The BCS program was based on the incorporation of Bandura’s self-efficacy and social exchange theory. The BCS program lasted for 12 weeks covering four cycles of chemotherapy and had four components: 1) a Learning forum; 2) a Discussion forum; 3) an Ask-the-Expert forum; and 4) a Personal Stories forum. Objective: As a part of the RCT, this study aimed to explore the participants’ perception of BCS program, the strengths and weaknesses of the BCS program, as well as their suggestions on improvement of the intervention. Methods: A descriptive qualitative study was employed. Thirteen women with breast cancer from two university affiliated hospitals in P. R. China, who were randomly allocated to the BCS program in the RCT, were interviewed from November 2016 to February 2017. Purposive sampling were used on the basis of women’s scores of self-efficacy after the completion of the intervention. Inductive content analysis was used to analyze the transcript, allowing the categories and themes to flow from the data. Results: The qualitative interviews revealed that the participants perceived the BCS program to be helpful in enhancing knowledge, improving confidence level, and promoting emotional well-being. Women also identified access to tailored advice from experts and convenience as the benefits of the BCS program. Physical/psychological health status, stigma related with breast cancer, and app instability were mentioned as the challenges to BCS engagement. Suggestions for BCS improvement included adding message reminders to prompt instant communication and search engine to locate information quickly, supplementing more interesting and practical knowledge, updating the information more often, and quickening the responses to women’s questions. The participants recommended the BCS program to be incorporated as routine care to support women during chemotherapy. Conclusions: This study demonstrates the potential of the BCS program to support women during chemotherapy. Future app-based interventions should apply family-centred approach and provide more support on stigma associated with the disease to encourage the app engagement. Suggestions of improvement regarding the design, content, and operation of the app-based intervention should be addressed in future studies. It is promising to incorporate the BCS program into routine care to generalize the benefits. Clinical Trial: ACTRN: ACTRN12616000639426, Registered 17 May, 2016. http://www.ANZCTR.org.au/ACTRN12616000639426.aspx. Archived at: http://www.webcitation.org/6v1n9hGZq

  • What Predicts Patients’ Adoption of Mobile Health Services in China?

    From: JMIR mHealth and uHealth

    Date Submitted: Oct 31, 2017

    Open Peer Review Period: Nov 2, 2017 - Dec 28, 2017

    Background: With the increasing concern of Healthy China and the development of information technology, mobile health enables patients access health information and interacting with doctors anytime an...

    Background: With the increasing concern of Healthy China and the development of information technology, mobile health enables patients access health information and interacting with doctors anytime and anywhere. Since the success of mobile health would depend on the adoption of patients, examining patients’ willingness to use it is considered critical. Objective: This study aims to explore the determinants of mobile health services adoption among Chinese patients by an extended TAM with trust and perceived risk. Methods: We conducted a questionnaire-based survey in three large Chinese hospitals, and analyzed the data with structural equation model. Results: The results reveal that the proposed model fits well. Specifically, trust, perceived usefulness and perceived ease of use positively correlate with mobile health services adoption. While, privacy risk and performance risk negatively correlate with the patients’ trust and adoption intention toward mobile health. In addition, age and chronic condition of patients could predict their trust level and adoption intention towards mobile health respectively. Conclusions: We conclude that TAM works for the context of mobile health adoption in general, though the significance has declined. Supplementary to technical factors, trust and perceived risk are critical in explaining mobile health services adoption among Chinese patients.

  • The Usability of Electronic Medical Record Systems Implemented in Sub-Saharan Africa: A Systematic Review of the Evidence

    From: Journal of Medical Internet Research

    Date Submitted: Oct 31, 2017

    Open Peer Review Period: Oct 31, 2017 - Dec 26, 2017

    Background: Electronic Medical Record systems hold the promise of accurate, real time access to patient healthcare data. This review evaluated the usability of EMR systems implemented in sub-Saharan A...

    Background: Electronic Medical Record systems hold the promise of accurate, real time access to patient healthcare data. This review evaluated the usability of EMR systems implemented in sub-Saharan Africa (SSA) based on a usability evaluation criteria developed by the Healthcare Information and Management Systems Society (HIMSS). Objective: To evaluate electronic medical record system implementations in sub-Saharan Africa against a well defined evaluation methodology and assess their usability based on a defined set of metrics. To identify the extent to which usability has been an enabling or hindering factor in the implementation of electronic medical record systems in sub-Saharan Africa. To identify approaches for incorporating usability in new EMR system implementations to facilitate successful system adoption and use. Methods: 5 key metrics for evaluating EMR system usability were developed based on the methodology proposed by HIMSS. These include efficiency, effectiveness, ease of learning, cognitive load and user satisfaction. A five point rating system was developed for the review. EMR systems in 20 reviewed publications were scored based on this rating system. It awarded 5 points per metric to any EMR system that was identified as excellent, 4 points for good, 3 points for fair, 2 points for poor and 1 point for bad. Additionally the effectiveness of each system carried a maximum weighted score of 30, efficiency 25, ease of learning 20, user satisfaction 15 and cognitive load 10. The percentage scores for each metric were then computed from these weighted scores from which the final overall usability score was derived. Results: In contributing to the usability of implemented EMR systems, ease of learning obtained the highest percentage score of 67% of the publications reviewed followed closely by user satisfaction which obtained a percentage score of 66%. Effectiveness and efficiency obtained similar percentage scores of 65%. Cognitive load obtained the lowest percentage score of 59%. The overall usability score for all systems was calculated to be 64%. Conclusions: The usability of electronic medical record systems implemented in sub-Saharan Africa has been only fair with ease of learning and user satisfaction being the biggest positive contributors to this rating. Effectiveness and efficiency have been third joint contributors in positively influencing the usability of EMR implemented systems. Cognitive load has impeded EMR system usability in in sub-Saharan Africa and hasn’t been given adequate attention by EMR system designers.

  • The patient perspective on the impact of Tenosynovial Giant Cell Tumors on daily living Crowdsourcing study on physical function and quality of life in 337 patients from 30 countries

    From: Journal of Medical Internet Research

    Date Submitted: Nov 1, 2017

    Open Peer Review Period: Nov 2, 2017 - Dec 28, 2017

    Background: Tenosynovial Giant Cell Tumor(TGCT) is a rare, benign lesion affecting the synovial lining of joints, bursae and tendon sheaths. It is generally characterized as a locally aggressive and o...

    Background: Tenosynovial Giant Cell Tumor(TGCT) is a rare, benign lesion affecting the synovial lining of joints, bursae and tendon sheaths. It is generally characterized as a locally aggressive and often recurring tumor. A distinction is made between localized- and diffuse-type. The impact of TGCT on daily living is currently ill described. Objective: This crowdsourcing study evaluates impact of TGCT on physical function, daily activities, societal participation(work, sports and hobbies) and overall quality of life from a patient perspective. Secondary aim is to define risk factors for deteriorated outcome in TGCT. Methods: Crowdsourcing was used to obtain big data. In a timeframe of six months, TGCT patients were invited to complete an online questionnaire by advertising on the largest known TGCT Facebook-community, ‘PVNS is Pants!!’. The questionnaire, mainly multiple-choice, comprised self-constructed questions on patient- and tumor characteristics, treatments, medical history, TGCT-symptoms, employment and sports, as well as the Visual Analogue Scale(VAS) worst pain and stiffness, the PROMIS-physical functioning(PF) questionnaire, the Short-Form(SF)-12 and the EuroQoL(EQ-5D-5L). To confirm disease presence and TGCT-type, patients were requested to share histological- or radiological-proof. Unpaired t-tests and chi-squared tests were used to compare groups with and without proof of TGCT and define determinants for daily living. Results: 337 Questionnaires(32% with disease confirmation), originating from 30 countries, were completed. Median age at diagnosis was 33(IQR25-42)years, majority was female(80%), diffuse-TGCT(70%) and affected lower extremities: knee(71%), hip(10%). In 299 lower extremity TGCT-patients, recurrence-rate was 36% and 70% in localized- and diffuse-type, respectively. For both types, pain and swelling decreased after treatment, but stiffness worsened and range of motion decreased. Due to TGCT, 13% of localized- and 11% of diffuse-type was unable to (fully)perform their employment and 58% of localized- and 64% of diffuse-type was unable to practice sport-activities. Compared with general population, all patients showed lower PROMIS-PF T-score, SF-12 PCS- and MCS-scores and EQ5D-5L utility-score. The decrease in PROMIS-PF, SF-12 PCS and EQ-5D-5L score was considered clinically relevant, according to estimated Minimal Important Difference(MID). In comparing localized- and diffuse-TGCT, diffuse-type scored almost 0.5 standard-deviation lower for PROMIS-PF(P<.001) and 5% lower for EQ-5D-5L(P.03). In localized-TGCT, recurrent disease and ≥2surgeries negatively influenced scores of VAS-pain/stiffness, SF-12 PCS-score and EQ-5D-5L(P<0.05). In diffuse-type, recurrence resulted in lower score for VAS-pain/stiffness, PROMIS-PF, SF-12 MCS-score and EQ-5D-5L(P<0.05). In both types, patients with treatment ≤1year ago had significantly lower SF-12 PCS-score. Conclusions: TGCT has huge impact on daily living in a relatively young and working population. Patients with diffuse-type, recurrent disease and ≥2surgeries represent lowest functional and quality-of-life outcomes. Physicians and other relevant health care providers(e.g. physiotherapists) should be aware that TGCT patients frequently continue to experience declined health-related quality of life and physical function and often remain limited in daily activities, sports and employment, even after treatment(s).

  • Designing an Intensive Care Unit Visualization Dashboard: An Integrative Literature Review

    From: Journal of Medical Internet Research

    Date Submitted: Nov 1, 2017

    Open Peer Review Period: Nov 1, 2017 - Dec 27, 2017

    Background: Intensive Care Units (ICUs) in the United States admit more than 5.7 million people each year. The ICU level of care helps people with life-threatening illness or injuries and involves cl...

    Background: Intensive Care Units (ICUs) in the United States admit more than 5.7 million people each year. The ICU level of care helps people with life-threatening illness or injuries and involves close, constant attention by a team of specially-trained health care providers. Delay between condition onset and implementation of necessary interventions can dramatically impact the prognosis of patients with life-threatening diagnoses. Evidence supports a connection between information overload and medical errors. A tool that improves display and retrieval of key clinical information has great potential to benefit patient outcomes. The purpose of this review is to synthesize research on the use of visualization dashboards in health care. Objective: The purpose of conducting this literature review is to synthesize previous research on the use of visualization dashboards. A review of the existing literature on this subject can be used to identify gaps in prior research and to inform further research efforts on this topic. Ultimately, this evidence can be used to guide the development, testing, and implementation of a new solution to optimize the visualization of clinical information, reduce clinician cognitive overload, and improve patient outcomes. Methods: Articles were included if they addressed the development, testing, implementation, or use of a visualization dashboard solution in a health care setting. An initial search was conducted of literature on dashboards only in the intensive care unit setting, but there were not many articles found that met the inclusion criteria. A secondary follow-up search was conducted to broaden the results to any health care setting. The initial and follow-up searches returned a total of 17 articles that were analyzed for this literature review. Results: Visualization dashboard solutions decrease time spent on data gathering, difficulty of data gathering process, cognitive load, time to task completion, errors, and improve situation awareness, compliance with evidence-based safety guidelines, usability, and navigation. Conclusions: Researchers can build on the findings, strengths, and limitations of the work identified in this literature review to bolster development, testing, and implementation of novel visualization dashboard solutions. Due to the relatively few studies conducted in this area, there is plenty of room for researchers to test their solutions and add significantly to the field of knowledge on this subject.

  • Does mode of delivery matter for smoking cessation interventions? A meta-analysis of mHealth versus face-to-face interventions for smoking cessation among people living with HIV

    From: JMIR mHealth and uHealth

    Date Submitted: Nov 16, 2017

    Open Peer Review Period: Nov 16, 2017 - Jan 11, 2018

    Background: The prevalence of smoking among people living with HIV (PLHIV) is higher than in the general population and a significant risk factor for non-communicable diseases in this group. Mobile ph...

    Background: The prevalence of smoking among people living with HIV (PLHIV) is higher than in the general population and a significant risk factor for non-communicable diseases in this group. Mobile phone interventions to promote healthier behaviours (mHealth) have the potential to reach a large number of people at a low cost. It has been hypothesized that mHealth interventions may not be as effective as face-to-face strategies in achieving smoking cessation, but there is no systematic evidence to support this, especially among PLHIV. Objective: To compare two modes of intervention delivery (mobile technology versus face-to-face) for smoking cessation among PLHIV. Methods: Literature on randomised controlled trials (RCTs) investigating the effects of mHealth or face-to-face intervention strategies on short-term (4 weeks to <6 months) and long-term (≥6 months) smoking abstinence among PLHIV were sought. We systematically reviewed the relevant RCTs and conducted pairwise meta-analyses to estimate the relative treatment effects of mHealth and face-to-face interventions using standard care as comparison. Given the absence of head-to-head trials comparing mHealth with face-to-face interventions, we performed an adjusted indirect comparison meta-analyses to compare these interventions. Results: Ten studies involving 1,772 PLHIV met the inclusion criteria. Average age of the study population was 45 years and women comprised about 37%. At short term, mHealth delivered interventions were significantly more efficacious in increasing smoking cessation than no intervention control (Risk Ratios [RR] 2.81, 95% CI 1.44 to 5.49) and face-to-face interventions (RR 2.31, 95% CI 1.13 to 4.72). At short-term, face-to-face interventions were no more effective than no intervention in increasing smoking cessation (RR 1.22, 95% CI 0.94 to 1.58). In terms of achieving long term results among PLHIV, there was no significant difference in the rates of smoking cessation between mHealth delivered, face-to-face interventions and those who received no intervention. Conclusions: Compared with face-to-face interventions, mHealth delivered interventions can better increase smoking cessation rate in the short term. However, it remains unclear how long the effects of such interventions last. Future research should focus on strategies for sustaining the treatment effect in the long term.

  • Mapping of crowdsourcing in health: a systematic review

    From: Journal of Medical Internet Research

    Date Submitted: Nov 2, 2017

    Open Peer Review Period: Nov 3, 2017 - Dec 29, 2017

    Background: Crowdsourcing involves obtaining ideas, needed services, or content by soliciting online contributions from a crowd. The four types of crowdsourced tasks (problem solving, data processing,...

    Background: Crowdsourcing involves obtaining ideas, needed services, or content by soliciting online contributions from a crowd. The four types of crowdsourced tasks (problem solving, data processing, surveillance/monitoring and surveying) can be applied in the three categories of health (promotion, research and care). Objective: We aimed to map the different applications of crowdsourcing in health in order to assess the fields of health that are using crowdsourcing and the crowdsourced tasks used. We also describe the logistics of crowdsourcing and the characteristics of crowd workers. Methods: MEDLINE, EMBASE and ClinicalTrials.gov were searched for available reports from inception to March 30th, 2016 with no restriction on language or publication status. Results: We identified 202 relevant studies that used crowdsourcing, including 9 randomized controlled trials, only one with results posted at ClinicalTrials.gov. Crowdsourcing was used in health promotion (45%), research (36%) and care (19%). The four most frequent areas of application were public health (33%), psychiatry (16%), surgery (11%) and oncology (7%). Half of the reports (49%, n=99) referred to data processing, 35% (n=70) surveying, 10% (n=21) surveillance/monitoring and 6% (n=12) problem solving. Labor-market platforms (e.g., Amazon Mechanical Turk) were used in most studies (94%). The crowd workers’ characteristics were poorly reported and crowdsourcing logistics were missing from two thirds of reports. When reported, the median size of the crowd was 424 [Q1-Q3: 167-802]; crowd workers’ median age was 34 years [32-36] and 55% were men. Crowd workers were mainly recruited nationally, particularly in the United States. For many studies (59%), previous experience in crowdsourcing was required, and passing a qualification test or training was seldom needed (about 12% of studies). For half of the studies, monetary incentives were mentioned, mainly less than 1 USD. The time needed to perform the task was mostly less than 10 min (59% of studies). Data-quality validation was used in 54 studies (27%), mainly by attention-check questions or by replicating the task with several crowd workers. Conclusions: Our results illustrate the increasing use of crowdsourcing for the three areas of health. However, the description of crowdsourcing logistics and crowd workers’ characteristics is frequently missing in study reports. Clinical Trial: We uploaded a pre-specified protocol to a publicly accessible institutional Website (http://www.clinicalepidemio.fr/protocols/).

  • Outcomes of a Digitally Delivered Low-Carbohydrate Type 2 Diabetes Self-Management Program: 1-Year Results of a Single-Arm Longitudinal Study

    From: Journal of Medical Internet Research

    Date Submitted: Dec 6, 2017

    Open Peer Review Period: Dec 6, 2017 - Dec 16, 2017

    Background: Type 2 diabetes is prevalent, burdensome, and costly. The standard treatment includes a low-calorie, low-fat diet. However, some theory and research suggests that a carbohydrate-restricted...

    Background: Type 2 diabetes is prevalent, burdensome, and costly. The standard treatment includes a low-calorie, low-fat diet. However, some theory and research suggests that a carbohydrate-restricted diet would be a more effective approach. Objective: Our objective was to evaluate the 1-year efficacy of the Low-Carb Program (LCP), a digitally delivered, nutrition-focused, structured, 10 weekly session lifestyle intervention for glycemic control, hypoglycemic medication use, and weight loss for adults with type 2 diabetes. The LCP provides behavior change support and reinforcement about carbohydrate restriction using solution-focused education, behavioral self-monitoring, and peer support. Methods: We randomly selected adults with type 2 diabetes (N=1000; mean age 56.1, SD 15.7, years; 59% (593/1000) women; mean HbA1c 7.8, SD 2.1, %; mean body weight 89.6, SD 23.1, kg; taking an average of 1.2 diabetes medications) who joined the Low-Carb Program (LCP) to be followed for 1 year. Results: The percentage of individuals with an HbA1c level of <6.5% increased from 25.7% (257/1000) to 50.3% (503/1000). Almost half (46.4%, 464/1000) of all participants lost at least 5% of their body weight. Of participants who were taking at least one hypoglycemic medication at baseline, 40.4% (289/714) reduced one or more of these medications. Overall, glycemic control and weight loss improved, especially for participants who completed all 10 modules of the program. For example, participants with elevated baseline HbA1c (≥7.5%) who engaged with all 10 weekly modules reduced their HbA1c from 9.2% to 7.1% (P<.001) and lost an average of 6.9% of their body weight (P<.001). Conclusions: Especially for participants who fully engage, an online program that teaches a carbohydrate-reduced diet to adults with type 2 diabetes can be effective for glycemic control, weight loss, and reducing hypoglycemic medications.

  • Patient developed NPPE in recovery room

    From: Journal of Medical Internet Research

    Date Submitted: Nov 15, 2017

    Open Peer Review Period: Nov 15, 2017 - Jan 10, 2018

    Postoperative pulmonary edema is a rare life threatening complication associated with general anesthesia. Laryngospasm leads to forced inspiration generating large amount of negative intrathoracic pre...

    Postoperative pulmonary edema is a rare life threatening complication associated with general anesthesia. Laryngospasm leads to forced inspiration generating large amount of negative intrathoracic pressure leading to negative pressure pulmonary edema. It usually develops immediately after extubation . This is a rare case report where patient developed NPPE in recovery room. In this paper we report a young fit adult who developed NPPE after an uneventful appendectomy in the post-operative period. The aim of this paper is to highlight the dramatic presentation of this rare condition in post-operative period and to remind that it can be lethal if immediate remedial steps are not taken. The anesthetist and paramedical staff in recovery room should be well aware of this condition.

  • Recommendations for assessment of the reliability and validity of data provided by wearable sensors

    From: JMIR mHealth and uHealth

    Date Submitted: Nov 6, 2017

    Open Peer Review Period: Nov 7, 2017 - Jan 2, 2018

    Although it is becoming increasingly popular to monitor parameters related to training, recovery and health with wearable sensor technology (wearables), scientific evaluation of the reliability and va...

    Although it is becoming increasingly popular to monitor parameters related to training, recovery and health with wearable sensor technology (wearables), scientific evaluation of the reliability and validity of such data is limited and, where available, has involved a wide variety of approaches. To improve the trustworthiness of data collected by wearables and facilitate comparison, we outline here recommendations for standardized evaluation. We discuss the wearable devices themselves, as well as experimental and statistical considerations. Adherence to these recommendations should be beneficial not only for the individual, but also for regulatory organizations and insurance companies.

  • Reducing workplace sitting: feasibility and impact evaluation of the beta (test) version of the BeUpstandingTM Champion Toolkit

    From: Journal of Medical Internet Research

    Date Submitted: Nov 7, 2017

    Open Peer Review Period: Nov 8, 2017 - Jan 3, 2018

    Background: The online, evidence-informed BeUpstandingTM Champion Toolkit was developed to provide employers (via a “train the champion approach”) with the resources and support to address reducin...

    Background: The online, evidence-informed BeUpstandingTM Champion Toolkit was developed to provide employers (via a “train the champion approach”) with the resources and support to address reducing prolonged sitting within their own desk-based workplace. As part of a five-phase research-to-dissemination process this study reports on the evaluation of the beta (test) version of this toolkit (Phase 2). Objective: To evaluate: 1) implementation of the toolkit by workplace champions; and, 2) impact of the toolkit on: sitting (primary outcome), standing, and moving; use of activity-promoting strategies; knowledge and attitudes; and, indicators of health and work performance. Methods: An implementation study using a pre-post design was conducted in seven desk-based workplaces in Australia (September 2015 to May 2016), with work teams (one per workplace) purposively recruited to ensure representation across a range of sectors (white-/blue-collar), organisational sizes (small/medium/large), and locations (metropolitan/regional). All staff within participating teams were invited to participate in the relevant toolkit activities. Implementation outcomes (time commitment required by champions and toolkit activities completed) were collected from each champion via telephone interviews. Changes in impact outcomes, measured via an online questionnaire completed by employees at baseline and three months post implementation, were assessed using mixed models, correcting for clustering. Results: Champions reported a 30-60 min/week time commitment to the toolkit activities. All teams formed a wellbeing committee and sent the staff surveys at both time points, while most champions held a staff consultation workshop (6/7), identified team-level strategies within that workshop (5/7); used the communication resources provided within the toolkit (emails, posters; 6/7); and, completed the action plan (5/7). In total, 315 employees (52%) participated in at least one survey and 97 completed both surveys. At follow-up, there was a significant (P<0.05) reduction in self-reported workplace sitting time compared to baseline (-6.3%, 95%CI -10.1% to -2.5%; n=85) equating to ≈30 min/workday. Significant benefits were also observed for use of activity-promoting strategies, with small, non-significant changes observed for knowledge and attitudes, and indicators of health and work performance. Conclusions: The beta version of the BeUpstanding Champion Toolkit was feasible to implement and effective at reducing self-reported workplace sitting across a broad range of desk-based workplaces. The next phase (Phase 3) will build on these learnings to optimise the toolkit for wider-scale implementation and longer-term evaluation.

  • Quantitative Content Analysis of Mobile Applications for Caregivers of Older Adults

    From: Journal of Medical Internet Research

    Date Submitted: Nov 6, 2017

    Open Peer Review Period: Nov 7, 2017 - Jan 2, 2018

    Background: Informal caregivers of older adults provide critical support for their loved ones but are subject to negative health outcomes because of burden and stress. Interventions to provide informa...

    Background: Informal caregivers of older adults provide critical support for their loved ones but are subject to negative health outcomes because of burden and stress. Interventions to provide information and resources as well as social and emotional support reduce burden. Mobile applications featuring access to information, assistance with scheduling, and other features can automate support functions inexpensively and conveniently and reach a greater proportion of caregivers than otherwise possible. Objective: The aim was to identify mobile applications geared towards caregivers of older adults, catalog features, and suggest best practices for adoption based on empirical findings of beneficial interventions in the caregiving literature. Methods: Search for applications focused on those for caregivers of older adults in Google Play and iTunes, compiling their features, and identifying features reflecting categories of support identified in successful intervention studies to negative caregiver outcomes. Intervention research indicates that provision of information and resources, assistance in practical problem solving, coordinating care among multiple caregivers, and emotional support reduce caregiver burden. Results: Despite approximately over 200,000 mobile health­-related applications, availability of mobile applications for caregivers is relatively sparse with 44 apps as of October 2017. Applications generally addressed specific categories of support, including information and resources, family communication, and/or caregiver­-recipient interactions. Few applications were comprehensive, with only 18% (8 apps) with features that addressed three or more categories. Few applications provided specific stress reduction exercises for caregivers, important for reducing burden. Conclusions: Mobile applications have the potential to provide resources, just­-in­-time information for problem solving, and stress reduction strategies for caregivers. Many applications offer functions that have been shown to reduce burden and improve health outcomes in caregivers, but few provide emotional support. Using an evidence­-based practice approach, mobile applications for caregivers can provide multiple beneficial support functions. Applications can serve a much larger proportion of this highly underserved population in their mobile form than more traditional means, improving their health and quality of life.

  • Do Physicians Ratings Matter?

    From: Interactive Journal of Medical Research

    Date Submitted: Nov 7, 2017

    Open Peer Review Period: Nov 8, 2017 - Jan 3, 2018

    Background: : Information from ratings sites are increasingly informing decisions related to health care and the selection of physicians. Objective: The current study seeks to determine the validity o...

    Background: : Information from ratings sites are increasingly informing decisions related to health care and the selection of physicians. Objective: The current study seeks to determine the validity of physician ratings through comparison with an objective “ground truth”. Methods: We obtained 223,715 reviews of 41,104 physicians from the 10 largest cities in the United States, including 1,142 physicians who were listed as “America’s Top Doctors” in the Castle Connolly Medical rankings, the “ground truth” used for this study. To mitigate issues related to “fake” reviews, physicians with fewer than three reviews were excluded from analysis. Results: This large scale study found limited differences in patient ratings of physicians by ground truth. However, patient ratings for several “primary care” and “high patient contact” specialties (i.e., Family Medicine, Allergists, Internal Medicine and Pediatrics) were higher for those physicians listed in Castle Connolly Medical versus those who were not. Conclusions: The presence of online ratings sites will likely continue to grow and expand across all segments of the economy. The results of this large scale study indicate that while patient ratings are consistent with physician peer review ratings for “high patient contact” practitioners like Allergists and Pediatricians, patient reviews were not consistent with medical peer review for specializations characterized by less patient contact like Neurology or General Surgery, indicating that patients may not be sufficiently knowledgeable to provide informed physician ratings for these types of practitioners.

  • Better ask than Tell: Addressees’ response to mHealth interrogative reminders and its association with subsequent uptake of colorectal cancer screening

    From: Journal of Medical Internet Research

    Date Submitted: Nov 7, 2017

    Open Peer Review Period: Nov 7, 2017 - Jan 2, 2018

    Background: Altering the approach to medical recommendations delivery could enhance patient adherence. Text-message reminders, in interrogative form are effective and inexpensive in enhancing colorect...

    Background: Altering the approach to medical recommendations delivery could enhance patient adherence. Text-message reminders, in interrogative form are effective and inexpensive in enhancing colorectal cancer (CRC) screening. Objective: To examine responses to text-message reminders and associate responses with senders' characteristics and subsequent screening. Methods: Prospective cohort intervention. Text-message reminders to undergo colorectal cancer (CRC) screening, randomized into interrogative and declarative phrasing, sent to non-adherent women and men (40,000), aged 50 to 74, at CRC average-risk. Recipients’ responses were analyzed by message type and recipients’ characteristics; for content, the latter predicting subsequent CRC screening per program database. Results: Interrogative text-message reminders elicited 1475 (8.4%) responses; declarative ones elicited 146 responses. Text-message respondents screened significantly more than non-respondents six months following the reminders (25.8% vs. 8.8%, χ2=420.7, P<0.0001); a year later (21.7% vs.12.4%, χ2=98.6, P<0.0001); two years later (14.2% vs.10.5%, χ2=19.2, P<0.0001). Text-message responses were grouped: position towards CRC screening and intention to screen. Positions towards CRC screening were positive (81.7%); 67.1% intended to undergo Fecal Occult Blood Test. In a multivariable logistic regression among text-message respondents, screening at six months was significantly predicted by older age, past sporadic screening and intentions; gender was non-predictive. Conclusions: Interrogative text-message reminders reached previously uninvolved sectors in the CRC target population: men, sporadic-screenees, and the 'never-tested' before. This novel application resulted in a population-level, incremental enhanced screening. Asking patients about their future health-behavior enhanced cancer screening, and is relevant for enhancing other health-behaviors, in preventive medicine and in clinical settings.

  • Serious Games to Assess Mild Cognitive Impairment: ‘The game is the assessment’

    From: JMIR Serious Games

    Date Submitted: Nov 9, 2017

    Open Peer Review Period: Nov 11, 2017 - Jan 6, 2018

    Background: Background: Early recognition of mild cognitive impairment (MCI) and subtle changes to cognitive abilities that precede an MCI diagnosis has the potential to improve the efficacy of thera...

    Background: Background: Early recognition of mild cognitive impairment (MCI) and subtle changes to cognitive abilities that precede an MCI diagnosis has the potential to improve the efficacy of therapeutic treatment programs. Objective: Objective: The work addresses mobile games’ potential as empirical assessment tools for cognitive processes within the domains of attention, recognition, recall, and memory applied to game strategy. Methods: Methods: Two games have been developed with this objective. WarCAT is based on a familiar card game, War, and “Lock Picking” is a search for an optimal score, akin to finding the combination that opens a lock. Results: Both games provide players with immediate feedback but engage different algorithms and heuristics to solve the respective problems at hand. Conclusions: Conclusions: By collecting player data on large scales to allow for baseline establishment of cognitive abilities across demographic (age) profiles, longitudinal performance of individuals and of groups can be established, and from there, the potential exists to employ machine learning methods to detect subtle changes in an individual’s cognitive processes over time. Clinical Trial: n/a

  • An agent-based model to investigate the impact of HIV self-testing programs for men who have sex with men in Atlanta and Seattle

    From: JMIR Research Protocols

    Date Submitted: Nov 13, 2017

    Open Peer Review Period: Nov 14, 2017 - Jan 9, 2018

    Background: Men who have sex with men (MSM) remain the most heavily impacted group in the US HIV epidemic. Prevention science is increasingly organized around HIV testing as a launch point into an HIV...

    Background: Men who have sex with men (MSM) remain the most heavily impacted group in the US HIV epidemic. Prevention science is increasingly organized around HIV testing as a launch point into an HIV prevention continuum for MSM who are not living with HIV and into an HIV care continuum for MSM who are living with HIV. Increasing HIV testing frequency among MSM might reduce future HIV infections by linking men who are living with HIV to ARV care, resulting in viral suppression. Distributing HIV self-test kits is a strategy to increase HIV testing. Our previous modeling work suggests that the impact of HIV self-tests (HIVST) on transmission dynamics will depend not only on the frequency of the tests and the tester’s behavior, but also on epidemiologic and testing characteristics of the population as well. Objective: We developed an agent-based model in order to inform public health strategies to promote safe and effective HIVST to reduce HIV incidence among MSM in Atlanta and Seattle, cities representing very different epidemiologic settings. Methods: We adapted and extended an agent-based stochastic simulation model of HIV transmission dynamics that was developed and parameterized to examine racial disparities in HIV prevalence among MSM in Atlanta, Georgia. The extension involved several activities: adding a new set of model parameters for Seattle MSM; adding new parameters for tester types (regular, risk-based, opportunistic, or never testers); adding parameters for simplified pre-exposure prophylaxis (PrEP) uptake following HIV-negative tests; and developing a conceptual framework for the ways in which provision of HIVST might change testing behaviors. City-specific parameters were derived from previous cohort and cross-sectional studies of MSM in Atlanta and Seattle. The simulated populations each included 10,000 MSM, and we targeted an equilibrium HIV prevalence of 28% in Atlanta and 11% in Seattle. Results: Sufficient data were available from previous studies to develop estimates for the model parameters representing nuanced HIV testing patterns and HIVST distribution. We calibrated the models to simulate epidemics representing Atlanta and Seattle, including matching the expected stable HIV prevalence of 28% and 11% in Atlanta and Seattle, respectively. The revised model now allows for the estimation of changes in 10-year HIV incidence based on counterfactual scenarios of HIVST distribution strategies and their impacts on testing behaviors. Conclusions: We demonstrated that an extension of an existing agent-based HIV transmission model was sufficient to simulate HIV epidemics among MSM in Atlanta and Seattle, to accommodate a more nuanced depiction of HIV testing behaviors than previous models, and to serve as a platform to evaluate how HIVST might impact testing and HIV transmission patterns among MSM in Atlanta and Seattle. Future work will utilize the model to test how different HIVST distribution strategies might affect HIV incidence in MSM.

  • A Study of Calorie Estimation in Pictures of Food

    From: Journal of Medical Internet Research

    Date Submitted: Nov 8, 2017

    Open Peer Review Period: Nov 9, 2017 - Jan 4, 2018

    Background: Software to accurately estimate food calories from still images could help users and health professionals more efficiently identify dietary patterns and food choices associated with health...

    Background: Software to accurately estimate food calories from still images could help users and health professionals more efficiently identify dietary patterns and food choices associated with health and health risks. However, calorie estimation from images is difficult, and no publicly available software can do so accurately while minimizing the burden associated with data collection and analysis. Objective: The aim of this study is to determine the accuracy of crowdsourced annotations of calorie content in food images, and to identify and quantify sources of bias and noise as a function of respondent characteristics and food qualities (e.g., energy density). Methods: We invited adult social media users to provide calorie estimates for 20 food images (for which ground truth calorie data were known) using a custom-built webpage that administers an online quiz. The images were selected to provide a range of food types and energy density. Participants optionally provided age range, gender, and their height and weight. Additionally, five nutrition experts provided annotations for the same data to form a basis of comparison. We examined estimate accuracy on the basis of expertise, demographic data, and food qualities using linear mixed effects models with participant and image index as random variables. We also analyzed the advantage of aggregating nonexpert estimates. Results: 2028 respondents agreed to participate in the study (males: 770 [38%], mean body mass index: 27.5). Average accuracy was 5 out of 20 correct guesses, where “correct” was defined as a number within 20% of the ground truth. Even a small crowd of 10 individuals achieved an accuracy of 7, exceeding the average individual's and expert annotator’s accuracy of 5. Women were more accurate than men (P<.001), and younger people were more accurate than older people (P<.001). The calorie content of energy-dense foods was overestimated (P=.024). Participants did not perform better when images contained reference objects (such as credit cards) for scale. Conclusions: Our findings provide new information about the way we process food information, which can inform the design of future calorie-estimation applications.

  • Development of a Comprehensive Mobile Care System for Patients with Advanced Gastrointestinal Cancer: The Life Manager App

    From: JMIR mHealth and uHealth

    Date Submitted: Nov 8, 2017

    Open Peer Review Period: Nov 9, 2017 - Jan 4, 2018

    Background: Chemotherapy is the most common treatment plan for individuals with advanced cancer. Although this treatment improves the survival of patients, their quality of life is still poor because...

    Background: Chemotherapy is the most common treatment plan for individuals with advanced cancer. Although this treatment improves the survival of patients, their quality of life is still poor because of its adverse effects. Mobile health applications (apps) have emerged as an alternative in managing this condition. However, only few apps have self-monitoring features, and they are not standardized and validated by health experts. Objective: This study aimed to develop a comprehensive mobile care system with self-monitoring features that can be useful in providing information and facilitating communication in patients with advanced cancer. Methods: In this context, the establishment of a comprehensive mobile health management system was divided into three steps. First, the service scope was set up, and the measurement tools were standardized. Second, the service flow of the mobile care system was organized. Third, the mobile app (Life Manager) was developed. Results: The general services can be used for the management of chemotherapy side effect, nutrition, and rehabilitation. To effectively identify patient symptoms using the mobile app, we used the modified PROCTCAE (Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events) questionnaire to determine the patients’ condition. To measure the clinical effect of the mobile app, the following survey tools were used: PGSGA (Scored Patient-Generated Subjective Global Assessment), distress, EORTC-QLQ (European Organisation for Research and Treatment of Cancer - Quality-of-Life questionnaire), IPAQ-SF (International Physical Activity Questionnaire-short form), LARS score (Low anterior resection syndrome score), and measurement of satisfaction. The service protocol is based on the medical information that is communicated by a patient to a medical provider in the hospital. A patient can enter a question or information anytime and anywhere using the app service, and they can obtain real-time and accurate health information from medical personnel based on clinical evidence. Healthcare providers meet the participants in person to explain the online research service process and the use of the daily-life app with a wearable device in person. Online programs are established based on the patient’s initial information, such as results of physical examination and laboratory tests and health domain. The main themes of the application are: To-do-list, Health information, and In-app-chat service. When a patient logs into the app, the “To-do-list” theme first appears on the screen. The patient can check the “Daily tasks” on this screen. The common contents of the health information consist of drug explanation, general side effects, and countermeasures against the side effects of chemotherapy. Using the “In-app-chat service” the patient can communicate with experts anytime and anywhere. The wearable device that is linked to the app via Bluetooth can measure performed activities. Conclusions: In terms of service flow, a clinical evidence-based care system was established, which can provide high-quality care and run both offline and online. In terms of life-manager app development, a mobile health app with multidisciplinary effects for patients with advanced gastrointestinal cancer patients was created.

  • The Relationship between Internet Health Information and Patient Compliance based on Trust: an Empirical Study

    From: Journal of Medical Internet Research

    Date Submitted: Nov 8, 2017

    Open Peer Review Period: Nov 8, 2017 - Jan 3, 2018

    Background: The Internet has become a major means of acquiring health information due to the increasing demand for health information and the development of the Internet. However, Internet health info...

    Background: The Internet has become a major means of acquiring health information due to the increasing demand for health information and the development of the Internet. However, Internet health information is of mixed quality and may therefore significantly affects health-related behaviour and decisions. The trust of patients in their physicians may potentially change because of health information obtained from the Internet, thereby affecting their compliance to medical diagnoses and treatment. Hence, it is significant to discuss the relationship between Internet health information and patient compliance from the perspective of trust. Objective: This study aimed to discuss the relationship between Internet health information and patient compliance from the dimensions of quality and source through theoretical principle (i.e. cognition- and affect-based trust) and empirical study. Methods: An online survey involving 375 participants from 28 cities in China was conducted to assess the research model, which included two independent variables (i.e. Internet health information quality and source of Internet health information), two mediator variables (i.e. cognition- and affect-based trust) and one dependent variable (i.e. patient compliance). All variables were measured using multiple-item scales from previously validated instruments. The scales’ reliability and validity were analysed, demographic analysis was performed and hypotheses were tested using structural equation modelling (SEM). Results: The questionnaire response was 89.6%, and the reliability and validity was acceptable (Cronbach’s α = .950 > .700, KMO = .907 > .700, P < .001). This study indicated that the quality and source of Internet health information impacted cognition- and affect-based trust, consequently, patient compliance. In addition, Internet health information source also directly affected patient compliance, and the Internet health information quality was more important than the source of information. Furthermore, cognition- and affect-based trust had significant positive impacts on patient compliance, and cognition-based trust had a significant impact on affect-based trust. Unexpectedly, a nonsignificant relationship between source of Internet health information and affect-based trust was found. Conclusions: The Internet health information quality plays a more important role than the source of information in impacting patient trust, consequently, patient compliance. Therefore, patient compliance should be improved by strengthening the management of Internet health information quality and urging physicians to focus on health websites, and acquire health information from these websites to understand the information accessed by patients and enrich their knowledge structure to show their specialization and reliability in their interaction with patients. Cognition- and affect-based trust directly impact patient compliance. Therefore, physicians can communicate with patients through health websites to allow patients to acquire health information from physicians online and establish cognition-based trust in advance. Furthermore, physicians should focus on providing care and respect for patients and foster a safe atmosphere in which patients can express themselves sufficiently.

  • Consensus on quality indicators of postgraduate medical e-learning: a Delphi study

    From: JMIR Medical Education

    Date Submitted: Nov 8, 2017

    Open Peer Review Period: Nov 8, 2017 - Jan 3, 2018

    Background: The progressive use of e-learning in postgraduate medical education calls for proper quality indicators. Currently many evaluation tools exist. However, these are diversely used and their...

    Background: The progressive use of e-learning in postgraduate medical education calls for proper quality indicators. Currently many evaluation tools exist. However, these are diversely used and their empirical foundation is often lacking. Objective: We aimed to identify an empirically founded set of quality indicators to set the bar for “good enough” e-learning. Methods: We performed a Delphi procedure with a group of 13 international education experts and 10 experienced users of e-learning. The questionnaire started with 57 items. These items were the result of a previous literature review and focus group study performed with experts and users. We used a Rate of Agreement (RoA) of less than two thirds resulted in its rejection. Results: In the first round, 37 items of the 57 were accepted as important, there was no consensus on 20, and 15 new items were added by the participants. In the second round, we added the comments of the first round to the items on which there was no consensus, and added the 15 new items. After this round, a total of 72 items were questioned and of these, 37 items were accepted and 35 were rejected due to lack of consensus. Conclusions: This study provides a list of 37 items which can form the basis of an evaluation tool to evaluate postgraduate medical e-learning. This is the first time that quality indicators for postgraduate medical e-learning have been defined and validated. The next step is to create and validate an e-learning evaluation tool from these items.

  • The impact of low back pain clinical trials measured by the Altmetric score: an analysis of 200 articles

    From: Journal of Medical Internet Research

    Date Submitted: Nov 8, 2017

    Open Peer Review Period: Nov 9, 2017 - Jan 4, 2018

    Background: There is interest from authors and publishers in sharing the results of their studies over the internet in order to increase their readership. In this way, articles tend to be discussed an...

    Background: There is interest from authors and publishers in sharing the results of their studies over the internet in order to increase their readership. In this way, articles tend to be discussed and the impact of these articles tends to be increased. In order to measure this type of impact a new score (named Altmetric) was created. Altmetric aims to understand the individual impact of each article through the attention attracted online. Objective: The primary objective of this study was to analyze potential factors related with with the publishing journal and the publishing trial that could be associated with Altmetric scores on a random sample of low back pain randomised controlled trials. The secondary objective of this study was to describe the characteristics of these trials and their Altmetric scores. Methods: We searched for all low back pain randomised controlled trials indexed on the Physiotherapy Evidence Database (www.pedro.org.au) published between 2010 and 2015. A total of 200 articles were randomly selected. We extracted data related to the publishing trial, the publishing journal, methodological quality of the trials (measured by the 0-10 item PEDro scale) and total and individual scores of Altmetric mentioned and Altmetric reader. Multivariate regression models and descriptive statistics were used to present statistical analysis. Results: A total of four variables were associated with Altmetric mentioned score: impact factor (β= 3.4 points), number of years since publication (β= -4.9), number of citations divided by years since publication (β= 5.2 points) and descriptive title (β= -29.4 points). Only one independent variable was associated with Altmetric reader score: number of citations divided by years since publication (β= 10.1 points, 95% CI (7.74 to 12.46)). Descriptive statistics showed that the majority of articles were published in English, with a descriptive title and published in open access journals endorsing the CONSORT statement. Conclusions: Researchers should preferrably select high impact factor journals for submission and use declarative or interrogative titles, as these factors are likely to increase the visibility of their studies in social media.

  • A structured review of health information on firefighter websites

    From: Journal of Medical Internet Research

    Date Submitted: Nov 8, 2017

    Open Peer Review Period: Nov 9, 2017 - Jan 4, 2018

    Background: Since firefighters have high health risks, access to health information specific to their needs is essential. Objective: To search and catalogue the information resources available on Cana...

    Background: Since firefighters have high health risks, access to health information specific to their needs is essential. Objective: To search and catalogue the information resources available on Canadian firefighter websites. The intention was to focus on gaps in online resources available to firefighters to guide electronic resource creation and future research. Methods: A search of health resources on Canadian firefighter (union, employer) websites was conducted on Google (July 2017). Data was extracted and collated to describe the nature of the resources in terms of their health focus and format. Results: From the total (n=313) number of websites reviewed, 41 websites contained health information, totalling 128 resources on firefighter mental (46%), physical (34%), and work health (20%). Resources were most dense on the international/national websites (13 resources/website) and least dense on local websites (1 resource/7 websites). General mental health (34%), post-traumatic stress disorder (24%), and suicide (24%) were the most prevalent topics in mental health resources, while half (49%) of all physical health resources were on cancer. Ontario, Québec, and British Columbia were key contributors, accounting for 81% of resources found on the provincial/local level. No resources from Northern Canada were found. Musculoskeletal health was not mentioned in any resources identified. Conclusions: While pockets of excellent information to support firefighter health are available, there are substantial gaps and a clear lack of coordination of resources, since the focus of health information is highly variable across firefighter websites. Quality evaluation and coordination of resources are needed to advance firefighter health.

  • Effective Facebook Advertising Strategies for Large-Scale Online RCT Recruitment

    From: Journal of Medical Internet Research

    Date Submitted: Nov 8, 2017

    Open Peer Review Period: Nov 9, 2017 - Jan 4, 2018

    Targeted Facebook advertising can be an effective strategy to recruit participants for a large-scale online study. Facebook advertising is useful for reaching people in a wide geographic area, matchin...

    Targeted Facebook advertising can be an effective strategy to recruit participants for a large-scale online study. Facebook advertising is useful for reaching people in a wide geographic area, matching a specific demographic profile. It can also target people who would be unlikely to search for the information and would thus not be accessible via Google AdWords. It is especially useful when it is desirable not to raise awareness of the study in a demographic group that would be ineligible for the study. This paper describes the use of Facebook advertising to recruit and enroll 1,145 women over a 15-month period for a randomized clinical trial to teach support skills to female partners of male smokeless tobacco users. This tutorial shares our study team’s experiences, “lessons learned,” and recommendations to help researchers to design Facebook advertising campaigns. Topics covered include designing the study infrastructure to optimize recruitment and enrollment tracking, creating a Facebook presence via a “fan page,” designing ads that attract potential participants while meeting Facebook’s strict requirements, and planning and managing an advertising campaign that accommodates the rapid rate of diminishing returns for each ad.

  • Understanding Users’ ENDS Vaping Experience from Social Media Using Sentiment Opinion Summarization Techniques

    From: Journal of Medical Internet Research

    Date Submitted: Nov 10, 2017

    Open Peer Review Period: Nov 11, 2017 - Jan 6, 2018

    Background: E-liquid is one of the main components in electronic nicotine delivery systems (ENDS), it is possible that ENDS review comments could serve as an early warning on use patterns, and even fu...

    Background: E-liquid is one of the main components in electronic nicotine delivery systems (ENDS), it is possible that ENDS review comments could serve as an early warning on use patterns, and even function to serve as an indicator of problems or adverse events pertaining to the use of specific e-liquids – much like the types of responses that are tracked by the Food and Drug Administration (FDA) regarding medications. Objective: This paper aims to understand users’ vaping experience using sentiment opinion summarization techniques, which can help characterize how consumers, ENDS vendors, and others think about specific e-liquids and their characteristic (e.g. flavor, throat hit, vapor production, etc.). Methods: We collected e-liquid reviews on JuiceDB from June 26, 2013 to May 16, 2017 by using its public application programming interface (API), which is the world’s largest independent e-liquid and vape juice resource. The dataset contains 25449 reviews for 8039 e-liquid products, 5956 users and 1567 businesses; each review is accompanied by user information, business information, an overall rating and a set of four aspect ratings of an e-liquid, each on a scale of 1-5: flavor accuracy, throat hit, value and cloud production; each user includes user name, user type, description, etc. An Iterative Dichotomiser 3 (ID3) based influential aspect analysis model is proposed to learn the key elements that have impacts on using e-liquid, then, fine-grained sentiment analysis is employed to mine opinions on various aspects of the vaping experience related to e-liquid. Results: We found that (1) 67.50%(17177/25449) of the reviews were positive and 12.50%(3180/25449) of the reviews were negative, which indicates that users generally hold positive attitude towards e-liquid products. Among the nine flavors, fruity and sweet were the top 2 most popular flavors with the most positive, negative and total number of reviews, nutty and coffee were top 2 flavors with the least positive, negative and total number of reviews; (2) flavor accuracy and value were the two most important aspects influence users sentiments toward e-liquid products; (3) users are satisfied with fruity flavors since the flavors taste great, sweet, nice, good, amazing, and strong, the price/value is good, great, reasonable, the throat hit is strong, good, nice and perfect, meanwhile, weird, sour, bad, weak, and disappointing tastes make users dislike the flavor, some users complain that the price is steep and expensive, the quality is bad, the throat hit is harsh; (4) at the product level, among 1009 products labeled as rich flavor, 72.35% of the products were positive, among 432 products labeled as spiced flavor, 20.14% of the products were negative, rich and spiced flavors were the categories whose percentage of positive products and negative products was the largest. Slevin, ‘nana Cream and Unicorn Milk ranked top 3 in 8039 products; (5) at the user level, top 3 user categories with the most reviews were Unverified user, Verified user, and Trusted user, Business owner and Verified user had higher scores on products; (6) at the business level, top 5 most polular businesses were Mt.Baker Vapor, The Vapor Chef, Adirondack Vapor, Blue Dot Vapors, and Carpe Diem Vapor. And 14.1% of reviews were discussing the products provided by these popular businesses. The mined data-driven findings can help regulatory authorities automatically monitor e-liquid product information across the platforms and largely improving work efficiency. These findings can help distinguish e-liquid characteristics that impact use or lack of use of specific e-liquids in particular e-liquids. Conclusions: It is the first study to provide an effective mechanism to analyze users’ ENDS vaping experience based on sentiment opinion summarization techniques. Sentiment trend and opinions for aspect, product, and business can be found using our method, which is of great importance to monitor e-liquid products across the platforms and largely improving work efficiency of management department.

  • Analyzing the Adherence of a Mobile App to Follow up Tobacco-Quitting Patients

    From: JMIR mHealth and uHealth

    Date Submitted: Nov 9, 2017

    Open Peer Review Period: Nov 9, 2017 - Jan 4, 2018

    Background: Tobacco smoking is a major risk factor for a wide range of respiratory and circulatory diseases in active and passive smokers. Well-designed campaigns are raising awareness to the problem...

    Background: Tobacco smoking is a major risk factor for a wide range of respiratory and circulatory diseases in active and passive smokers. Well-designed campaigns are raising awareness to the problem and an increasing number of smokers seek medical assistance to quit their habit. In this context, there is the need to develop mHealth Apps that assist and manage large smoke quitting programs in efficient and economic ways. Objective: To analyse and evaluate the results of using a mobile application (TControl) on a smoking cessation program. Methods: Analysis of 197 patients were we wanted to find out the effectiveness of the application on decreasing the number of relapses and the success cases of patients using it. Results: Actually, the difference between using TControl or not have been the number of relapses which is way lower than not using it, and it could considerably retain more patients on the treatment than the conventional treatment. Conclusions: TControl was designed and successfully implemented in the context of an anti-smoking treatment in a public hospital in Catalunya, Spain. TControl can be successfully deployed in medical centers to keep track of smoke-quitting patients.

  • Validity and Reliability of Brief Smartphone Self-Monitoring of Diet, Stress, and Physical Activity in a Diverse Sample of Mothers

    From: Journal of Medical Internet Research

    Date Submitted: Nov 9, 2017

    Open Peer Review Period: Nov 9, 2017 - Jan 4, 2018

    Background: There are multiple strategies but no gold standards for self-monitoring diet, physical activity (PA), and perceived stress. Although self-monitoring is a core element of self-management an...

    Background: There are multiple strategies but no gold standards for self-monitoring diet, physical activity (PA), and perceived stress. Although self-monitoring is a core element of self-management and behavior change, the success of mHealth behavioral tools is dependent on validity and reliability, which is lacking in evidence. African-American and Latina mothers in the United States are high priority populations for applications addressing diet, PA, and stress because mothers typically increase body mass index (BMI) for several years after childbirth and the risks of obesity and its’ sequelae diseases are elevated among minority populations. Objective: This pilot study examined inter-method reliability and concurrent validity of smartphone-based self-monitoring by ecological momentary assessments (EMA) and daily-diaries for diet, stress, and PA compared to brief recall measures, anthropometric bio-measures and bloodspot biomarkers. Methods: A purposive sample (n=42) of primarily African-American (39%) and Latina (44%) mothers (about one-third normal weight, overweight, or obese) was assigned AndroidTM smartphones with the Ohmage application to self-monitor diet, perceived stress, and PA over six months. Participants were assessed at 3- and 6-month follow-ups. Recall measures included brief food frequency screeners, PA assessments adapted from NHANES, and the PSM-9 stress measure. Anthropometric bio-measures included BMI, body fat, waist circumference, and blood pressure (BP). Bloodspot assays for Ebstein-Barr Virus (EBV) and C-Reactive Protein (CRP) were used as biomarkers of systemic load and stress. EMA and daily diary questions assessed perceived quality and quantity of meals, perceived stress levels, and moderate, vigorous, and light PA. Units of analysis were follow-up assessments (n=29 to n=45 depending on domain) nested in participants (N=29 with sufficient data for analyses). Correlations, R2 statistics, and multivariate linear regressions assessed strength of associations between variables. Results: Almost all participants (93%) completed the study. Inter-method reliability between smartphone EMA/diary reports and their corresponding recall reports was highest for stress and diet, with correlations ranging from .27 to .52 (with p<.05), but was unexpectedly low for PA with no significant associations. Concurrent validity was demonstrated for diet EMA/diary reports with systolic BP (r = -.32), CRP (r = -.34), and moderate and vigorous PA recalls (r = .35 to .48), suggesting co-variation between healthy diet and PA behaviors. Stress EMA/diary reports were not associated with EBV and CRP biomarkers. Moderate and vigorous PA diary reports were negatively associated with BMI and body fat (r = -.35 to -.44, p<.05). Conclusions: Brief smartphone EMA may be valid and reliable for long-term self-monitoring of diet, stress, and PA. Lack of inter-method reliability for PA measures is consistent with prior research. More research is needed on the efficacy of smartphone self-monitoring for self-management and behavior change support.

  • Severely burdened individuals do not need to be excluded from internet-based mobile-supported stress management: effect modifiers of treatment outcomes from three randomized controlled trials

    From: Journal of Medical Internet Research

    Date Submitted: Nov 11, 2017

    Open Peer Review Period: Nov 11, 2017 - Jan 6, 2018

    Background: Although internet-based mobile-supported stress management interventions (iSMIs) may be a promising strategy to reach employees suffering from high chronic stress, it remains unknown wheth...

    Background: Although internet-based mobile-supported stress management interventions (iSMIs) may be a promising strategy to reach employees suffering from high chronic stress, it remains unknown whether participants with high symptom severity of depression or anxiety also profit, or should be excluded from iSMIs. Objective: The study aimed to evaluate the efficacy of iSMIs in subgroups with high symptom severity. Methods: Data from three randomized controlled trials (RCTs; N=791) were pooled to identify effect modifiers, and to evaluate efficacy in subgroups with different levels of initial symptom severity. The outcomes perceived stress (PSS), depressive (CES-D) and anxiety (HADS) symptom severity were assessed at baseline, 7-week post-treatment, and 6-month follow-up. In multiple moderation analyses (MMAs) potential moderators were tested in predicting differences in change of outcome. Through simple slope analyses efficacy of the iSMI was compared in subgroups with low, moderate and severe initial symptomology based on means and standard deviations of the study population. Results: Individuals with high stress (PSS≥30), depression (CES-D≥33), anxiety (HADS≥15) and emotional exhaustion (MBI≥5.6) profited significantly from the intervention with great reductions of stress (dpost=[0.86-1.16], dFU=[0.93-1.35]), depression (dpost=[0.69-1.08], dFU=[0.91-1.19]), and anxiety (dpost=[0.79-1.19], dFU=[1.06-1.21]), and effects were sustained at 6-month follow-up. Symptom severity moderated treatment outcomes, as individuals with higher symptom severity at baseline profited significantly more from the intervention than individuals with lower symptom severity. Conclusions: Highly burdened individuals benefit greatly from iSMIs and should, therefore, not be excluded from participation. Clinical Trial: German clinical trial registry DRKS00005112, DRKS00005384, DRKS00004749 (https://drks-neu.uniklinik-freiburg.de/drks_web/setLocale_DE.do)

  • Characteristics of Social Interaction and Support in a Synchronous Virtual Environment for Adults with Type 2 Diabetes

    From: Journal of Medical Internet Research

    Date Submitted: Nov 10, 2017

    Open Peer Review Period: Nov 11, 2017 - Jan 6, 2018

    Background: Virtual environments (VEs) facilitate interaction and support among individuals with chronic illness, yet the characteristics of these VE-interactions remain unknown. Objective: This study...

    Background: Virtual environments (VEs) facilitate interaction and support among individuals with chronic illness, yet the characteristics of these VE-interactions remain unknown. Objective: This study described social interaction and support among individuals with type 2 diabetes (T2D) who interacted in a VE. Methods: Data included VE-mediated synchronous conversations and text-chat and asynchronous emails and discussion board posts from a study that facilitated interaction among individuals with T2D and diabetes educators (N = 24) in two types of sessions, educational and support. Results: Virtual environment interactions consisted of: communication techniques (how individuals interact in the VE), expressions of self-management (T2D-related topics), depth (personalization of topics), and breadth (number of topics discussed). Individuals exchanged support more often in the education (n=723, 62%) than in the support (n=406, 34%) sessions. Of all support exchanges, 535 (46%) were informational, 377 (32%) were emotional, 217 (19%) were appraisal and 41 (4%) were instrumental. Comparing session types, education sessions predominately provided informational support (357 or 49%), and the support sessions predominately provided emotional support (159 or 39%). Conclusions: Virtual environment-mediated interactions resemble those in face-to-face environments, as individuals in VEs engage in bidirectional exchanges with others to obtain self-management education and support. Similar to face-to-face environments, individuals in the VE revealed personal information, sought information, and exchanged support during the moderated education sessions and unstructured support sessions. With this versatility, VEs are able to contribute substantially to support for those with diabetes and, very likely, other chronic diseases. Clinical Trial: n/a

  • Use of a smartphone for the early detection of melanoma: A systematic review.

    From: Journal of Medical Internet Research

    Date Submitted: Nov 15, 2017

    Open Peer Review Period: Nov 16, 2017 - Jan 11, 2018

    Background: The early diagnosis of melanoma is associated with a decreased mortality. The smartphone, with its applications and the possibility of sending photographs to a dermatologist, could improve...

    Background: The early diagnosis of melanoma is associated with a decreased mortality. The smartphone, with its applications and the possibility of sending photographs to a dermatologist, could improve melanoma screening. Objective: The aim of our review was to report evidence on 1) the diagnostic performance of smartphone applications and store-and-forward teledermatology via a smartphone in the early detection of melanoma; 2) the impact on the patient’s medical care course; and 3) the feasibility criteria (focusing on the modalities of picture taking, transfer of data, and time to get a reply). Methods: We conducted a systematic search of PubMed for the period from January 1, 2007, (launch of the first smartphone) to November 1, 2017, according to the PRISMA guidelines. Results: Of the thirty-one articles included, fourteen concentrated on store-and-forward teledermatology, and thirteen studied the diagnostic performance of applications. Store-and-forward teledermatology opens several new perspectives: it accelerates the care course (less than 10 days vs 80 days), and its sensitivity is higher than that of application algorithms. However, the concordance between the conclusion of a teledermatologist and the conclusion of a dermatologist who conducts a face-to-face examination depended on the study (k=0.2 to 0.84; median k=0.6). The use of a dermoscope may improve the concordance (k=0.29 to 0.87; median k=0.74). Regarding smartphone applications, the major concerns are their low sensitivity, which ranges from 7% to 90% (median 64%), the lack of assessment in clinical practice conditions, and the lack of assessment in primary care populations. In this literature review, up to 20% of the photographs transmitted were of insufficient quality. The modalities of picture taking and encryption of the data were only partially reported. Conclusions: The use of teledermatology could improve access to a dermatology consultation by optimizing the care course. Our review confirmed the absence of evidence of the safety and efficacy of smartphone medical apps. Further research is required to determine quality criteria, as there was major variability among the studies.

  • Medical students views

    From: JMIR Medical Education

    Date Submitted: Nov 12, 2017

    Open Peer Review Period: Nov 13, 2017 - Jan 8, 2018

    Background: The importance of assessment in the educational process is well emphasized in medical education. The system of continuous assessment (CA) used in the College of medicine, KKU can be descri...

    Background: The importance of assessment in the educational process is well emphasized in medical education. The system of continuous assessment (CA) used in the College of medicine, KKU can be described as frequent summative assessments in each course since there was no regular feedback. The CA adopted carries 50% of the total marks. Achievement of students in CA is critical to their pass or failure of any course. Excessive use of summative assessment was identified as problematic by some research work. But, at the same time a single terminal summative assessment is not recommended. The objective of this study was to examine the relation between each of gender, feedback and students' perception of learning with performance in CA. Objective: To get the views of medical students about their performance in continuous assessment and the factors affecting the continuous assessment. Methods: The target population of this study was the 4th, 5th and 6th year students of the college of medicine, KKU. Non-probability convenience sampling was used aiming at 25% - 30% of the total. A correlational design was adopted. A structured self-administered questionnaire was developed. This was based on four constructs: performance on CA: 3 items, feedback: 6 items, students' perception of learning: 12 items and gender. A 5-point Likert scale was used ranging from strongly agree to strongly disagree to the stated statements in the instrument. The questionnaire was validated before use. Pearson’s correlation coefficient (r) was computed using SPSS. P value of <0.05 was considered significant. Results: This is a cross sectional study . The total number of respondents was 128 with 58% of them males and 42% females. The computed r for the perception of learning with performance in CA was .741 and for feedback with performance in CA was .766. This clearly indicated a significant positive correlation between them. Gender had no significant correlation with performance in CA. Although profound evidence does exist on the positive effect of CA on academic performance and motivation of students, this effect seems to be dependent on how the assessment system is used. In one experimental study, it was found that CA had positive effect on students' academic performance, learning and satisfaction compared to summative assessment. On the other hand, when continuous assessment was done in form of frequent summative assessment, the positive effect was lost and in fact a negative effect was evident Conclusions: The respondents viewed their perception of learning and feedback strongly and positively correlated with their performance in CA, while gender had no significant correlation.

  • Measuring engagement in e- & mHealth behaviour change interventions: a methodological overview

    From: Journal of Medical Internet Research

    Date Submitted: Nov 15, 2017

    Open Peer Review Period: Nov 15, 2017 - Jan 10, 2018

    Background: Effective engagement in e -& mHealth behaviour change interventions is important for intervention effectiveness and efficacy. Detailed definitions and conceptual models of engagement help...

    Background: Effective engagement in e -& mHealth behaviour change interventions is important for intervention effectiveness and efficacy. Detailed definitions and conceptual models of engagement help to improve our understanding of engagement. However, to test the hypotheses generated by these models we first need to know how to measure engagement in a valid and reliable way. Objective: This paper provides a comprehensive overview of engagement measurement options that can be employed in e- & mHealth behaviour change interventions. Methods: Measures (n = 120) identified in systematic reviews of engagement research, as well as those utilised in studies known to the authors were extracted and critically reviewed. Results: A wide range of methods to measure engagement were identified, including qualitative measures, self-report questionnaires, ecological momentary assessments, system usage data, sensor data, social media data and psychophysiological measures. Each measurement method is reviewed, and examples are provided to illustrate possible use in e-&mHealth behaviour change research. Recommendations for future research are provided, based on the limitations of current methods and the heavy reliance on system usage data as the sole assessment of engagement in research thus far. The use of mixed methods to assess engagement components related to interest, attention and affect, aThis paper provides a comprehensive overview of measurement methods for user engagement in e- & mHealth behaviour change interviews. We anticipate that the results from our study will help to advance the field of e- & mHealth and behaviour change by facilitating the use of a wider range of engagement measurements and their thoughtful application to the study of engagement and its antecedents. s well as the behaviour change process are encouraged. Conclusions: This paper provides a comprehensive overview of measurement methods for user engagement in e- & mHealth behaviour change interviews. We anticipate that the results from our study will help to advance the field of e- & mHealth and behaviour change by facilitating the use of a wider range of engagement measurements and their thoughtful application to the study of engagement and its antecedents.

  • Findings of a randomised controlled feasibility trial to reduce sedentary time using wearable and mobile technologies with educational support: Chronic Obstructive Pulmonary Disease-Sitting and ExacerbAtions Trial (COPD-SEAT)

    From: Journal of Medical Internet Research

    Date Submitted: Nov 13, 2017

    Open Peer Review Period: Nov 13, 2017 - Jan 8, 2018

    Background: Targeting sedentary time post-exacerbation may be more relevant than targeting structured exercise for individuals with COPD. Focussing interventions on sitting less and moving more after...

    Background: Targeting sedentary time post-exacerbation may be more relevant than targeting structured exercise for individuals with COPD. Focussing interventions on sitting less and moving more after an exacerbation may act as a stepping stone to increase uptake to pulmonary rehabilitation. Objective: To conduct a randomised trial examining trial feasibility and the acceptability of an education and self-monitoring intervention using wearable technology to reduce sedentary behaviour for individuals with COPD admitted to hospital for an acute exacerbation. Methods: Participants were recruited and randomised in-hospital into three groups with the intervention lasting two weeks post-discharge. The Education group received verbal and written information about reducing their time spent sitting face-to-face with a study researcher. The Education+Feedback group received the same education component along with real-time feedback on their sitting time, stand-ups and steps at home through a waist-worn inclinometer linked to a smart device application. Patients were shown how to use the technology by the same study researcher. The inclinometer also provided vibration prompts to encourage movement at patient defined intervals of time. Patients and healthcare professionals involved in COPD exacerbation care were interviewed to investigate trial feasibility and acceptability of trial design and methods. Main quantitative outcomes of trial feasibility were eligibility, uptake and retention, and for acceptability, were behavioural responses to the vibration prompts. Results: 111 patients were approached with 33 patients recruited (11 Control, 10 Education and 12 Education+Feedback). Retention at two-week follow-up was 51.5% (6 Control, 3 Education and 8 Education+Feedback). No study-related adverse events occurred. Collectively, patients responded to 106 out of 325 vibration prompts from the waist-worn inclinometer (33%). 41% of responses occurred within 5 minutes of the prompt with patients standing for 1.4±0.8 minutes and walking for 0.4±0.3 minutes (21±11 steps). Interviews indicated that being unwell and overwhelmed after an exacerbation was the main reason for not engaging with the intervention. Healthcare staff considered reducing sedentary behaviour potentially attractive for patients but suggested starting the intervention as an inpatient. Conclusions: Whilst the data support that it was feasible to conduct the trial, modifications are needed to improve participant retention. The intervention was acceptable to most patients and healthcare professionals. Clinical Trial: ISRCTN 13790881. Registration date: 30-Oct-2015. Enrolment of first participant date: 05-Feb-2016.

  • Remote patient monitoring and telemedicine in neonatal and pediatric settings: A scoping literature review

    From: Journal of Medical Internet Research

    Date Submitted: Nov 13, 2017

    Open Peer Review Period: Nov 13, 2017 - Jan 8, 2018

    Background: Telemedicine and telehealth solutions are emerging rapidly in healthcare, and have the potential to decrease costs for insurers, providers and patients in various settings. Pediatric popu...

    Background: Telemedicine and telehealth solutions are emerging rapidly in healthcare, and have the potential to decrease costs for insurers, providers and patients in various settings. Pediatric populations that require specialty care, are disadvantaged socially or economically, or have chronic health conditions will greatly benefit from results of studies utilizing telemedicine technologies. This paper examines the emerging trends within pediatric populations as part of a systematic literature review and provides a scoping review of the type, extent, and quantity of research available. Objective: This paper aims to examine the role of remote patient monitoring and telemedicine in neonatal and pediatric settings. Findings can be used to identify strengths, weaknesses, and gaps in the field. The identification of gaps will allow for interventions or research to improve healthcare quality and costs. Methods: A systematic literature review is being conducted in order to gather an adequate amount of relevant research for telehealth in pediatric populations. The fields of remote patient monitoring and telemedicine are not yet very well established by the healthcare services sector and definitions vary across healthcare systems, and thus the terms are not always defined similarly throughout the literature. Three databases were scoped for information for this specific review, and 56 articles are included so far Results: Three major telemedicine trends emerged from the review of 45 relevant papers: remote patient monitoring, teleconsultation, and monitoring patients within the hospital, but without contact, thus decreasing likelihood of infection or other adverse health effects. Conclusions: While the current telemedicine approaches show promise, limited conditions studied and small sample sizes affect generalizability, therefore warranting further research. The information presented can inform healthcare providers of the most widely implemented, studied, and effective forms of telemedicine for patients and their families, and the telemedicine initiatives that are most cost efficient for health systems. While the focus of this review is to summarize some telehealth applications in pediatrics, there are also research studies presented which can inform providers of the importance of data sharing of remote monitoring data between hospitals. Further reports will be developed to inform health systems as the systematic literature review continues.

  • The Evaluation of Two Mobile Health Applications in the Context of Smoking Cessation: A Longitudinal Qualitative Study

    From: Journal of Medical Internet Research

    Date Submitted: Nov 15, 2017

    Open Peer Review Period: Nov 15, 2017 - Jan 10, 2018

    Background: mHealth (mobile health) applications can offer a number of benefits for users, representing a feasible and acceptable means of administering health interventions, such as Cognitive Behavio...

    Background: mHealth (mobile health) applications can offer a number of benefits for users, representing a feasible and acceptable means of administering health interventions, such as Cognitive Behavioural Therapy (CBT). CBT is commonly used in the treatment of mental health conditions, where it has a strong evidence base, suggesting that it represents an effective method to elicit health behaviour change. Importantly, CBT has shown to be effective in smoking cessation, whereby smoking-related costs to the NHS were estimated to be £2.6bn in 2015. Whilst the evidence base for computerised CBT in mental health is strong, there is limited literature on its use in smoking cessation. This, combined with the cost-effectiveness of mHealth interventions, advocates a need for research into the effectiveness of CBT-based smoking cessation applications. Objective: The objective of this study is to investigate the impact of two mHealth applications, one CBT-based application, Quit Genius (QG), and one non-CBT-based application, NHS SmokeFree (SF), in promoting positive behaviour change with respect to smoking cessation. Methods: A qualitative short-term longitudinal study was conducted, using a sample of 29 smokers allocated to one of the two applications, QG or SF. Each user underwent two one-to-one semi-structured interviews, one week apart. From the primary data collected, thematic analysis was carried out and themes were identified. Results: Results indicated that QG generally led to a perceptional change in participants’ smoking behaviour and increased confidence in their ability to quit, thus eliciting greater effects than SF on their positive behaviour change, after one week of use. A greater proportion of participants using QG compared to SF reported smoking fewer cigarettes per day (QG 53% vs SF 14%, p<.05). QG participants were similarly more likely to recommend the application compared to SF (73% vs 36%, p<.05) and participants stated a higher likelihood to continue using QG compared to SF (67% vs 36%, p <.05). Conclusions: The findings support the use of CBT in the context of mHealth applications as an effective smoking cessation tool. mHealth applications must be well-developed, preferably with an underlying behavioural change mechanism, to promote positive health behaviour change. Digital CBT thus has the potential to become a powerful tool in overcoming current healthcare challenges. Future research is required to focus on the effect of greater personalisation on measures of behavioural change, and on understanding the psychological barriers to the adoption of new mHealth solutions.

  • Public Perception Analysis of Tweets during the 2015 Measles Outbreak Using a Neural Network Model

    From: Journal of Medical Internet Research

    Date Submitted: Nov 14, 2017

    Open Peer Review Period: Nov 14, 2017 - Jan 9, 2018

    Background: Timely understanding of public perceptions allows public health agencies to provide up-to-date responses to health crises such as infectious diseases outbreaks. Social media such as Twitte...

    Background: Timely understanding of public perceptions allows public health agencies to provide up-to-date responses to health crises such as infectious diseases outbreaks. Social media such as Twitter provides an unprecedented way for the prompt assessment of the large-scale public response. Objective: This study has two aims: 1) to develop a scheme for a comprehensive public perception analysis of a measles outbreak from Twitter data; 2) to demonstrate the superiority of the neural network-based approach (compared with conventional machine-learning methods) on measles outbreak-related tweets classification tasks with a relatively small and highly unbalanced gold standard training set. Methods: We first designed a comprehensive scheme for the analysis of public perception of measles based on tweets, including three dimensions: Discussion themes, Emotions expressed, and Attitude toward vaccination. All 1,154,156 tweets containing the word “measles” posted between December 1st, 2014 and April 30th, 2015 were purchased and downloaded from DiscoverText.com. Two expert annotators curated a gold standard of 1,151 (approximately 1% of all the tweets) tweets based on the three-dimensional scheme. Next, a tweet classification system based convolutional neural network (CNN) was developed. We compared the performance of the CNN model to that of four conventional machine-learning models. We also compared the performances of two word embeddings: (1) Stanford GloVe embedding trained on billions of tweets in general domain and (2) measles-specific embedding trained on our 1 million measles related tweets. Results: Cohen’s Kappa inter-coder reliability values for the annotation were: 0.781, 0.723, and 0.796 on three dimensions. Class distributions in the gold standard were highly unbalanced for all dimensions. The CNN model with measles-specific embedding and Stanford GloVe embedding performed significantly better on all classification tasks than K-nearest Neighbors, Naïve Bayes, Support Vector Machines, or Random Forest. Detailed comparison between Support Vector Machines and CNN model with two tweet embeddings showed that the major contributor to the overall superiority of the CNN models is the significant improvement on recall, especially for those classes with low occurrence. The CNN model with Stanford GloVe embedding achieved the best performance overall, while the CNN model with measles-specific tweet embedding achieved better performance for some classes with lower abundance. Conclusions: Compared to conventional machine-learning methods, our CNN models showed superiority on measles related tweet classification tasks with a relatively small and highly unbalanced gold standard. Our proposed scheme and neural network based tweets classification system could be used for the analysis of tweets about other infectious diseases such as influenza and Ebola.

  • A patient portal, why (not) use it? A study to explore the use and the users of a patient portal

    From: Journal of Medical Internet Research

    Date Submitted: Nov 14, 2017

    Open Peer Review Period: Nov 14, 2017 - Jan 9, 2018

    Background: Patient portals support patient involvement in health care by offering the patients access to their medical information and tools to communicate with healthcare providers. It has been sho...

    Background: Patient portals support patient involvement in health care by offering the patients access to their medical information and tools to communicate with healthcare providers. It has been shown that patient portals could have positive effects on health outcomes and on quality and efficiency of healthcare. It is therefore important for healthcare organizations: to identify the patients who (do not) make use of the patient portal and to explore the reasons for (not) using the patient portal. The Unified Theory of Acceptance and Use of Technology (UTAUT) is the most frequently used theory for explaining the use of information technology, with constructs Performance Expectancy, Effort Expectancy, Social Influence and Facilitating Conditions. Objective: To explore how often a patient portal is used and which patients use or do not use a patient portal. The main constructs of UTAUT, together with demographics, disease and care related characteristics have been measured to explore predicting factors of portal use. Methods: A cross-sectional study was carried out in adult patients visiting the outpatient departments of a university hospital in the Netherlands. Outcomes were: self-reported portal use, characteristics of users as demographics, disease and care related data, eHealth literacy and scores of UTAUT constructs. Descriptive analyses, univariate and multivariate logistic regression were also carried out. Results: 439 adult patients were included in the analyses. Of them 32% indicated to be a user of the patient portal; 31% indicated to be a non-user, but knew about the existence of the portal and 37% was non-user and did not know the portal. The factors being native Dutch (OR 2.77, 95%CI 1.30 -5.88) and eHealth literacy (OR 1.11, 95% CI 1.06- 1.16) best predicted portal use. Users more often agreed with factors that increase the acceptance of the portal than non-users who knew about the portal, namely Effort expectancy (88 versus 43%), Social influence (31 versus 17%), Facilitating conditions (58 versus 37%), Performance expectancy (74 versus 24%), Behavioral Intention to Use (90 versus 60%) and recommendation to others (79 versus 18%). Conclusions: About one third of the patients of a university hospital self-reported to use the patient portal and most of them were satisfied with it. Users were characterized by having higher eHealth literacy scores and being native Dutch. The Unified Theory of Acceptance and Use of Technology (UTAUT), explained use of the patient portal; especially the ease of use of the patient portal, knowledge and skills related to portal were of influence. Interventions to improve eHealth literacy skills and further integration of the patient portal in usual care is needed to increase potential positive effects for patients.

  • Internet based interventions for problem gambling: A scoping review.

    From: JMIR Rehabilitation and Assistive Technologies

    Date Submitted: Nov 14, 2017

    Open Peer Review Period: Nov 14, 2017 - Jan 9, 2018

    Background: The rate of treatment seeking for problem gambling has been demonstrated to be low across several research environments. This is in part due to the systemic barriers that would be treatmen...

    Background: The rate of treatment seeking for problem gambling has been demonstrated to be low across several research environments. This is in part due to the systemic barriers that would be treatment seekers face to accessing traditional face-to-face treatment. Making problem gambling treatment resources available through the Internet is one way to reduce the impact of those systemic barriers. The use of Internet based resources to address problem gambling has been growing and a field of research evaluating it has developed as well. However, there has been little done to examine this growing field of research as a whole. Objective: To collect and evaluate research on the use of Internet based intervention for problem gambling in order to provide an understanding of the current state of the field. A secondary objective of this study is to outline the advantages and challenges that are associated with addressing problem gambling using Internet based resources. Methods: A scoping review was performed of five peer-reviewed research data bases (PsychINFO, CINAHL, Medline, Social Science Abstracts and Scopus) and three grey literature databases (MedEdPortal, Proquest: dissertations and Opengrey). Article inclusion required to have been published in the last ten years (2007-2017), include an intervention for problem gambling, and involve the use of the Internet to deliver that intervention. Results: A total of 21 articles were found that met the review requirements. Studies were found from several different areas with particularly strong representation for Australia and New Zealand, and Scandinavia. Cognitive behavioural therapy was the most common form of Internet based intervention. Internet based interventions we generally shown to be effective by the collected research in reducing problem gambling scores and gambling behaviours. Stated advantages include lower feelings of stigma, greater flexibility in time of treatment, and ease of access to relevant information. Stated disadvantages include ethical concerns related to clients in crisis and confidentiality, a lack of rapport in the client-provider relationship, and high rates of attrition. Conclusions: Internet based interventions are a promising direction for treatment and prevention of problem gambling, particularly in reducing barrier to accessing professional help. The state of the current literature is sparse and more research is needed in directly comparing Internet based interventions and their traditional counterparts.

  • Ethical Challenges in Consumer Digital Psychotherapy

    From: JMIR Mental Health

    Date Submitted: Nov 14, 2017

    Open Peer Review Period: Nov 15, 2017 - Jan 10, 2018

    This article focuses on the ethical challenges presented by digital psychotherapy services that are direct-to-consumer and do not involve oversight by a professional mental health provider. These serv...

    This article focuses on the ethical challenges presented by digital psychotherapy services that are direct-to-consumer and do not involve oversight by a professional mental health provider. These services include apps that connect users to peer counseling and counseling steered by artificial intelligence and conversational agents. These services can potentially assist in improving access to mental health care for the many people would otherwise not have the resources or ability to connect with a therapist. However, the lack of adequate regulation in this area exacerbates concerns over how safety, privacy, liability, and other ethical obligations to protect a client are addressed by these services. In the traditional therapeutic relationship, there are ethical obligations that serve to protect the interests of the client and provide warnings. In contrast, in a direct-to-consumer therapy app, there are not clear lines of accountability or associated ethical obligations to protect the user seeking mental health services. There is a need for increased oversight of direct-to-consumer non-professional psychotherapy services to better protect the consumer.

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

    From: Journal of Medical Internet Research

    Date Submitted: Nov 27, 2017

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

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

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

  • Stigma and its association with glycemic control and hypoglycemia in adolescents and young adults with type 1 diabetes, a cross-sectional study

    From: Journal of Medical Internet Research

    Date Submitted: Nov 16, 2017

    Open Peer Review Period: Nov 16, 2017 - Jan 11, 2018

    Background: In type 1 diabetes, qualitative studies indicate that visibility of diabetes supplies, self-care, and hypoglycaemia symptoms are associated with stigma and suboptimal management. This may...

    Background: In type 1 diabetes, qualitative studies indicate that visibility of diabetes supplies, self-care, and hypoglycaemia symptoms are associated with stigma and suboptimal management. This may be particularly salient in youth who face concurrent challenges such as establishing autonomy and vocational choices. Objective: To estimate stigma prevalence in youth (14-24 years) with type 1 diabetes and associations with glycemic control. Methods: Participants, recruited largely through social media, were asked to complete an online survey and mail in capillary blood samples for A1C measurement. The primary definition of stigma required endorsement of one or more of three stigma-specific items of the Barriers to Diabetes Adherence questionnaire. These addressed avoidance of diabetes management with friends present, difficulty telling others about diabetes diagnosis, and embarrassment in performing diabetes care with others present. Poor glycemic control was defined as A1C >9% (i.e., >75 mmol/mol; measured value when available, else self-report) and/or ≥1 severe hypoglycemic episode in the previous year (reported requiring assistance from someone else during the episode). Stigma prevalence was computed (95% confidence intervals, CI) and associations with glycemic control evaluated (multivariate logistic regression models). Results: Among the 380 respondents, stigma prevalence was 65.5% (95% CI 60.7-70.3). Stigma was associated with a two-fold higher odds of poor glycemic control overall (OR 2.25, 95% CI 1.33-3.80; adjusted for age, sex, type of treatment). There were specific associations with both A1C >9% (75 mmol/mol; OR 3.05, 95% CI 1.36-6.86) and severe hypoglycemia in the previous year (OR 1.86, 95% CI 1.05-3.31). Conclusions: There is a high prevalence of stigma in youth with type 1 diabetes that is associated with both high A1C and severe hypoglycemia. Targeted strategies to address stigma are needed. Clinical Trial: linicalTrials.gov NCT02796248

  • How might digital technology augment chronic illness management among Black men? A commentary.

    From: Journal of Medical Internet Research

    Date Submitted: Nov 16, 2017

    Open Peer Review Period: Nov 16, 2017 - Jan 11, 2018

    Health disparities associated with chronic illness experiences of Black men demonstrate widespread systematic failures to meet an urgent need. Well-established social and behavioral determinants that...

    Health disparities associated with chronic illness experiences of Black men demonstrate widespread systematic failures to meet an urgent need. Well-established social and behavioral determinants that have led to health disparities among Black men, include racism, discrimination, and stress. While advocacy work that includes community-engagement and tailoring health promotion strategies have shown local impact, evidence shows the gaps are increasing. We suspect that failure to reduce current disparities may be due to conventional public health interventions and programs; therefore, we submit that innovative interventions, ones that embrace digital technologies and their ability to harness naturally occurring social networks within groups, like Black men, have particular importance and deserve attention. This commentary characterizes the current literature on chronic illness among Black men as well as health interventions that use digital technology, to build a case for expanding research in this area to reduce the overwhelming burden of chronic illness among Black men.

  • Acceptability and feasibility of using mobile technology to improve bone-related lifestyle risk factors in young women with low bone mineral density: a pilot study

    From: Journal of Medical Internet Research

    Date Submitted: Nov 16, 2017

    Open Peer Review Period: Nov 17, 2017 - Jan 12, 2018

    Background: Poor bone health in adolescent and young females is a growing concern. Given the widespread use of smartphones in this population, mobile health (mHealth) interventions may help improve li...

    Background: Poor bone health in adolescent and young females is a growing concern. Given the widespread use of smartphones in this population, mobile health (mHealth) interventions may help improve lifestyle behaviours related to bone health in young women. Objective: To determine the effectiveness and feasibility of a mHealth intervention called “Tap4Bone” in improving lifestyle behaviours associated with the risk of osteoporosis in young women. Methods: The mHealth intervention comprised the use of mobile phone apps, short messaging service (SMS) and web emails to encourage lifestyle behaviour changes. The education group received osteoporosis prevention education leaflets. Changes in bone-health-related lifestyle behaviours namely, exercise, smoking and calcium intake were assessed. Users’ experiences and acceptance of the app were collected through focus group interviews. Results: A total of 35 were randomised to either the smartphone (intervention n =18) or education (control n = 17) group. All participants from the mHealth intervention group started taking calcium supplements after commencing the study, compared to fewer in the education control group (100.0% vs 44.4%, P < .001). Though there were trends towards improvement in sports activity and smoking behaviours in the mHealth intervention group, compared to the education group, these were not statistically significant. Approximately 70% of the sample said they would use a mobile phone app in future to improve their bone health. Conclusions: The Tap4Bone mHealth intervention was widely accepted by users and more effective than traditional education at encouraging calcium supplement intake to support bone health in young women.

  • Preferences for Health Information Technologies among U.S. Adults: Findings from the Health Information National Trends Survey

    From: Journal of Medical Internet Research

    Date Submitted: Nov 16, 2017

    Open Peer Review Period: Nov 17, 2017 - Jan 12, 2018

    Background: Emerging health technologies are increasingly being used in health care for communication, data collection, patient monitoring, education, and to facilitate adherence to chronic disease ma...

    Background: Emerging health technologies are increasingly being used in health care for communication, data collection, patient monitoring, education, and to facilitate adherence to chronic disease management. However, there is also lack of studies on differences in preference for using information exchange technologies between chronic and non-chronic disease patients and factors affecting these differences. Objective: The purpose of this paper is to understand preferences and interests in use of technology for information exchange among a nationally representative sample of adults with and without chronic disease conditions and to assess whether these preferences differ according to varying demographic variables. Methods: We utilized data from the 2021 and 2014 iteration of the Health Information National Trends Study (HINTS, N=7307). We modeled negative responses using multiple logistic regressions adjusting for relevant covariates to identify independent factors associated with lowers odds of using health information technology and therefore identify targets for awareness. Analyses were weighted for the US population and adjusted for the sociodemographic variables of age, gender, race and US census region. Results: Analysis included 7,307 participants (weighted population 230,993,888) and 3,529 participants of this sample (weighted population of 90,748,995) reported CVD, diabetes, or hypertension. In the unadjusted models, individuals with Diabetes/CVD/Hypertension were more likely to report using email to exchange medical information with their provider (Odds Ratio [OR] 1.431; 95% Confidence Interval [95% CI] 1.113, 1.838) and less likely to not use any of the technology in health information exchange (OR 0.778; 95% CI 0.618, 0.979). In unadjusted model, additional significant odds ratio values are observed. However, after adjustment, all relationships regarding use and interest in exchanging information with the provider were no longer significant. As a next step, we looked at adjusted odds ratios for demographic variables. Individuals above 65 years old (OR 2.32; 95% CI 1.55, 3.49) and Hispanics (OR 1.95; 95% CI 1.26, 3.01) were less likely to report using email to exchange medical information with their provider. Minorities were less likely to indicate they had no interest in exchanging general health tips with a provider electronically ((Hispanics OR 0.55; 95% CI 0.34, 0.88), (Non-Hispanic Blacks OR 0.36; 95% CI 0.23, 0.56), (Asians OR 0.33; 95% CI 0.16-0.70)). Conclusions: Health information technology related interventions; particularly design of m-health technologies should focus more on demographic factors including race, age and region than chronic disease status to increase likelihood of use. Future research is needed to understand and explore more patient friendly use and design of m-health applications which can be utilized by variety of age, race or education/ health literacy groups efficiently to further bridge the gap in communication between patients and their provider.

  • A Mobile Application of Breast Cancer e-Support Program for Chinese Women with Breast Cancer Undergoing Chemotherapy: Results of a Multicenter Randomized Controlled Trial

    From: Journal of Medical Internet Research

    Date Submitted: Nov 19, 2017

    Open Peer Review Period: Nov 20, 2017 - Jan 15, 2018

    Background: Women with breast cancer undergoing chemotherapy have frequently reported unmet supportive care needs. Easily accessible and innovative support is lacking. Mobile applications (apps) provi...

    Background: Women with breast cancer undergoing chemotherapy have frequently reported unmet supportive care needs. Easily accessible and innovative support is lacking. Mobile applications (apps) provide a promising platform to provide supportive care where women with breast cancer can acquire knowledge and interact with peers or health care professionals when and where needed. Objective: The purpose of this trial was to determine the effectiveness of an app-based Breast Cancer e-Support (BCS) program to address women’s self-efficacy, social support, symptom distress, quality of life, and anxiety and depression. Secondary objectives included exploring the association between women’s health outcomes and the BCS usage data. Methods: A multi-center, single-blinded, randomized controlled trial was used. One hundred and fourteen women with breast cancer, who were commencing chemotherapy and were able to use mobile phone to access internet, were recruited in the clinics from two university affiliated hospitals in China. Women were randomized into either intervention group (n=57) receiving BCS plus care as usual (CAU) or control group (n=57) receiving CAU alone. The health care team and RA collecting data were blinded to the women’s group allocation. Bandura’s self-efficacy theory and the social exchange theory guided the development of the BCS program, which has four components: 1) a Learning forum; 2) a Discussion forum; 3) an Ask-the-Expert forum; and 4) a Personal Stories forum. Moderated by an experienced health care professional, the BCS program supported women for 12 weeks covering 4 cycles of chemotherapy. Health outcomes were self-assessed through paper questionnaires in clinics at baseline before randomization (T0), after 3 (T1) and 6 months (T2) of follow-ups. Results: Fifty-five participants in the intervention group and 49 in the control group completed the follow-up assessments (response rate: 91.2%). During the 12-week intervention, the login frequency ranged from 0 to 774 times (medium: 11; interquartile range: 5~27), and the total usage duration ranged from 0 to 9371 minutes (medium: 100; interquartile range: 27~279). Repeated measures MANCOVA (Intention-to-treat) found that BCS+CAU participants had significant improvement at 3 month regarding self-efficacy (21.05; 95% Cl: 1.87 to 40.22; P=0.03; d=0.53), symptom interference (-0.73; 95% Cl: -1.35 to -0.11; P=0.02; d=-0.51), and QoL (6.64; 95% Cl: 0.77 to 12.50; P=0.027, d=0.46), but not regarding social support, symptom severity, anxiety and depression compared to CAU participants. These beneficial effects were not sustained at 6 months. Spearman's rank-order correlation showed that the BCS usage duration was positively correlated with self-efficacy (r=.290, P=.032), social support (r=.320, P=.017), and QoL (r=.273, P=.044) at 3 months. Conclusions: The BCS program demonstrated its potential as an effective and easily accessible intervention to promote women’s self-efficacy, symptom interference, and QoL during chemotherapy. Clinical Trial: ACTRN: ACTRN12616000639426, Registered 17 May, 2016. http://www.ANZCTR.org.au/ACTRN12616000639426.aspx. Archived at: http://www.webcitation.org/6v1n9hGZq

  • Mobile phone support for diabetes self-care among diverse adults: Protocol for a 3-arm randomized controlled trial evaluating long-term outcomes

    From: JMIR Research Protocols

    Date Submitted: Nov 20, 2017

    Open Peer Review Period: Nov 27, 2017 - Dec 11, 2017

    Background: Nonadherence to self-care is common among patients with type 2 diabetes (T2D) and often leads to severe complications. Moreover, patients with T2D who have low socioeconomic status (SES) a...

    Background: Nonadherence to self-care is common among patients with type 2 diabetes (T2D) and often leads to severe complications. Moreover, patients with T2D who have low socioeconomic status (SES) and are racial/ethnic minorities disproportionately experience barriers to adherence and poor outcomes. Basic phone technology (text messages and phone calls) provides a practical medium for delivering content to address patients’ barriers to self-care adherence; however, trials are needed to explore the long-term and sustainable effects of mobile phone interventions among diverse patients. Objective: We are conducting a 3-arm, 15-month randomized controlled trial (RCT) with a type 1 hybrid effectiveness-implementation approach to evaluate the effects of mobile phone-based diabetes support interventions on self-care adherence and hemoglobin A1c (HbA1c) among adults with T2D. The trial consists of 2 intervention arms – Rapid Encouragement/Education And Communications for Health (REACH) and REACH + Family-focused Add-on for Motivating Self-Care (FAMS) – plus a control condition. Methods: We are recruiting 500 primary care patients with T2D from federally qualified health centers (13 locations) and an academic medical center (3 locations), prioritizing recruitment of publicly insured and minority patients from the latter. Eligible patients are currently prescribed daily diabetes medication and own a cell phone with text messaging capability. We exclude patients whose most recent HbA1c result within 12 months is <6.8%. Participants are randomly assigned to REACH only, REACH + FAMS, or the control condition. REACH provides text messages tailored to address patient-specific barriers to medication adherence based on the Information-Motivation-Behavioral skills model, whereas FAMS provides a human component via monthly phone coaching with related text message content focused on family and friend barriers to diet and exercise adherence. Exposure to either treatment is for 12 months. We collect HbA1c and self-reported survey data at baseline and at 3, 6, and 12 months, and again at 15 months to assess sustained changes. We will use Generalized Estimating Equation models to test the effects of REACH (either intervention arm) on HbA1c relative to the control group, while testing the potential additive effects of FAMS and effects of either intervention on adherence to self-care behaviors and diabetes self-efficacy. Results: To date, we have enrolled 465 participants in the trial. We project to complete recruitment in January 2018, and end the trial in May 2019. Conclusions: Our study will be one of the first to evaluate a long-term, theory-based text messaging intervention to promote self-care adherence among racially/ethnically and socioeconomically diverse adults with T2D. Moreover, our study will assess the feasibility of a family-focused intervention delivered via mobile phones and compare the effects of text messaging alone versus text messaging plus phone coaching. Findings will advance our understanding of how interventions delivered by phone can benefit diverse patients with chronic conditions. Clinical Trial: Clinicaltrials.gov NCT02409329; https://clinicaltrials.gov/ct2/show/NCT02409329 Clinicaltrials.gov NCT02481596; https://clinicaltrials.gov/ct2/show/NCT02481596

  • End-user and expert perspectives on the acceptability of a tailored, self-guided smartphone app-based intervention for depression.

    From: JMIR mHealth and uHealth

    Date Submitted: Nov 17, 2017

    Open Peer Review Period: Nov 18, 2017 - Jan 13, 2018

    Background: Despite the growing number of mental health apps available for smartphones, acceptability of these from the perspectives of end-users or healthcare experts has rarely been reported. Usabil...

    Background: Despite the growing number of mental health apps available for smartphones, acceptability of these from the perspectives of end-users or healthcare experts has rarely been reported. Usability information is vital, particularly for self-guided mHealth interventions, as navigability and quality of content is likely to impact participant engagement and treatment compliance. Objective: The overall aim of the present study was to conduct a usability evaluation of a personalized, self-guided app-based intervention for depression. Methods: Participants were administered the System Usability Scale and open-ended questions as part of a semi-structured interview. There were 15 participants from three groups: (1) individuals with clinical depression who were the target audience for the app; (2) mental health professionals; and (3) researchers who specialize in the area of eHealth interventions and/or depression research. Results: The end-user group rated the app highly, both in quantitative and qualitative assessments. The two expert groups highlighted the self-monitoring features, and range of established psychological treatment options (such as behavioral activation and cognitive restructuring), but had concerns that the amount and layout of content may be difficult for end-users to navigate in a self-directed fashion. The end-user data did not confirm these concerns. Conclusions: Encouraging participant engagement via self-monitoring and feedback, as well as personalized messaging may be a viable way to maintain participation in self-guided interventions. Further evaluation is necessary to determine whether levels of engagement with these features enhance treatment effects.

  • Patient reported Quality of Life in men treated with Radium-223 for Metastatic Prostate Cancer: A Canadian Experience.

    From: Journal of Medical Internet Research

    Date Submitted: Nov 19, 2017

    Open Peer Review Period: Nov 24, 2017 - Jan 19, 2018

    Background: Radium-223 dichloride, under the brand name Xofigo was approved by Health Canada in December 2013 for the treatment of castration-resistant prostate cancer with symptomatic bone metastases...

    Background: Radium-223 dichloride, under the brand name Xofigo was approved by Health Canada in December 2013 for the treatment of castration-resistant prostate cancer with symptomatic bone metastases and no visceral metastatic disease. The disease-specific Functional Assessment of Cancer-Therapy Prostate (FACT-P) questionnaire is a 27-item questionnaire that assess patients function over the past 7 days and was used in this study for the evaluation of the quality of life experienced over six treatments. Objective: The aim of this study was to assess the improvement of the FACT-P quality of life scores in CRPC patients over successive treatments using an electronic data collection tool while providing real-time analysis in a Canadian population. Methods: This study targeted patients (n=72) across two large teaching hospitals in one metropolitan area. Statistical analysis software (SPSS) was used to analyze the data. Results: A total of 72 patients completed the survey but 9 patients were excluded due to missing treatment details therefore, this left 63 patients with a total number of 6 treatments for analysis. The overall score changed from a total score 72.9 (Treatment 1) to 77.2 (Treatment 6) with the highest being 78.7 (Treatment 5) which was not Significant (p Value = 0.997). Physical well-being parameter, the patients were most affected by “I have nausea” and “I am bothered by side effects of the treatment”, which had an average score of 2.8 and 2.5, respectively (Somewhat). Social/family well-being, “emotional support, support from friends, family acceptance, family communication, close to partner and satisfied with sex life” all were given a high rating ranging from 3.9 to 4.4 (Quite a bit). However, “I feel close to my friends” was given the lowest rating of 1.8 (A little bit). Emotional well being, “losing hope” was given the highest rating of 3.8 (Quite a bit) and gradually increased over successive treatments and then plateaus in treatments 4, 5 and 6. In contrast, “I feel sad, satisfied with coping, I feel nervous, worry about dying and worry about getting worse” were all given a low rating of 1.8 (A little bit). Functional-well being, “I have accepted my illness, sleeping well and enjoy fun” were all given a high rating of ranging from 3.6 to 4.0 (Quite a bit). In contrast, “I am able to work, work fulfilling, enjoy life and qualify of life” were all given a lower rating ranging from 2.7 to 3.2 (Somewhat). Conclusions: Results of this study demonstrate that radium therapy is the most effective in the functional well-being portion of the FACT-P questionnaire, which increases over time with each treatment. Future directions include applying this questionnaire over a wider population across Canada and in other countries around the world. Clinical Trial: NA

  • Engagement with a Trauma Recovery eHealth Intervention Explained with the Health Action Process Approach (HAPA)

    From: JMIR Mental Health

    Date Submitted: Nov 18, 2017

    Open Peer Review Period: Nov 25, 2017 - Jan 20, 2018

    Background: There has been a growing trend in the delivery of mental health treatment via technology (i.e., eHealth). However, engagement with eHealth interventions is a concern and theoretically base...

    Background: There has been a growing trend in the delivery of mental health treatment via technology (i.e., eHealth). However, engagement with eHealth interventions is a concern and theoretically based research in this area is sparse. Factors that influence engagement are poorly understood, especially in trauma survivors with symptoms of posttraumatic stress. Objective: The aim of this study was to examine engagement with a trauma recovery eHealth intervention using the Health Action Process Approach theoretical model. Outcome expectancy, perceived need, pre-treatment self-efficacy, and trauma symptoms influence the formation of intentions (motivational phase), followed by planning which mediates the translation of intentions into engagement (volitional phase). We hypothesized the mediational effect of planning would be moderated by level of treatment self-efficacy. Methods: Trauma survivors from around the U.S. used the eHealth intervention for two weeks. We collected baseline demographic, social cognitive predictors and distress symptoms and measured engagement subjectively and objectively throughout the intervention. Results: The motivational phase model explained 48% of the variance and outcome expectations (β = .36), perceived need (β = .32), pre-treatment self-efficacy (β = .13), and trauma symptoms (β = .21) were significant predictors of intention (N = 440). In the volitional phase, results of the moderated mediation model indicated for low levels of treatment self-efficacy, planning mediated the effects of intention on levels of engagement, B = 0.89, 95% CI[0.143, 2.605] (N = 115). Conclusions: Though many factors can affect engagement, these results offer a theoretical framework for understanding engagement with an eHealth intervention. This study highlighted the importance of perceived need, outcome expectations, self-efficacy and baseline distress symptoms in the formation of intentions to use the intervention. For those low in treatment self-efficacy, planning may play an important role in the translation of intentions into engagement. Results of this study may help bring some clarification to the question of what makes eHealth interventions work.

  • Key Influence Factors of Consumers’ Intentions Towards Mobile Health Care Promotion: An Empirical Study Based on the DDANPMV Model

    From: Journal of Medical Internet Research

    Date Submitted: Nov 22, 2017

    Open Peer Review Period: Nov 23, 2017 - Jan 18, 2018

    Abstract: Identifying the key influence factors of mobile health care adoption is a key issue. We established an evaluation index system for consumer adoption and verified the effectiveness of our mod...

    Abstract: Identifying the key influence factors of mobile health care adoption is a key issue. We established an evaluation index system for consumer adoption and verified the effectiveness of our model by using a DDANPMV model. This model comprises three parts: (1) the decision making trial and evaluation laboratory (DEMATEL) technique, which is used to establish an influence network relationship map at both the “dimensions” and “criteria” levels; (2) a DEMATEL-based analytic network process (ANP; DANP), which determines the interrelationships and influential weights among the criteria; and (3) a modified VlseKriterijumska Optimizacija I Kompromisno Resenje (VIKOR) method, which applies the influence weights obtained through DANP to performance gaps regarding consumer perception. VIKOR thereby evaluates and improves performance gaps with the aims of satisfying consumer needs, achieving continuous improvement, and enabling sustainable product development. The main innovation of this method is the construction of the DDANPMV model, which integrates the DEMATEL, DANP, and modified VIKOR approaches to examine consumers’ adoption of mobile health care. This method was developed to not only help decision-makers evaluate alternative mobile health care and determine the best option but also use to identify and improve the performance gap of alternative products with the goal of satisfying the aspirations of consumers. Four types of mobile health care products were analyzed. The results indicate that social norms, product image, and consumer trust are three key factors in consumer adoption. This finding can guide product improvement strategies for decision-makers and illustrates the effectiveness of this modified VIKOR method.

  • Mobile Based Quantitative Measure of Stress

    From: JMIR Mental Health

    Date Submitted: Nov 19, 2017

    Open Peer Review Period: Nov 19, 2017 - Jan 14, 2018

    Background: The aim of the present study was to show the validity of a mobile based application (“Serenita”) , as a tool for measuring stress level quantitatively. In this interactive app, the use...

    Background: The aim of the present study was to show the validity of a mobile based application (“Serenita”) , as a tool for measuring stress level quantitatively. In this interactive app, the user places his finger on the mobile`s camera lens, through which information related to the user’s blood flow, heart rate, and heart rate variability (HRV) is extracted. Physiological signals are then being filtered and processed through a certain machine- algorithm, resulting in a quantitative estimation of the user’s stress level. Method: a mixed sex group of 50 volunteers were recruited to participate in a standardized laboratory experiment, where a psychosocial stress protocol (Trier Social Stress Test-TSST) was implemented. Throughout the course of the experiment, physiological stress response was measured using both salivary cortisol level and Serenita app, hence, using a within subject design. Results: Serenita algorithm was able to effectively detect changes in the participant`s estimated stress level, as expected by the different experimental conditions and followed the robust physiological response pattern usually obtained by the TSST protocol. In addition, a cross correlation of .93 was obtained between the estimated stress level, using Serenita`s algorithm, and Cortisol level measures. Conclusions: these results serve a double validation for Serenita as an effective tool to quantitatively measure physiological stress response. This innovative technique bears important implications for the field of stress research and treatment, providing to the best of our knowledge the first clinically validated non-lab based quantitative physiological stress measurement tool. Objective: The aim of the present study was to show the validity of a mobile based application (“Serenita”) , as a tool for measuring stress level quantitatively. Methods: The current study was designed to validate and fine-tune the algorithms supporting the stress estimation function in this mobile application, under a clinical setting. In order to validate Serenita as an adequate stress estimator it was necessary to build a standardized experimental protocol able to i) effectively induce stress on a set of volunteers, ii) and properly quantify the stress variation. To this end, we adopted the Trier Social Stress Test (TSST -Kirschbaum, Pirke, & Hellhammer, 1993) as this well documented laboratory procedure, was shown to reliably induce stress in human research participants and used extensively in the field of stress studies (e.g., Kudielka, Hellhammer, Kirschbaum, Harmon-Jones, & Winkielman, 2007; Allen, Kennedy, Cryan, Dinan, & Clarke, 2014). The efficiency of TSST as a stress inducer, was explored not only through properly calibrated questionnaires but also with the analysis of the Cortisol, as physiological stress indicator, which is extensively used in clinical setting to determine stress levels and the response to stressful events. Similarly, the current study followed the typical experimental protocol. However, its novelty lies in combining traditional as solid stress inducer (TSST) and indicator (saliva cortisol), with an innovative digital-health assessment tool (Serenita application). Utilizing both tools to measure physiological stress in the course of the experiment, will not only comply with our research goal of establishing reliability and validity, but also will neutralize any potential variability in stress response that might be stemming from sex differences (e.g., Kirschbaum, Klauer, Filipp, & Hellhammer, 1995; Kelly, Tyrka, Anderson, Price, & Carpenter, 2008). Results: Serenita algorithm was able to effectively detect changes in the participant`s estimated stress level, as expected by the different experimental conditions and followed the robust physiological response pattern usually obtained by the TSST protocol. In addition, a cross correlation of .93 was obtained between the estimated stress level, using Serenita`s algorithm, and Cortisol level measures. Conclusions: these results serve a double validation for Serenita as an effective tool to quantitatively measure physiological stress response. This innovative technique bears important implications for the field of stress research and treatment, providing to the best of our knowledge the first clinically validated non-lab based quantitative physiological stress measurement tool. Conclusions: The present study aimed at investigating if the stress estimation algorithm, used by the Serenita app, was able to accurately estimate variations on stress levels. The TSST widely established as the standard protocol for stress induction was used to induce stress on a controlled clinical environment. The estimated stress levels show a high agreement rate with the expected stress response of the TSST. Furthermore, the analysis of salivary cortisol levels provided an objective measure of the real variation on stress levels, the average cortisol curve has a correlation index of 0.93 with the estimated stress provided by Serenita’s stress algorithm, supporting the stress estimation algorithm as a feasible way to estimate stress. Finally, in many stress monitoring applications it is useful to know, not just the relative change in stress along the time, but also to obtain a quantitative value for the stress level at any given time. Due to the highly subject-dependent nature of the basal level of stress (and cortisol) this task is relatively complex, however using a priori information such as age, gender, health condition, among others, it is possible to project the stress function into a bounded quantitative stress scale e.g. 0 − 100%. As far as we know this is the first time where an application is providing a quantitative and validated method comparable to measuring stress with a lab test. This tool could serve as a research tool in stress studies.

  • Support or subversion? – The reasons that medical students use online discussion forums.

    From: Journal of Medical Internet Research

    Date Submitted: Nov 19, 2017

    Open Peer Review Period: Nov 19, 2017 - Jan 14, 2018

    Background: Internet use has increased enormously over the last several decades. One popular use of the Internet is to engage with online discussion forums to discuss and seek advice from others. Thes...

    Background: Internet use has increased enormously over the last several decades. One popular use of the Internet is to engage with online discussion forums to discuss and seek advice from others. These forums form a safe and often anonymous place to carry out various discussions and are understandably popular amongst young adults who typically have concerns and questions they feel unable to discuss openly. Such forums are therefore commonly used amongst medical students in the UK, as they provide a safe, non-judgemental environment. Medical students are usually self- directed and eager to learn as they generally seek groups of colleagues to study together with and contact tutors to improve their learning. Online forums provide another method for peer learning which is not constrained by the availability of others and may allow less confident learners to engage. Research also shows that students who do not participate as much in class due to being more introverted or lacking confidence or prior knowledge tend to contribute more actively on online forums. Objective: This study was conducted to explore the types of engagement medical students in the UK have with such forums. This will help identify areas of education, advice and support that may be required by medical students. Methods: ‘Thestudentroom’ online forum was found to be the most popularly used by medical students in the UK. Data and associated responses were extracted from its sub-forum ‘Current Medical Students and Doctors.’ Each month had on average, approximately 20 to 30 posts. Due to the high number of posts, the first 6 posts per month, from 2015 were extracted and analysed in this project. Posts were coded thematically in textual form by the student author. The idea of this thematic coding was to identify the best fit coding categories under which any discussion post can suitably fit. A second researcher then validated a proportion of the data coding. Results: In total 72 threads with 420 lines of individual text response were extracted for analysis. Codes were grouped into relevant broad categories and four themes emerged: study advice, career advice, health issues and personal & professional support. Validation of feelings and emotional support were additional over-arching factors that emerged throughout. Conclusions: This study identified four main areas of discussion and suggests where additional advice from medical schools may be needed. It also highlighted important roles anonymous forums play, in allowing students to seek opinion, personal and study support in the competitive environment of a medical school and obtain validation and reassurance about decisions. Forums appear to have benefitted students hence, medical schools should encourage their students to engage in such forums in a professional manner.

  • Privacy-Preserving Harmonization of Contextual Embeddings From Different Sources

    From: Journal of Medical Internet Research

    Date Submitted: Nov 20, 2017

    Open Peer Review Period: Nov 21, 2017 - Jan 16, 2018

    Background: Data sharing has been a big challenge in biomedical informatics due to privacy concerns. Contextual embedding models have demonstrated very strong representative capability to describe med...

    Background: Data sharing has been a big challenge in biomedical informatics due to privacy concerns. Contextual embedding models have demonstrated very strong representative capability to describe medical concepts (and their context), and they have shown promise as an alternative way to support deep learning applications without the need to disclose original data. However, contextual embedding models acquired from individual hospitals cannot be directly combined because their embedding spaces are different and naive pooling renders combined embeddings useless. Objective: We present a novel approach to address these issues to promote sharing representation without sharing data. We can build a global model from representations learned from local private data without sacrificing privacy and synchronize information from multiple sources. Methods: We propose a methodology that harmonizes different local contextual embeddings into a global model. We use Word2Vec to generate contextual embeddings from each source and Procrustes to fuse different vector models into one common space by using a list of corresponding pairs as anchor points. With harmonized embeddings, we performed prediction analysis. Results: We used sequential medical events extracted from the Medical Information Mart for Intensive Care III database to evaluate the proposed methodology in predicting the next likely diagnosis of a new patient using either structured data or unstructured data. Under different experimental scenarios, we confirmed that the global model built from harmonized local models achieves more accurate prediction than local models and global model built from naive pooling. Conclusions: Such aggregation of local models using our unique harmonization can serve as the proxy for a global model, combining information from a wide range of institutions and information sources. It allows information unique to a certain hospital to become available to other sites, increasing the fluidity of information flow in health care.

  • The Interactive Child Distress Screener: Development and Preliminary Feasibility Testing

    From: Journal of Medical Internet Research

    Date Submitted: Nov 21, 2017

    Open Peer Review Period: Nov 22, 2017 - Jan 17, 2018

    Background: Early identification of child emotional and behavioral concerns is essential for the prevention of mental health problems, however, few suitable child-report screening measures are availab...

    Background: Early identification of child emotional and behavioral concerns is essential for the prevention of mental health problems, however, few suitable child-report screening measures are available. Digital tools offer an exciting opportunity for obtaining clinical information from the child’s perspective. Objective: This paper describes the initial development and pilot testing of the Interactive Child Distress Screener (ICDS). The ICDS is a web-based screening instrument for the early identification of emotional and behavioral problems in children aged between 5 and 12 years. Methods: This paper utilized a mixed-methods approach to a) develop and refine item content using an expert review process (Study 1) and b) develop and refine prototype animations and app interface using co-design with child users (Study 2). Study 1 involved an iterative process comprised of four steps: 1) initial development of target constructs, 2) preliminary content validation (face validity, item importance and suitability for animation) from an expert panel of researchers and psychologists (N = 9), 3) item refinement, and 4) follow-up validation with the same expert panel. Study 2 also comprised four steps: 1) development of prototype animations, 2) development of the app interface and response format, 3) child interviews to determine feasibility and obtain feedback, and 4) refinement of animations and interface. Cognitive interviews were conducted with 18 children aged between 4 and 12 years who tested three prototype animated items. Children were asked to describe the target behavior, how well the animations captured the intended behavior, and provide suggestions for improvement. Their ability to understand the wording of instructions was also assessed, as well as the general acceptability of character and sound design. Results: In Study 1, a revised list of 15 constructs was generated from the first and second round of expert feedback. These were rated highly in terms of importance (M = 6.32/7, SD = 0.42) and perceived compatibility of items (M = 6.41/7, SD = 0.45). In Study 2, overall feedback regarding the character design and sounds was positive. Children’s ability to understand intended behaviors varied according to target items, and feedback highlighted key objectives for improvements, such as adding contextual cues or improving character detail. These design changes were incorporated through an iterative process, with examples presented. Conclusions: The ICDS has potential to obtain clinical information from the child’s perspective that may otherwise be overlooked. If effective, the ICDS will provide a quick, engaging and easy-to-use screener that can be utilized in routine care settings. This project highlights the importance of involving expert review and user co-design in the development of digital assessments for children. Clinical Trial: n/a

  • Development of an internet-administered, guided, CBT based, psychological, self-help intervention (ENGAGE) for parents of children previously treated for cancer and the procedures for future studies testing and evaluating the intervention: A Participatory Action Research approach

    From: Journal of Medical Internet Research

    Date Submitted: Nov 20, 2017

    Open Peer Review Period: Nov 20, 2017 - Jan 15, 2018

    Background: Parenting a child through cancer is a distressing experience and a subgroup of parents report negative long-term psychological consequences years after treatment completion. However, there...

    Background: Parenting a child through cancer is a distressing experience and a subgroup of parents report negative long-term psychological consequences years after treatment completion. However, there is a lack of evidence-based psychological interventions for parents who experience distress in relation to a child’s cancer disease after end of treatment. Objective: To develop an internet-administered, guided, CBT based, psychological, self-help intervention (ENGAGE) for parents of children previously treated for cancer, and identify acceptable procedures for future feasibility and efficacy studies testing and evaluating the intervention. Methods: Participatory Action Research (PAR) methodology was used. The study included face-to-face workshops and related online exercises. Six parents (four mothers, two fathers) of children previously treated for cancer were involved as parent research partners (PRPs). Two clinical psychologists were involved as expert research partners (ERPs). Research partners and research group members worked collaboratively throughout the study. Data were analysed iteratively using written summaries of the workshops and online exercises parallel to data collection. Results: A 10-week, internet-administered, guided, CBT based, psychological, self-help intervention (ENGAGE) was developed in collaboration with PRPs and ERPs. The content of the intervention, mode and frequency of e-therapist support and individualised approach for feedback were modified based on research partner input. Shared solutions were reached regarding the type and timing of support from an e-therapist, duration and timing of intervention, and the removal of “unnecessary” support functions. Preferences for study procedures in future studies testing and evaluating the intervention were discussed, but consensus was not reached. Conclusions: The PAR process contributed to the further development of an internet-administered, guided, CBT based, psychological self-help intervention (ENGAGE) for parents of children previously treated for cancer and identified areas for further study regarding acceptable procedures for future studies testing and evaluating the intervention. To the best of our knowledge this study is the first use of a PAR approach to develop a psychological intervention for parents of children previously treated for cancer and to identify acceptable study procedures. Involvement of parents with lived experience was vital in the development of a potentially relevant and acceptable intervention for this population.

  • Applications of Space Technologies to Global Health: A Scoping Review

    From: Journal of Medical Internet Research

    Date Submitted: Nov 20, 2017

    Open Peer Review Period: Nov 21, 2017 - Jan 16, 2018

    Background: Space technology has an impact on many domains of activity on earth, including in the field of global health. With the recent adoption of the United Nations’ (UN) Sustainable Development...

    Background: Space technology has an impact on many domains of activity on earth, including in the field of global health. With the recent adoption of the United Nations’ (UN) Sustainable Development Goals, which highlight the interdependence and possible synergies of different domains, it is useful to better characterize the relationship between space technology and global health. Objective: To identify the applications of space technologies to global health, the key stakeholders in the field as well as the gaps and challenges. Methods: We used a scoping review methodology, including a literature review and the involvement of stakeholders via self-administered questionnaires. A distinct search on several search engines was conducted for each of the four key technological domains that were previously identified by the UN Office for Outer Space Affair’s expert group on space and global health (domain A: remote sensing, B: global navigation satellite systems, C: satellite communication and D: human space flights). Themes in which space technologies are of benefit to global health were extracted. Key stakeholders as well as gaps, challenges and perspectives were identified. Results: 222 sources were included for domain A, 82 sources for domain B, 144 sources for domain C and 31 sources for domain D. 3 questionnaires out of 16 sent were answered. Global Navigation Satellite Systems (GNSS) and Global Information Systems were used for the study and forecasting of communicable and non-communicable diseases; Satellite communication and GNSS for disaster response; Satellite communication for telemedicine and tele-education; GNSS for autonomy improvement; access to healthcare, as well as for safe and efficient transportation. Various researches and technologies developed for inhabited space flights have been adapted for terrestrial use. Conclusions: Although numerous examples of space technology applications to global health exist, improved awareness, training and collaboration of the research community is needed.

  • Which features are important for the effectiveness of physical activity-related apps? Results of an expert panel approach.

    From: JMIR mHealth and uHealth

    Date Submitted: Nov 22, 2017

    Open Peer Review Period: Nov 22, 2017 - Jan 17, 2018

    Background: A large number of people participate in individual or unorganized sports on a recreational level. Also, it has been shown that many participants drop-out due to injury or lowered motivatio...

    Background: A large number of people participate in individual or unorganized sports on a recreational level. Also, it has been shown that many participants drop-out due to injury or lowered motivation. Potentially physical activity-related applications (apps) could motivate people during sport participation and help them to follow and maintain a healthy active lifestyle. However, the question is whether the quality of currently available apps is sufficient to support recreational sport participants. It remains unclear how the quality of running, cycling and walking apps can be assessed and if some app features may be more important than others for participation in recreational sports. Therefore, more insight into the value of different app features is necessary. Objective: The aim was to identify which features are important for the effectiveness of physical activity-related apps for participation in individual, recreational sports based on experts. Methods: The data were gathered via an expert panel approach using the Nominal Group Technique (NGT). Two expert panels were organized to identify and rank app features relevant for sport participation. Experts with a scientific background in ICT, service-design, industrial design or research through design (expert panel 1) and with a scientific background in behavioral, psychological, health or human movement sciences or practical experience in these domains and affinity with physical activity-related apps (expert panel 2) were included. Each panel session consisted of three consultation rounds. The ten most important features per expert were collected. We calculated the frequency of the features in the top 10 as well as the mean importance score per feature (0-100). In addition, the sessions were taped and transcribed verbatim. A thematic analysis was conducted on the qualitative data and focused on the answers that illustrated and supported the experts’ ranking choices. Results: In expert panel 1 applied feedback and feedforward (91.3) and fun (91.3) were found most important (scale 0-100). Together with flexibility and “look and feel” these features were mentioned most often (all n=4, 41.3 and 43.8 respectively). The experts in panel 2 found instructional feedback (95.0), motivating / challenging (95.0) and monitoring / statistics (92.5) most important. The feature that was ranked most often was usability (n=7), followed by monitor/statistics (n=5) and fun/pleasure (n=5) (77.5 – 92.5). Based on the qualitative analysis, we identified two main themes of features from the expert panels, which were features related to (behavior change) theories and entry requirements for apps. Conclusions: Taken together, the results show that a variety of features, including design, technical and behavior change, are considered as important for the effectiveness of physical activity-related apps by experts from different fields of expertise. These insights may assist in the development of an improved app rating scale for these apps.

  • Using Facebook and Instagram Ads and Intercept Recruitment in LGBT Bars and Nightclubs to Recruit LGBT Young Adults for Survey Research

    From: Journal of Medical Internet Research

    Date Submitted: Nov 20, 2017

    Open Peer Review Period: Nov 20, 2017 - Jan 15, 2018

    Background: Tobacco public education campaigns are focusing increasingly on hard-to-reach (HTR) populations at higher risk for smoking (eg, lesbian, gay, bisexual, and/or transgender [LGBT] young adul...

    Background: Tobacco public education campaigns are focusing increasingly on hard-to-reach (HTR) populations at higher risk for smoking (eg, lesbian, gay, bisexual, and/or transgender [LGBT] young adults), prompting campaign content creators and evaluators to develop marketing and participant recruitment strategies to reach HTR populations in virtual and physical spaces where they frequently spend time. Objective: This study describes 2 novel recruitment strategies and compares characteristics of participants recruited via these strategies for FDA’s This Free Life campaign evaluation targeting LGBT young adults. Methods: We recruited LGBT adults aged 18–24 in 24 designated market areas in the United States via Facebook and Instagram ads (N= 1,709, mean age= 20.94, SD= 1.94) or intercept in LGBT social venues (N= 2,348, mean age= 21.98, SD= 1.69) for the baseline evaluation survey. Covariates related to recruitment strategy were age, race/ethnicity, LGBT identity, education, pride event attendance, and alcohol, cigarette, and social media use. Results: Lesbian/gay women (aOR= 1.88, P< .001), bisexual men and women (aOR= 1.46, P= .001), gender minorities (aOR= 1.68, P< .001), and other sexual minorities (aOR= 2.48, P< .001) were more likely than gay men to be recruited via social media (than intercept). Hispanic (aOR= 0.73, P= .001) and other/multiracial, non-Hispanic participants (aOR= .70, P= .006) were less likely than white, non-Hispanic participants to be recruited via social media. As age increased, odds of recruitment via social media decreased (aOR= .76, P< .001). Participants with some college (aOR= 1.27, P= .03) were more likely than those with a college degree to be recruited via social media. Participants reporting alcohol use in the past 30 days were less likely to be recruited via social media (aOR= 0.33, P< .001). Participants who reported past-year pride event attendance were more likely to be recruited via social media (aOR= 1.31, P= .02) as well as those who used Facebook at least once a day (aOR= 1.43, P= .002). Participants who reported using Instagram at least once a day were less likely to be recruited via social media (aOR= .73, P< .001). Social media recruitment was faster and more cost effective than intercept but had greater data quality issues—a larger percentage of social media respondents were lost due to duplicate and low quality responses (8.4%) compared to intercept respondents lost to interviewer misrepresentation (.3%) (P< .001). Conclusions: Social media provided access to important LGBT subpopulations (bisexual and gender and other sexual minority) and a more diverse LGBT sample when combined with intercept. Social media methods have more data quality issues but are faster and less expensive than intercept. Recruiting HTR populations via novel, audience-tailored strategies enabled recruitment of one of the largest known LGBT young adult samples, suggesting the promise of these methods for accessing HTR populations.

  • Detecting Motor Impairment in Early Parkinson’s Disease via Natural Typing Interaction with Keyboards: Validation of the neuroQWERTY Approach in an Uncontrolled At-Home Setting

    From: Journal of Medical Internet Research

    Date Submitted: Nov 20, 2017

    Open Peer Review Period: Nov 20, 2017 - Jan 15, 2018

    Background: Parkinson’s disease (PD) is the second most prevalent neurodegenerative disease and one of the most common forms of movement disorder. Although there is no known cure for PD, existing th...

    Background: Parkinson’s disease (PD) is the second most prevalent neurodegenerative disease and one of the most common forms of movement disorder. Although there is no known cure for PD, existing therapies can provide effective symptomatic relief. However, optimal titration is crucial in order to avoid adverse effects. Today, decision making for PD management is challenging because it relies on subjective clinical evaluations that require a visit to the clinic. This challenge has motivated recent research initiatives to develop tools that can be used by non-specialists to assess psychomotor impairment. Among these emerging solutions, we recently reported the neuroQWERTY index (nQi), a new digital marker able to detect motor impairment in an early PD cohort through the analysis of the key press/release timing data collected during a controlled in-clinic typing task. Objective: Our aim is to extend the in-clinic implementation to an at-home implementation by validating the applicability of the neuroQWERTY approach in an uncontrolled at-home setting, using the typing data from subjects’ natural interaction with their laptop to enable remote and unobtrusive assessment of PD signs. Methods: We implemented the data collection platform and software to enable access and storage of the typing data generated by users’ when using their computer at home. We recruited a total of 60 participants, from whom 52, 25 people with Parkinson’s and 27 healthy controls (CNT), provided enough data to complete the analysis. Finally, to evaluate if our in-clinic built algorithm could be used in an uncontrolled at-home setting, we compared its performance on the data collected during the controlled typing task in the clinic and the results of our method using the data passively collected at home. Results: Despite the randomness and sparsity introduced by the uncontrolled setting, our algorithm performed nearly as well in the at-home data (AUC of 0.76 and 0.73/0.69 sensitivity/specificity) as it did when used to evaluate the in-clinic data (AUC 0.83 and 0.77/0.72 sensitivity/specificity). Moreover, the keystroke metrics presented a strong correlation between the two typing settings, which suggests a minimal influence of the in-clinic typing task in users’ normal typing. Conclusions: The finding that an algorithm trained on data from an in-clinic setting has comparable performance with tested on data collected through naturalistic at home computer use reinforces the hypothesis that subtle differences in motor function can be detected from typing behavior. This work represents another step towards an objective, user-convenient and quasi-continuous monitoring tool for PD. Clinical Trial: NCT02522065

  • The Efficacy of eHealth supported Home Exercise Interventions for Patients with Osteoarthritis of the Knee: A Systematic Review

    From: Journal of Medical Internet Research

    Date Submitted: Nov 27, 2017

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

    Background: Osteoarthritis of the knee is the most common cause for disability and limited mobility in the elderly with considerable individual suffering and high direct and indirect disease related c...

    Background: Osteoarthritis of the knee is the most common cause for disability and limited mobility in the elderly with considerable individual suffering and high direct and indirect disease related costs. Non-surgical interventions such as exercise, enhanced physical activity and self-management have shown beneficial effects in terms of pain reduction as well as improvement of physical function and quality of life, for many access to these treatments is limited due to lack of mobility or adequate health care facilities. Therefore home therapy is strongly recommended, however adherence to these programs is low. Patients report lack of motivation, feedback and personal interaction as the main barriers to home therapy adherence. To overcome these barriers, eHealth is seen as a promising opportunity. eHealth technology such as mobile apps or web-based programs offer tailored instructions, allow monitoring of progress and interaction with fellow patients, therapists and medical personnel. While beneficial effects have been shown in the literature for other chronic diseases such as chronic pain, cardiovascular disease and diabetes, a systematic literature review on the efficacy of eHealth interventions for patients with osteoarthritis of knee is missing so far. Objective: To compare the efficacy of eHealth interventions to no or other interventions regarding pain, physical function and health related quality of life (QoL) Methods: Medline, CENTRAL, CINAHL and PEDro were systematically searched using the keywords osteoarthritis knee, eHealth and exercise. An inverse variance random-effects meta-analysis was carried out pooling standardized mean differences of individual studies. The Cochrane tool was used to assess risk of bias in individual studies and the quality of evidence across studies was evaluated following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results: The literature search yielded a total of 648 results. After screening of titles, abstracts and full-texts, seven RCTs were included. Pooling the data of individual studies demonstrated beneficial short-term (pain SMD -0.31, 95% CI -0.58 to -0.04, low quality; QoL SMD 0.24, 95% CI 0.05 to 0.43, moderate quality) and long-term effects (pain -0.30, 95% CI -0.07 to -0.53, moderate quality; physical function 0.41, 95% CI 0.17 to 0.64, high quality; QoL SMD 0.27, 95% CI 0.06 to 0.47, high quality). Conclusions: eHealth supported exercise interventions resulted in less pain, improved physical function and health-related quality of life compared to no or other interventions, however these improvements were small (SMD<0.5) and may not make a meaningful difference for individual patients. Low adherence is seen as one limiting factor of eHealth interventions. Future research should focus on participatory development of eHealth technology integrating evidence-based principles of exercise science and ways of increasing patient motivation and adherence. Clinical Trial: Review Registration: PROSPERO 2017 CRD42017072079

  • Satisfying Product Features of a Falls Prevention Smartphone Application and Potential Users’ Willingness-to-pay: Web-based Survey among Older Adults

    From: JMIR mHealth and uHealth

    Date Submitted: Nov 21, 2017

    Open Peer Review Period: Nov 21, 2017 - Jan 16, 2018

    Background: Falls and fall-related injuries are a major challenge for healthcare systems worldwide as a substantial proportion of falls occur for older adults who are neither frail nor at high risk. H...

    Background: Falls and fall-related injuries are a major challenge for healthcare systems worldwide as a substantial proportion of falls occur for older adults who are neither frail nor at high risk. Hence, preventive measures are needed, sensitizing older adults for their possible fall risk. Health applications seem to be a promising attempt to address this problem, as they enable users to assess their individual fall risk on their own. Objective: Identify product features of a fall prevention smartphone application which increase or decrease users’ satisfaction and therefore their motivation to use such an application. Additionally willingness-to-pay was assessed to get to know how such an application could be monetarized. Methods: A total of 96 participants completed an open self-selected Web-based survey. Participants answered various questions regarding health status, subjective and objective fall risk, and technical readiness. Seventeen predefined product features of a fall prevention smartphone application were rated according the Kano model by participants. This model is known from user oriented product development and captures expectations towards and satisfaction by a product. Results: Five product features were identified to increase users’ acceptance including a checklist of typical tripping hazards, an emergency guideline in case of a fall incidence, description of exercises and integrated workout plans which decrease risk of falling. Participants’ willingness-to-pay was assessed after all 17 product features were rated and revealed a monthly payment rate of €7.56 Euros (SD = 12.6). Conclusions: The results show various motivating product features that should be incorporated into a fall prevention smartphone application. Our results show aspects that fall prevention and intervention designers should keep in mind to encourage individuals to start joining their program and facilitate long-term user engagement, resulting in a greater interest in fall risk prevention. Clinical Trial: Not applicable.

  • Telehealth Nursing Effectiveness in Stroke Patients

    From: Journal of Medical Internet Research

    Date Submitted: Nov 21, 2017

    Open Peer Review Period: Nov 21, 2017 - Jan 16, 2018

    Background: Stroke care requires immediate assessment and treatment, to reduce the risk of death and disability. Many patients do not receive timely interventions due to lack of immediate health care...

    Background: Stroke care requires immediate assessment and treatment, to reduce the risk of death and disability. Many patients do not receive timely interventions due to lack of immediate health care expertise and specialist services.Therefore better collaboration, communication and coperation between the health care providers and the stroke patients is needed. Telehealth enabling interventions with stroke patients and nurses are considered to improve medical outcomes. Objective: The primary objective of this review is to analyze the effectiveness of telestroke nursing interventions .A further focus is laid on the themes and findings extracted from these papers. This review was aimed to address the broad research question in mind, which is as follows: Does telehealth enabling interventions involving stroke patients and nurses improve medical outcomes? Methods: A systemic review design was conducted using the Preferred Reporting Items of Systemic Reviews Meta-Analyses (PRISMA) guidelines. A comprehensive and systemic search was undertaken using PubMed/ Medline as well as EMBASE electronic databases .The search strategy included the Medical Subject Headings (MeSH) terms; “telehealth” “telemedicine” “nursing” and “stroke”. Article selection was done through a process of removing duplicates, analyzing the title and abstract, and then reviewing the full text of the article. Results: The query results were evaluated and narrowed down to 37 articles. Studies suggest that telestroke along with the proper health care providers input and nursing support can help in providing enhanced stroke diagnosis, and improve long-term outcomes. . Four of the selected articles were pertaining to telehealth nursing management and education for stroke patients(10%, n=4), two articles were about the benefits of telestroke for speedy discharge and recovery(5.4%, n=2), seven were about telehealth nursing education and care for stroke patients as well as caregivers(18.92%, n=7), two covered the topic of a stroke-specific, care coordination home telehealth (CCHT) program (5.4%,n=2), two were related to acceptance of telestroke by caregivers in home setting(5.4%, n=2), five articles emphasized how telehealth and such techniques help in savings and decrease stroke patient cost( 13.5%,n=5), seven more papers discussed how telemedicine is considered along with other strategies to manage stroke(18.92%, n=7), six papers described the methods in which acute ischemic stroke is managed in emergency medicine with telehealth and related techniques(16.27%,n=6) and two articles covered how telehealth helps in diagnosis of stroke(5.4%, n=2). Conclusions: The review of the papers overall highlight a positive role of telehealth nursing towards stroke patient care. More data collection and statistical analysis is needed to validate and address the research question. Technological breakthroughs have contributed tremendously toward stroke care of patients, leading us to believe that telestroke along with the proper health care providers input and nursing support can help in providing enhanced stroke diagnosis, increased tissue plasminogen activator administration and improved long-term outcomes.

  • Electronic clinical surveillance system to identify unmet treatment needs for patients encountering osteoporotic fracture

    From: Journal of Medical Internet Research

    Date Submitted: Nov 26, 2017

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

    Background: Traditional clinical surveillance relied on the results from clinical trials, and observational studies of administrative databases. However, these studies not only require a lot of valuab...

    Background: Traditional clinical surveillance relied on the results from clinical trials, and observational studies of administrative databases. However, these studies not only require a lot of valuable resources but also faced a very long time lag. Objective: To illustrate a practical application of the National Taiwan University Hospital Clinical Surveillance System (NCSS) in the identification of patients with an osteoporotic fracture, and provide a high reusability infrastructure for a computerized workflow that capture of relevant longitudinal clinical data and make those data repositories be reuse. Methods: The NCSS integrates electronic medical records in the National Taiwan University Hospital (NTUH) with a data warehouse, and is equipped with a user-friendly interface. The NCSS was developed using professional insight from multidisciplinary experts including clinical practitioners, epidemiologists, and biomedical engineers. The practical example identifying the unmet treatment needs for patients encountering major osteoporotic fractures described herein was mainly achieved by adopting the computerized workflow in the NCSS. Results: We developed the infrastructure of the NCSS, including an integrated data warehouse and an automatic surveillance workflow. By applying the NCSS, we efficiently identified 2,193 patients who newly diagnosed with a hip or vertebral fracture between 2010 and 2014 at NTUH. By adopting the filter function, we identified 1,808 (82.4%) patients who continued their follow-up at NTUH, and 464 (21.2%) patients who were prescribed anti-osteoporosis medications, within 3 and 12 months post index fracture, respectively. Conclusions: The NCSS systems can integrate the workflow of cohort identification to accelerate the survey process of clinically relevant problems and provide decision support in the daily practice of clinical physicians, thereby making the benefit of evidence-based medicine a reality.

  • Game Plan: A Web Application to Help Men Who Have Sex with Men Reduce their HIV Risk and Alcohol Use

    From: JMIR mHealth and uHealth

    Date Submitted: Nov 22, 2017

    Open Peer Review Period: Nov 23, 2017 - Jan 18, 2018

    Background: Men who have sex with men (MSM) are at high risk for HIV, and alcohol use is a major risk factor for HIV infection. Internet-facilitated brief interventions have been shown to reduce alcoh...

    Background: Men who have sex with men (MSM) are at high risk for HIV, and alcohol use is a major risk factor for HIV infection. Internet-facilitated brief interventions have been shown to reduce alcohol use and HIV-risk behavior in other at-risk populations, but have so far incorporated limited content and have not been tested among MSM. Objective: This manuscript describes Game Plan, an interactive, tablet-optimized web application designed to help heavy drinking, high-risk MSM consider reducing their alcohol use and sexual risk behavior. Methods: In this paper, we discuss the rationale, goals, and flow for each of Game Plan’s components, which were modelled after common in-person and web-based brief motivational interventions for these behaviors. Results: The app is unique in that it includes content urging users to reflect more profoundly on their current behavior, and if prepared to change, strengthen their commitment to doing so. Conclusions: Should ongoing research support its efficacy in facilitating behavior change, Game Plan could represent a wide-reaching and scalable tool that is well-suited for use in settings where delivering evidence-based, in-person interventions would be difficult or cost-prohibitive.

  • Impact of mental health screening on online help-seeking: Randomised trial comparing normative vs humour-driven feedback

    From: Journal of Medical Internet Research

    Date Submitted: Nov 23, 2017

    Open Peer Review Period: Nov 23, 2017 - Jan 18, 2018

    Background: Given the widespread availability of screening and monitoring Apps for mental health problems, providing tailored feedback may encourage people at high risk to seek help to manage their sy...

    Background: Given the widespread availability of screening and monitoring Apps for mental health problems, providing tailored feedback may encourage people at high risk to seek help to manage their symptoms. While Apps typically provide personal score feedback only, feedback types that are user-friendly and increase personal relevance may encourage further help-seeking. Objective: The aim of this study is to compare the immediate effects of normative and humour-driven feedback based on online mental health help-seeking and to explore predictors that encourage help-seeking. Methods: An online sample of 549 adults were recruited using social media advertisements. Participants downloaded a smartphone App which allowed them to screen their mental wellbeing through completing standardised measures on Symptoms (K6), Wellbeing (WHO Five Wellbeing Index), and Resilience (Brief Resilience Scale). Participants were randomised to receiving normative feedback that compared their scores to a reference group or humour-driven feedback that presented their scores in an engaging fashion. Those who scored in the moderate or poor ranges in any measure were encouraged to seek further help by clicking on a link to an external online resource. Results: There was no significant difference of feedback type on online help-seeking for all the measures. A larger proportion of participants from the Wellbeing measure (62%) clicked on the links than the Resilience (26%) or Symptoms (35%) measures. There were no significant demographic factors associated with help-seeking for the Resilience or Wellbeing measures. Participants with previous poor mental health were less likely than those without such history to click on the external help-seeking link in the Symptoms measure (p=.003, OR=0.83). Conclusions: Normative and humour-driven feedback were no different in encouraging immediate online help-seeking. Limitations included lack of personal score control group, limited measures of predictors and other forms of help-seeking. Further investigation into factors that affect help-seeking after personal feedback is needed. Clinical Trial: ACTRN12616000707460

  • User-experience of Patients with Telehealth: Complementing a Clinical Trial with Human-Computer Interaction

    From: Journal of Medical Internet Research

    Date Submitted: Nov 23, 2017

    Open Peer Review Period: Nov 23, 2017 - Jan 18, 2018

    Background: The use of telehealth to monitor patients from home is on the rise. A telehealth technology is evaluated in a clinical trial with measures of health outcomes and cost effectiveness. Howeve...

    Background: The use of telehealth to monitor patients from home is on the rise. A telehealth technology is evaluated in a clinical trial with measures of health outcomes and cost effectiveness. However, what happens between a technology and the patients are not investigated during a clinical trial −the telehealth technology remains as a “black box”. Meanwhile three decades of research in the discipline of Human-Computer Interaction (HCI) presents design, implementation and evaluation of technologies with a primary emphasis on users. HCI research exposed the importance of user-experience (UX) as an essential part of technology development and evaluation. Objective: This research investigates Type 2 Diabetes (T2D) patients’ experiences of a telehealth in-home monitoring technology through HCI approach. How HCI could complement future telehealth clinical trials for patient-centred design and evaluation is also explored. Methods: We adopted an ethnographic philosophy to conduct a contextual inquiry due to time-limitations and semi-structured interviews of nine T2D patients. We defined the method as Clinical User-experience Evaluation (CUE). The patients were enrolled in a telehealth clinical trial of T2D. However, this research is an independent HCI study, conducted by information technologists and health researchers for a patient-centred evaluation of telehealth. Results: Key analytical findings depicted that patients value the benefits of in-home monitoring but the current device did not possess all functionalities that patients want. Results contain patients’ experiences and emotions while using the device, patients’ perceived benefits of the device, and domestication of the device in their homes. Further analysis showed the influence of the device on patients’ awareness, family involvement, and design implications for telehealth T2D. Conclusions: CUE could complement the telehealth clinical trial and uncovered knowledges about T2D patients’ experiences, future design implications and importance of understanding patients in telehealth.

  • Perceived drivers and barriers to the adoption of online treatment by psychologists: The construction of the Levels of Adoption of Online Treatment Model

    From: Journal of Medical Internet Research

    Date Submitted: Nov 23, 2017

    Open Peer Review Period: Nov 23, 2017 - Jan 18, 2018

    Background: The Internet offers major opportunities in supporting mental healthcare and a variety of online mental and behavioral health services have been developed. Yet despite growing evidence for...

    Background: The Internet offers major opportunities in supporting mental healthcare and a variety of online mental and behavioral health services have been developed. Yet despite growing evidence for the effectiveness of these services, its acceptance and use in clinical practice remains low. So far, the current literature still lacks a structured insight into the experienced drivers and barriers to the adoption of online treatment from the perspective of clinical psychologists. Objective: The aim of the current study was to gain an in-depth understanding of the drivers and barriers for psychologists in adopting online psychological treatment tools, and to arrive at a conceptual model that helps us understand how these drivers and barriers affect technology acceptance and use. Methods: The study adopted a qualitative descriptive approach consisting of in-depth semi-structured interviews with clinical psychologists working in the Netherlands (N = 12). Based on the findings, a model was constructed, which was then examined through a communicative validation. Methods: The study adopted a qualitative descriptive approach consisting of in-depth semi-structured interviews with clinical psychologists working in the Netherlands (N = 12). Based on the findings, a model was constructed, which was then examined through a communicative validation. Results: In general, a key driver for psychologists to adopt online counseling is the belief and experience that it can be beneficial to them or their clients. Perceived advantages that are novel to literature include the acceleration of the treatment process, increased intimacy of the therapeutic relationship, and new treatment possibilities due to online counseling. More importantly, a relation was found between the extent to which psychologists have adopted online counseling, and the particular drivers and barriers they experience. This differentiation is incorporated in the Levels of Adoption of Online Treatment (LAOT) model, which we developed to provide a structured representation of the factors that influence the adoption of online treatment. From the LAOT model it can be inferred that interventions to increase adoption should be tailored to the practitioners’ personal level of adoption of online treatment. Conclusions: The study finds that the nature and importance of the various drivers and barriers perceived by psychologists are dependent on the extent to which they have adopted online treatment. The LAOT model facilitates further research on the process of adopting online psychological treatment, which will subsequently enable targeted recommendations with respect to technology, training and clinical practice, in order to ensure that mental healthcare professionals as well as their clients will benefit optimally from the current (and future) range of available online treatment options in mental healthcare.

  • Usability study: Mobile App assessing Health-related Quality of Life in Oncological Patients with the EORTC QLQ-C30 questionnaire

    From: JMIR mHealth and uHealth

    Date Submitted: Nov 24, 2017

    Open Peer Review Period: Nov 25, 2017 - Jan 20, 2018

    Background: Mobile applications (apps) are an evolving trend also in the medical field. However, there is ongoing discussion whether such apps are really valuable and whether patients will accept thei...

    Background: Mobile applications (apps) are an evolving trend also in the medical field. However, there is ongoing discussion whether such apps are really valuable and whether patients will accept their use in day-to-day clinical life. Therefore, we initiated a usability study in our department. Objective: We present our results of the first app prototype and patient testing of HRQoL assessment in oncological patients. Methods: We developed an app prototype for the operating system iOS® within eight months in 3 phases: conception, initial development, and pilot testing. For the HRQoL assessment, we chose to implement only the EORTC QLQ-C30 questionnaire (German version 3). The usability testing was conducted for three months. Participation was voluntary and pseudonymized. After completion of the C30 questionnaire using iPads provided by our department, we performed a short survey with ten questions. This survey inquired patients’ opinion about general aspects, such as technical advances in medicine, mobile and app assistance during cancer treatment, and the app-specific functions such as interface and navigation. Results: After login, the user can choose between starting a questionnaire, reviewing answers (admin only) and log out. The questionnaire is displayed with the same information, questions, and answers as on the original C30 sheet. No alterations in wording were made. The usability was tested with 81 patients; median age was 55 years. The median time for completing the HRQoL questionnaire on the iPad was 4.0 min. Of all participants, 84% (68/81) own a mobile device. 84% (68/81) would prefer a mobile version of the HRQoL questionnaire instead of the paper-based version. Using the app in daily life during and after cancer treatment would be supported by 83% (67/81). In the current app version data were stored on the device, in the future, 79% (64/81) of the patients would agree to data transfer via the Internet. Conclusions: Our usability test showed good results for the presented design of our app. Moreover, our results demonstrate a high overall acceptance of mobile apps and telemedicine in oncology. The HRQoL assessment via app was accepted thoroughly by patients and individuals are keen to use it in clinical routine while data privacy and security must be ensured. Clinical Trial: The Ethics Committee of the Technical University of Munich (TUM) approved the nature and content of the study with the project number 321/16 S.

  • The Young-with-Diabetes App-Study: A 12-month Randomized Controlled Trial

    From: JMIR mHealth and uHealth

    Date Submitted: Nov 23, 2017

    Open Peer Review Period: Nov 25, 2017 - Jan 20, 2018

    Background: Young people often struggle to self-manage type 1 diabetes (T1DM). Applications may have the potential to support self-management, but evidence is limited. Objective: We assessed whether t...

    Background: Young people often struggle to self-manage type 1 diabetes (T1DM). Applications may have the potential to support self-management, but evidence is limited. Objective: We assessed whether the application Young with Diabetes (YWD) improved young people’s self-management. Methods: Young people (14-22 years) with inadequate glycemic control and their parents were enrolled in a randomized controlled trial and assigned either to YWD and usual care (YWD group) or to usual care alone (control). YWD use was monitored; functions included a chat room, contact the healthcare provider, reminders, tips, information about the diabetes department and T1DM topics, carbohydrate counting, and a parents’ section. Outcomes included glycated hemoglobin (HbA1c) and three self-reported psychometric scales. Data were collected at baseline and at 2, 7, and 12 months. Results: 151 young people were randomized (YWD group=76, control=75) and 49 parents agreed to participate. At 12 months, HbA1c was significantly higher (4.08 mmol/mol [0.4 %]) in the YWD group, compared to the control group (P = .04); this finding did not occur among app users and compliers. Young people used YWD on a mean of 10.5 days. They spent the most time chatting about alcohol and searching for information about sex. Most young people and half of the parents reported that YWD helped them. More than 80% would recommend YWD to peers. Conclusions: YWD did not improve HbA1c, but it may be a useful complement to self-management. Qualitative evaluation is needed to explore benefits and shortcomings of YWD. Healthcare providers should address young peoples’ knowledge about sensitive topics, provide them with peer support, and be aware of parents’ need for information about how to support. Clinical Trial: Clinical Trials Registry NCT02632383.

  • The development of a smart screening device for primary health care

    From: Journal of Medical Internet Research

    Date Submitted: Nov 24, 2017

    Open Peer Review Period: Nov 24, 2017 - Jan 19, 2018

    Background: Adequate recognition of mental health problems is prerequisite for successful treatment. Though most people tend to consult their general practitioner first when they experience mental hea...

    Background: Adequate recognition of mental health problems is prerequisite for successful treatment. Though most people tend to consult their general practitioner first when they experience mental health problems, general practices are not very well equipped to screen for various forms of psychopathology and determining patients’ need for treatment. Objective: In this paper, the development and characteristics of a computerized adaptive test battery build to facilitate triage in primary care settings is described, and first results of implementation are reported. Methods: A bottom-up approach was implemented during development in which regular meetings were organized with general practitioners and mental health assistants. During implementation, users were requested to appraise clients’ ranking on the domains to be tested as well as the treatment level anticipated before test administration. Results: The result is CATja, an online computerized adaptive test battery that can be used by caregivers to screen their clients on several psychopathology domains and on two positive psychology domains. Agreements for clients’ domain scores were mostly between .40-.50, and for treatment level advised .65. Conclusions: By using CATja, caregivers can efficiently generate profiles of their clients’ strengths and weaknesses on which decisions about treatment type and care level may be based. Further validation research is needed.

  • Affordances for Crush the Crave, a mobile app for quitting smoking among young adults.

    From: Journal of Medical Internet Research

    Date Submitted: Nov 23, 2017

    Open Peer Review Period: Nov 25, 2017 - Jan 20, 2018

    Background: Smartphone apps have emerged as a promising way to reach young adult smokers given their high smartphone ownership rates, and openness to receiving cessation support via digital technologi...

    Background: Smartphone apps have emerged as a promising way to reach young adult smokers given their high smartphone ownership rates, and openness to receiving cessation support via digital technologies. While emerging evidence indicates that quit smoking apps are an effective way to reduce smoking among young adults, lacking is formative evaluative research that captures the perspectives of end-users. Objective: The objective of this study was to contribute insights toward understanding how young adults interact with the Crush the Crave (CTC app), and how this interaction shapes young adults’ smoking cessation experiences and practices, with consideration for the influence of gender. Methods: Semi-structured interviews were conducted with 31 young adult CTC users. Guided by sociomateriality theory and an affordances approach, data were inductively analyzed to derive thematic findings in relation to the impacts of CTC on quit efforts, and to expose the underlying affordances (mechanisms) that lend to these outcomes. Findings were grouped according to the 4 design components of CTC: credibility, social support, task support and dialogue support. Results: The credibility component of CTC played an important role in harnessing the trust of young adults because it afforded them promise in relation to its potential effectiveness in assisting them with quitting smoking. Affordances of the social support component lent to various user practices and experiences that rendered this aspect as the weakest component in supporting quit efforts. While most functions situated in the task and dialogue support components were found to be helpful, there were a few affordances in CTC that resulted in negative experiences, notably weaning from smoking. Gender-related influences were also evident. For example, young men preferred to control and self-manage their quitting and, therefore, did not engage with functions that afforded journaling or reminding to stay on track. Women, by contrast were more likely to benefit from these affordances. Conclusions: An affordances approach is productive for gaining an in-depth understanding of how mobile apps interact with users to lend to particular outcomes. The study findings have implications for developing and improving apps for helping young adults quit smoking, as well as apps that target other health behaviours. Productive affordances may also serve as a beginning framework for leveraging apps for smoking cessation.

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

    From: Journal of Medical Internet Research

    Date Submitted: Nov 29, 2017

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

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

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

  • It´s Still Personal: Preferences of Underserved Chilean Women on a Mobile Technology Intervention for Cervical Cancer Screening.

    From: JMIR mHealth and uHealth

    Date Submitted: Nov 26, 2017

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

    Background. In Chile and Latin America, cervical cancer disproportionately affects women of low socioeconomic status. Mobile technology (mHealth) may be able to address this disparity by targeting wom...

    Background. In Chile and Latin America, cervical cancer disproportionately affects women of low socioeconomic status. Mobile technology (mHealth) may be able to address this disparity by targeting women in underserved populations. However, there is a paucity of information regarding barriers to the implementation of mHealth interventions in underserved populations. Methods. We conducted nine focus groups among women 25-64 years of age to better understand the implementation barriers and perceptions of a text message-based intervention designed to improve cervical cancer screening rates. We used the PRECEDE PROCEED model to categorize identified themes using template analysis. Results. Focus group results indicated that older women use mobile phones to receive calls from family and friends but seldom send text messages. They also prefer personal contact with their health care providers regarding Pap testing. Younger women on the other hand find text messaging easy to use, and frequently send texts to family and friends. Importantly, women of all ages mentioned they would like to get messages about Pap tests. Factors that would facilitate uptake of the intervention include ease of access to the Pap testing, the ability to include family members, and reminder messaging. Potential barriers include cost and the impersonal nature of messaging. These results overall support the implementation of an mHealth intervention to increase cervical cancer screening rates. Conclusion: Mobile technologies may improve adherence to cancer screening guidelines, particularly in younger women. Older women still prefer personal contact and phone calls. Knowledge surrounding these preferences will aid in the implementation of effective strategies to improve cancer screening in underserved populations.

  • Can I ask you a question? Improving automated risk assessment for parents who suspect their child has Autism Spectrum Disorder

    From: Journal of Medical Internet Research

    Date Submitted: Nov 30, 2017

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

    Background: Parents seek online communities to verify their suspicions of autism spectrum disorder (ASD) markers in their child. Automated tools support human decisions in many domains hence could pot...

    Background: Parents seek online communities to verify their suspicions of autism spectrum disorder (ASD) markers in their child. Automated tools support human decisions in many domains hence could potentially support concerned parents. Objective: Our goal was to test the feasibility of assessing ASD risk from online parental concerns, using automated text analysis tools and minimal standard questioning. Methods: Participants were 115 parents with concerns regarding their child’s social-communication development. Children were 16-30 months old, and 57% had a family history of ASD. Parents reported their concerns online, and completed an ASD specific screener, the Modified Checklist for Autism in Toddlers-Revised, with Follow-Up (M-CHAT-R/F) and a broad developmental screener, the Ages and Stages Questionnaire (ASQ). An algorithm predicted ASD risk using a combination of the parent's text and a single screening question, selected by the algorithm to enhance prediction accuracy. Results: Screening measures identified 58-88% of children at risk for ASD. Children with a family history of ASD were 3 times more likely to show ASD risk on screening measures. The prediction of a child’s risk on the ASQ or M-CHAT-R was significantly more accurate when predicted from text combined with an M-CHAT-R question selected (automatically) than from the text alone. The frequently automatically selected M-CHAT-R questions that predicted risk were: following a point, make-believe play, and concern about deafness. Conclusions: The internet can be harnessed to pre-screen for ASD using parental concerns by administering a few standardized screening questions to augment this process.

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

    From: Journal of Medical Internet Research

    Date Submitted: Nov 26, 2017

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

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

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

  • Digital transformation of the health care sector: What kind of disruption is underway?

    From: Journal of Medical Internet Research

    Date Submitted: Nov 26, 2017

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

    Background: Digital innovation, introduced across many industries, is a strong force of transformation. Some industries have seen faster transformation, whereas the health care sector only recently ca...

    Background: Digital innovation, introduced across many industries, is a strong force of transformation. Some industries have seen faster transformation, whereas the health care sector only recently came into focus. A context where “digital corporations” move into health care, payers strive to keep rising costs at bay and longer-living patients desire continuously improved quality of care, points to a digital and value based transformation with drastic implications for the health care sector. Objective: We tried to operationalize the discussion within the health care sector around digital and disruptive innovation to identify what type of technological enablers, business models as well as value networks seem to be emerging in different groups of innovators with respect to their digital transformational efforts. Methods: Through Forbes 2000- and the CBinsights data base we identified 100 leading technology, life science and start-up companies active in the health care sector. Further analysis identified projects from these companies within a digital context that were subsequently evaluated using the criteria: delivery of patient value, presence of a comprehensive and distinctive underlying business model, solutions provided and the customer needs addressed. Results: Our methodological approach recorded more than 400 projects and collaborations. We identified patterns that show, established corporations rely more on incremental innovation that supports their current business models, while start-ups engage their flexibility to explore new market segments with notable transformations of established business models. Thereby, start-ups offer higher promises of disruptive innovation. Additionally, start-ups offer more diversified value propositions addressing broader areas of the health care sector. Conclusions: Digital transformation is an opportunity to accelerate health care performance by lowering cost and improving quality of care. At an economic scale on the one hand existing business models can be strengthened as well as disruptive innovation models enabled. Corporations should look for collaborations with start-up companies to keep investment costs at bay and off the balance sheet. At the same time, the regulatory knowledge of established corporations might help start-ups to kick off digital disruption in the health care sector.

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

    From: Journal of Medical Internet Research

    Date Submitted: Nov 27, 2017

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

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

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

  • Development of a Mobile Clinical Prediction Tool to Estimate Future Depression Severity and Guide Treatment in Primary Care: A User Centered Design

    From: JMIR mHealth and uHealth

    Date Submitted: Nov 27, 2017

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

    Background: Around the world, depression is both under and over treated. The diamond clinical prediction tool (CPT) was developed to assist with appropriate treatment allocation by estimating the thre...

    Background: Around the world, depression is both under and over treated. The diamond clinical prediction tool (CPT) was developed to assist with appropriate treatment allocation by estimating the three-month prognosis among people with current depressive symptoms. Delivering CPTs in a way which will enhance their uptake in routine clinical practice remains challenging, however mobile apps show promise in this respect. To increase the likelihood that an app-delivered CPT can be successfully incorporated into clinical practice it is important to involve end-users in the app design process. Objective: The aim of the study was to maximise patient engagement in an app designed to improve treatment allocation for depression. Methods: An iterative, user-centered design process was employed. Qualitative data was collected via two focus groups with a community sample (n=17) and seven semi-structured interviews with people with depressive symptoms. The results of the focus groups and interviews were used by the computer engineering team to modify subsequent protoype/s of the app. Results: Iterative development resulted in three prototypes and a final app. The areas requiring the most substantial changes following end-user input were related to the iconography used and the way that feedback was provided. In particular, communicating risk of future depressive symptoms proved difficult; these messages were consistently misinterpreted and negatively viewed, and were ultimately removed. All participants felt positively about seeing their results summarized after completion of the CPT, but there was a need for a personalized treatment recommendation, made in conjunction with a consultation with a health professional. Conclusions: User-centered design led to valuable improvements in the content and design of an app designed to improve allocation of and engagement in depression treatment. Iterative design allowed us to develop a tool which allows users to feel hope, engage in self-reflection and motivate them to treatment. The tool is currently being evaluated in a randomized controlled trial.

  • Women’s Perceptions of Using Mobile Phones for Maternal and Child Health Support in Afghanistan

    From: JMIR mHealth and uHealth

    Date Submitted: Nov 27, 2017

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

    Abstract Growing rates of global mobile subscriptions pave the way for implementation of mobile health initiatives, especially among hard to reach populations. This study aimed to determine the perce...

    Abstract Growing rates of global mobile subscriptions pave the way for implementation of mobile health initiatives, especially among hard to reach populations. This study aimed to determine the perceptions of Afghan women regarding the use of mobile phones for maternal and child health services. A cross-sectional survey was conducted in both rural and urban districts of Nangarhar Province, Afghanistan. Of the 240 participants, 59% owned mobile phones and 92% routinely used mobile phones. Approximately 87% of participants were willing to receive health messages via mobile phone. Automated voice call was the most preferred method for sending health messages. More than 90% of the women reported that they would like to receive reminders for their children’s vaccinations and antenatal care visits. Users’ perception was associated with mobile phone ownership, literacy level, and experience using mobile phones. In the study area, where the literacy rate is low, mHealth was well perceived.

  • One step forward: The development of a program promoting active school transportation

    From: JMIR Research Protocols

    Date Submitted: Nov 28, 2017

    Open Peer Review Period: Nov 28, 2017 - Dec 12, 2017

    Background: Physical activity promotes health and learning. However, up to 80% of children in industrial countries do not achieve the recommended level of daily physical activity. By encouraging child...

    Background: Physical activity promotes health and learning. However, up to 80% of children in industrial countries do not achieve the recommended level of daily physical activity. By encouraging children to use active school transportation, it is possible to increase their overall physical activity. Objective: This article presents the development of an active school transportation intervention using social cognitive theory, empowerment, and gamification to promote physical activity in children. Methods: Intervention Mapping was used to illuminate the logic model for the problem and the solution, as well as the program’s design, production, and evaluation. A group of municipal researchers and stakeholders, 42 children (aged 7 years), and 63 parents participated in the planning and execution of the intervention. Results: The children walked or biked on average 1.4 km each day to and from school and they got motivated by the gamification elements of the intervention. The teachers found it rewarding to incorporate learning as it made it possible to use real-life situations to teach various subjects in the curriculum. Conclusions: The program provides one way to promote active school transportation for children in a school context. One factor contributing to the success of this program was engaging end-users and including important agents, such as parents and teachers, who control the environmental factors. Another success factor was gamification, which made it possible to integrate learning into active school transportation. Furthermore, this approach to integrate learning into transportation solutions could motivate schools to devote time and effort to implementing this program.

  • Assessment of MCQs in MBBS program in college of Medicine, King Khalid University Abha

    From: JMIR Formative Research

    Date Submitted: Nov 27, 2017

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

    Background: Multiple choice questions represent one of the commonest methods of assessment in medical education. They believed to be reliable and efficient. Their quality depends on good item construc...

    Background: Multiple choice questions represent one of the commonest methods of assessment in medical education. They believed to be reliable and efficient. Their quality depends on good item construction. Item analysis is used to assess their quality by computing difficulty index, discrimination index, distractor efficiency and test reliability. Objective: The aim of this study was to evaluate the quality of MCQs used in the college of medicine, King Khalid University, Saudi Arabia. Methods: Design: Cross sectional Study design Setting, Materials and methods Item analysis data of 21 MCQs exams were collected. Values for difficulty index, discrimination index, distractor efficiency and reliability coefficient were entered in MS excel 2010. Descriptive statistic parameters were computed. Results: Twenty one tests were analyzed. Overall, 7% of the items among all the tests were difficult, 35% were easy and 58% were acceptable. The mean difficulty of all the tests was in the acceptable range of 0.3-0.85. Items with acceptable discrimination index among all tests were 39%-98%. Negatively discriminating items were identified in all tests except one. All distractors were functioning in 5%-48%. The mean functioning distractors ranged from 0.77 to 2.25. The KR-20 scores lie between 0.47 and 0.97 Conclusions: Overall, the quality of the items and tests was found to be acceptable. Some items were identified to be problematic and need to be revised. The quality of few tests of specific courses was questionable. These tests need to be revised and steps taken to improve this situation.

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

    From: Journal of Medical Internet Research

    Date Submitted: Nov 27, 2017

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

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

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

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

    From: Journal of Medical Internet Research

    Date Submitted: Nov 29, 2017

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

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

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

  • A putative role of Apolipoprotein 1 polymorphism in renal parenchymal scarring following febrile urinary tract infection in Nigerian under-five children: A PhD research proposal

    From: JMIR Research Protocols

    Date Submitted: Nov 27, 2017

    Open Peer Review Period: Nov 28, 2017 - Dec 12, 2017

    Although urinary tract infection (UTI) resolves with prompt treatment with good outcome; some children also develop renal parenchymal scarring (RPS), especially, among those less than 5 years of age....

    Although urinary tract infection (UTI) resolves with prompt treatment with good outcome; some children also develop renal parenchymal scarring (RPS), especially, among those less than 5 years of age. RPS can be complicated by high blood pressure, and chronic kidney disease (CKD) that may progress to end stage kidney disease (ESKD). The prevalence of UTI among febrile under-five Nigerian children on hospital admission is between 9% to 37.1. With more than 250 tribes, Nigeria is a good setting for studying diversities in human genotypes and phenotypes as may affect UTI and risk of RPS. The African Americans (AAs) tend to have a greater than three-fold risk of developing ESRD following CKD. Reports also suggest that native Sub-Saharan African Blacks have a predilection to kidney disease as the AAs. A common genetic predisposition to kidney disease in these two populations is the possession of genetic APOL1 kidney risk variants that regulate the production of apolipoprotein L1. Apolipoprotein 1 may influence the development of RPS, as evidence affirms that its expression is increased in kidney tissue following UTI caused by bacteria. Thus, while APOL1 kidney risk variants confer resistance to infection by trypanosomes when inherited as one copy of either G1 or G2 variant; having the two copies of either variant should increase the risk of developing kidney disease. The author hypothesizes that inheriting two copies of G1/G2 APOL1 variants influences the development of RPS following a febrile UTI in Nigerian under-five children. This article proposes APOL1 kidney risk variants as a risk factor for RPS following UTI, in a population that is expected to have the APOLI kidney risk variants. A study of this nature may lay the foundation for future research that seeks to understand the association between genes and diseases, and the environmental risk factors (i.e. UTI) that may exist in between.

  • “The Only Chance of a Normal Weight Life” A qualitative analysis of online forum discussions about bariatric surgery.

    From: Journal of Medical Internet Research

    Date Submitted: Nov 28, 2017

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

    Background: Morbid obesity (body mass index >40) has increased worldwide. The only long-term effective treatment for morbid obesity is bariatric surgery, with Roux-en-Y gastric bypass (RYGB) being the...

    Background: Morbid obesity (body mass index >40) has increased worldwide. The only long-term effective treatment for morbid obesity is bariatric surgery, with Roux-en-Y gastric bypass (RYGB) being the most commonly used, typically resulting in about 25% weight loss. Previous research shows that patients often have unrealistic expectations of surgery. The Internet is now the most widely-used source of healthcare information, and studies show that most RYGB patients have accessed information about the procedure online and wish to come into contact with others who have had the surgery. It has also been shown that many patients have unrealistic expectations about the surgery, despite being given accurate information by healthcare staff. Objective: The aim of the present study was to describe shared values, feelings, and thoughts among forum posters visiting a web-based forum for those considering and/or undergoing bariatric surgery. Methods: The study was conducted as a cross-sectional observation study using qualitative contents analysis. The material consisted of an online discussion forum thread about bariatric surgery, with 498 posts. These were copied into a separate document, read and re-read in a familiarization process. Data was then coded into meaningful sections and grouped into categories, illustrated with suitable excerpts. Results: The following categories emerged from the analysis: a new life - anticipating dramatic changes of body and mind; b) negotiating the system and playing the waiting game; c) a means to an end - managing the pre-operative diet; and d) managing the attitudes of others. The results showed that many posters described the process of bariatric surgery as a journey, riddled with roadblocks, setbacks and trials, but also with joy and great expectations of a new and better life. They struggled with the pre-operative weight loss diet, and many feared negative comments from their surroundings, but the posters provided constant emotional support, information and encouragement to each other in the discussion forum. Conclusions: The results show that the process of making a decision to undergo surgery, and navigating the healthcare system, the preoperative preparations and the reactions of friends and family, can be seen as a journey. As such, it is a process wraught with roadblocks, setbacks and struggles, during which the forum posters provide practical, emotional and social support for each other. Professionals who encounter this group should be aware of their need for support throughout the process, and investigate the possibility of both pre- and postoperative support groups, either online or face-to-face.

  • Formative evaluation as an iterative input to the development of an eHealth concept: the applicability of combining different methodologies to facilitate a rapid development framework for complex eHealth solutions

    From: JMIR Research Protocols

    Date Submitted: Nov 29, 2017

    Open Peer Review Period: Nov 30, 2017 - Dec 14, 2017

    Background: Implementation of eHealth in traditional health care clinics requires an understanding of the complexity of involved health care systems, organisational settings, and stakeholder groups. M...

    Background: Implementation of eHealth in traditional health care clinics requires an understanding of the complexity of involved health care systems, organisational settings, and stakeholder groups. Moreover, understanding of the underlying interplay between groups and of the software/hardware technology is essential. Objective: The aim of this paper is to describe and discuss the relevance and applicability of an iterative process guiding the development of an eHealth concept as both a technical and organizational entity, developed across different health care systems. Methods: A formative evaluation comprising the methodologies of Participatory Design, Theory-based Stakeholder Evaluation, and a series of Feasibility Studies was conducted including patients, health care professionals, and software developers. Through continuous feedback and dialogs within the project consortium, we aimed at creating mutual insight and optimizing the development of an eHealth Information and Communication Technology platform and its components. Results: Drawing on different methodologies, the formative evaluation served as a continuous and applicable input to the development process of an eHealth concept for Rheumatoid Arthritis in diverse health care settings across Europe. Input from patients and health care professionals were actively used for adjusting the visual, conceptual, and practical design of the concept. Furthermore, the continuous dialog within the consortium enabled continuous learnings and adaptions of the eHealth concept as well as the evaluation. Conclusions: A formative evaluation process including continuous involvement of stakeholder groups provides valuable information guiding the development of an eHealth concept and constitutes a basis for a subsequent implementation and evaluation.

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

    From: JMIR Medical Informatics

    Date Submitted: Nov 29, 2017

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

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

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

  • Identifying medication management smartphone app features suitable for individuals with developmental disabilities: a Delphi consensus study

    From: JMIR mHealth and uHealth

    Date Submitted: Nov 30, 2017

    Open Peer Review Period: Dec 1, 2017 - Jan 26, 2018

    Background: Smartphone apps can be a tool to facilitate independent medication management among individuals with developmental disabilities (DDs). At present, multiple medication management apps exist...

    Background: Smartphone apps can be a tool to facilitate independent medication management among individuals with developmental disabilities (DDs). At present, multiple medication management apps exist in the market, but only one including basic features such as medication reminders, medication list, and tracking medications taken has been specifically designed for individuals with DDs. Before initiating further app developments targeting this population, input from stakeholders including patients, caregivers, and professionals regarding the most adequate features for this patient population should be obtained. Objective: The aim of this study was to identify medication management app features that are suitable to promote independence in the medication management process by young adults who have DDs using a Delphi consensus panel of experts in this area. Methods: A compilation of medication management app features was performed by searching the iTunes App Store USA on February 2016, using the following terms: “adherence”, “medication”, “medication management”, “medication list”, and “medication reminder”. After identifying features of retrieved apps, a final list of 42 items grouped into four modules (medication list, medication reminder, medication administration record and additional features) was included in a questionnaire for expert consensus rating. Fifty-two experts in DDs were invited to participate in a three-round Delphi technique to obtain consensus on app features that are suitable to promote independence in the medication management process among individuals with DDs. Consensus for the first, second, and third rounds was defined as ≥90%, ≥80%, and ≥75% agreement, respectively. Results: A total of 75 responses were received over the three Delphi rounds: 30 in the first, 24 in the second, and 21 in the third. At the end of the third round, cumulative consensus was achieved for 60% (12/20) items in the medication list module, 100% in the medication reminder module, 66.7% (2/3) in the medication administration record module, and 62.5% (10/16) in the additional features module. In addition to the medication list, medication reminder, and medication administration record features, experts selected as the top-3 most important additional features automatic refills through pharmacies, ability to share medication information from the app with providers, and ability to share medication information from the app with family, friends and caregivers. The top-3 least important features included: a link to an official drug information source, privacy settings and password protection, and prescription refill reminders. Conclusions: Although several mobile apps for medication management exist, few to none are specifically designed to support individuals who have DDs in the complex medication management process. Of the 42 different items assessed, about 65% achieved consensus for inclusion in a future medication management app. This study provides information on the features of a medication management app that are most important to individuals who have DDs and their caregivers. Clinical Trial: Not applicable.

  • Users´ perspectives on mHealth self-management of bipolar disorder. A qualitative focus group study.

    From: JMIR mHealth and uHealth

    Date Submitted: Nov 30, 2017

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

    Background: Recent research indicates that current mHealth applications for bipolar disorders show crucial shortcomings. They lack important functionality, are of inconsistent quality and insufficient...

    Background: Recent research indicates that current mHealth applications for bipolar disorders show crucial shortcomings. They lack important functionality, are of inconsistent quality and insufficiently evidence-based. In addition they need to be better adapted to the needs of users. However, the perspectives of adult service users with bipolar disorder regarding mHealth applications have not been well investigated. Objective: Therefore, the current study aims to examine the needs and expectations that users have regarding mHealth self-management of bipolar disorder. Methods: Two focus group sessions were organized in which patients’ views on self-management and design and functionality of an mHealth application for bipolar disorder were assessed. During session one, four focus groups were organized to identify users’ needs regarding support for self-management. Session two contained three co-creation focus groups. Through this method, the desired functionality and design were explored. Results: Participants indicated that they were in need of support in various ways. Not only support in psycho-education, which includes daily routine, sleep pattern, maintaining social contacts, maintaining a healthy lifestyle and avoidance of stimuli was considered important for them, but also gaining insight into their illness and behaviour was found to be crucial. Conclusions: According the participants, their illness related behaviour is a key factor in gaining insight in their mood pattern. Participants wanted a functional design that would increase daily use and prevent overstimulation. The results of the current study should be taken into account when developing new mHealth applications.

  • Empirical evidence for the outcomes of therapeutic video games for adolescents with anxiety disorders: A systematic review

    From: JMIR Serious Games

    Date Submitted: Nov 29, 2017

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

    Background: Extant evidence suggests that the proportion of adolescents suffering from anxiety disorders (AD) has increased by up to 70% since the mid-1980s, with experience of anxiety at this stage a...

    Background: Extant evidence suggests that the proportion of adolescents suffering from anxiety disorders (AD) has increased by up to 70% since the mid-1980s, with experience of anxiety at this stage associated with significant negative short- and long-term life outcomes. Existing therapeutic interventions (e.g.: CBT, ABM) have proven to have clinically measurable benefits in reducing anxiety, but their efficacy is often compromised by social and practical barriers. The growing discrepancy between demand for, and access to, clinical interventions for anxiety has led to the development of a range of electronic and mobile health interventions. One such protocol is therapeutic games, which aim to provide clinical frameworks in dynamic, adaptable and personalisable virtual environments. While some evidence exists to suggest therapeutic games are associated with reductions in subjective anxiety and observed stress reactivity, there is currently, to our knowledge, no systematic review of the adherence to, and effectiveness of, therapeutic games for adolescent anxiety. Objective: The aim of this review was to establish the effectiveness of therapeutic games in making clinically measurable reductions in AD symptoms in adolescent samples. Methods: A systematic search of existing academic literature published between 1990 and July 2017 was conducted using the databases JMIR, JSTOR, PsycARTICLES, PsycINFO, ScienceDIRECT and Scopus. Records linked to empirical papers on therapeutic games for anxiety using adolescent samples were evaluated. Results: A total of 5 studies (total number of participants N=410) met the inclusion criteria and 3 gamified anxiety interventions for adolescents were identified. Papers included a mixture of randomised-controlled trials, quasi-experimental studies and usability studies comprising of quantitative and qualitative measures, with varying degrees of mixed-methods. Extant evidence shows potential for therapeutic games to create clinically measurable reductions in symptoms of anxiety in adolescent samples, though findings are complicated in some cases by low sample size, and in other cases by research design and methodological complications, including anxiety reductions in control groups caused by control-game selection. Conclusions: While research into this field appears to be extremely limited, as demonstrated by the small number of articles meeting the inclusion criteria for this review, early findings suggest that therapeutic games have potential in helping to engage adolescents with anxiety and lead to clinically measurable reductions in symptoms. Considerations for future research are discussed. Clinical Trial: N/A

  • Integrated models of care for people living with hepatitis C virus and a substance use disorder: A protocol for a systematic review

    From: JMIR Research Protocols

    Date Submitted: Nov 30, 2017

    Open Peer Review Period: Dec 7, 2017 - Dec 21, 2017

    Background: People living with a substance use disorder (SUD) are a key population within the hepatitis C virus (HCV) epidemic. While integrated and community-based models of care have shown positive...

    Background: People living with a substance use disorder (SUD) are a key population within the hepatitis C virus (HCV) epidemic. While integrated and community-based models of care have shown positive outcomes among this population, the literature has been primarily focused on the human immunodeficiency virus (HIV) context. This paper outlines a systematic review protocol on the impact of various integrated models of care, which includes HCV and SUD services, on various treatment, and health-related outcomes among this population. Objective: Determine the impact of the impact of integrated models of care on HCV and addiction treatment and health-related outcomes for adults living with HCV and a SUD. Methods: We will search a total of five databases, article reference lists, and abstracts from relevant conferences that investigate the impact of integrated models of care on treatment and health-related outcomes among people living with HCV and a SUD. Database searches will be conducted and titles, abstracts, and full-text will be independently reviewed in separate stages. The methodological quality of included quantitative research studies will be assessed using a validated tool. Data from included articles will be extracted using a standardized form and synthesized in a narrative account. Conclusions: The systematic review will describe different integrated models of care that could be effective in improving the health and well-being of people living with HCV and a SUD. Results of this review could also identify quality improvement strategies to minimize the health and cost burden imposed on patients, healthcare professionals, and the healthcare system. Systematic Review Registration: PROSPERO CRD42017078445

  • Identifying and Understanding Communities Using Twitter to Connect About Depression

    From: JMIR Mental Health

    Date Submitted: Nov 29, 2017

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

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

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

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

    From: JMIR Rehabilitation and Assistive Technologies

    Date Submitted: Nov 29, 2017

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

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

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

  • Toward simplified and accurate surveys to monitor public health nutrition

    From: JMIR Public Health and Surveillance

    Date Submitted: Nov 30, 2017

    Open Peer Review Period: Dec 5, 2017 - Dec 19, 2017

    Background: Accurately identifying whether an individual's diet is in compliance with national nutritional guidelines requires the collection of a large amount of dietary data. A common method in publ...

    Background: Accurately identifying whether an individual's diet is in compliance with national nutritional guidelines requires the collection of a large amount of dietary data. A common method in public health nutrition is to record every food consumed by an individual, down to an exact weight of the foods. A previous study used the data mining technique of decision trees to find which foods were needed to accurately identify whether individuals were in compliance with the five main guidelines (sodium, saturated fats, sugars, fruit/vegetables, fats). The study, performed in the United Kingdom, found that tracking only 3% of all foods was sufficient to accurately infer compliance. While the possibility of only tracking 3% of the items significantly reduces participation burden, this may be further reduced if items did not need to be weighted exactly. A further reduction in participation burden would lower the costs for monitoring public health nutrition, and may also lower the chance of errors as much less will be required from participants. Objective: We will assess whether national public health nutrition surveys can be further simplified by only recording whether a food was consumed, rather than having to weigh it. Methods: Our data comes from a generalized sample of inhabitants in the United Kingdom, specifically from the National Diet and Nutrition Survey (NDNS) 2008-12. After simplifying food consumptions to a binary value (1 if an individual consumed a food and 0 otherwise), we built and optimized decision trees to find whether the foods could accurately predict compliance with the major five nutritional guidelines. Results: When using decision trees of a similar size to previous studies (i.e., involving as many foods), we were able to correctly infer compliance for the five guidelines with an average accuracy of 80.1%. This is an average increase of 2.5 percentage points over a previous study, showing that further simplifying the surveys can actually yield more robust estimates. When we allowed the new decision trees to use slightly more foods than in previous studies, we were able to optimize the performance with an average increase of 3.1 percentage points. Conclusions: While one may expect a further simplification of surveys to decrease accuracy, our study found that public health dietary surveys can be significantly simplified (from accurately weighing items to simply checking whether they were consumed) while improving accuracy. One possibility is that the simplification reduced noise, and made it easier for patterns to emerge. Using simplified surveys will allow to monitor public health nutrition in a more cost-effective manner, and possibly decrease the number of errors as participation burden is significantly reduced.

  • The unanticipated challenges associated with implementing an observational study protocol in a large scale physical activity and GPS data collection

    From: JMIR Research Protocols

    Date Submitted: Nov 30, 2017

    Open Peer Review Period: Dec 2, 2017 - Dec 16, 2017

    Large scale primary data collections are complex, costly, and time consuming. Study protocols for trial based research are now commonplace with a growing number of similar pieces of work being publis...

    Large scale primary data collections are complex, costly, and time consuming. Study protocols for trial based research are now commonplace with a growing number of similar pieces of work being published on observational research. However, a likely useful addition to the literature base are publications that describe the issues and challenges faced whilst conducting observational studies. These can provide researchers with insightful knowledge that can inform funding proposals or project development work. The SPACES (Studying Physical Activity in Children’s Environments across Scotland) study was designed to collect objectively measured physical activity and Global Positioning System (GPS) data from 10/11 year old children across Scotland, using a postal delivery method. In this paper we identify and reflectively discuss the unforeseen or often unpublished issues associated with organising and implementing a large scale objectively measured physical activity and GPS data collection. The three main phases of the project (recruitment, delivery of project materials, and data collection and processing) are described within a two stage framework: (i) intended design and (ii) implementation of the intended design. Unanticipated challenges arose that influenced the data collection process, and encompass four main impact categories: i) cost, budget and funding; ii) project timeline; iii) participation/engagement; and iv) data challenges. The main unforeseen issues that impacted our timeline included: the informed consent process for children under the age of 18; the use of, and coordination with, the postal service to deliver study information and equipment; the variability associated with when participants began the data collection and the time taken to send devices and consent forms back (1 – 12 months). Unanticipated budgetary issues included the identification of some study materials (AC power adapter) not fitting through letterboxes, and the employment of fieldworkers to increase recruitment and the return of consent forms. Finally, we encountered data issues when processing physical activity and GPS data that had been initiated across Daylight Savings Time (DST). We present learning points and recommendations that may benefit future studies of similar methodology in their early stages of development.

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

    From: Journal of Medical Internet Research

    Date Submitted: Nov 30, 2017

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

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

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

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

    From: Journal of Medical Internet Research

    Date Submitted: Nov 30, 2017

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

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

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

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

    From: Journal of Medical Internet Research

    Date Submitted: Dec 1, 2017

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

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

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

  • Effect and process evaluation of e-Powered Parents, an online support program for parents of children with a chronic kidney disease: a mixed method feasibility study

    From: Journal of Medical Internet Research

    Date Submitted: Dec 1, 2017

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

    Background: Parents of children with a chronic kidney disease (CDK) experience high levels of stress in daily management of their child’s disease. Although parents want continuously accessible suppo...

    Background: Parents of children with a chronic kidney disease (CDK) experience high levels of stress in daily management of their child’s disease. Although parents want continuously accessible support and information, online support programs are lacking. Therefore, e-Powered Parents (e-PP) was developed: an online program consisting of: 1) medical information, 2) an interactive part, and 3) four training modules (stress management, setting limits, communication and coping). Prior to a large scale evaluation, a feasibility study was conducted consisting of an effect study and process evaluation. Objective: 1) To identify outcomes measures most likely to capture potential benefit, 2) to evaluate potential effectiveness and effect size, and 3) to evaluate recruitment, reach, dose received and context. Methods: A mixed methods feasibility study with a two-armed wait-list randomized controlled trial (RCT) was conducted. Prior to baseline, parents (n=146) were randomly allocated to group 1 or group 2. After completing the baseline questionnaire, parents in group 1 got access to e-PP, and group 2 received usual care. At six month follow-up (T1), parents in group 2 got access to e-PP as well. After one year, an extra measurement (T2) evaluated the effect of long-term exposure. Outcomes were: the child’s quality of life (CVS), parental stress (PIP) and fatigue (MFI), self-efficacy in communication with health professionals (PEPPI) and parental perceptions of family management (FaMM). Floor and ceiling effects and percentage of parents showing no change in scores were calculated. Linear mixed models were used to evaluate potential effectiveness and effect sizes using intention to treat and per protocol analysis. Recruitment, reach, dose received and context were evaluated in the process evaluation, using a questionnaire send to the parents, login data, and a focus group interview with healthcare professionals. Results: At T1 (n=86) and T2 (n=51) no significant effects were found on any of the five outcomes. The PEPPI showed ceiling effects and high percentages of parents showing no change between the measurement times. The information and interactive part of the intervention were used by 84% of the parents in group 1 and 49% of the parents in group 2. Information pages were visited most frequently. 85% of the parents logged in at the training platform, 31% actually used the training modules. Conclusions: No significant effect on one of the outcomes was found. This could possibly be explained by the minimum use of the intervention and parents’ heterogeneity. For continued participation, a tailored intervention is recommended and further studies are necessary to find out if and how online programs could be used to support parents in the management of their child’s CKD. Clinical Trial: Dutch Trial Registration: NTR4808; www.trialregister.nl

  • A systematic review of internet-based interventions aimed at supporting family caregivers of people with dementia

    From: Journal of Medical Internet Research

    Date Submitted: Dec 1, 2017

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

    Background: Caring for someone with dementia is one of the most challenging caring roles. The need for support for family caregivers has been recognised for some time, but is often still lacking. With...

    Background: Caring for someone with dementia is one of the most challenging caring roles. The need for support for family caregivers has been recognised for some time, but is often still lacking. With an ageing population there is growing demand on health and social care services, and the population is increasingly looking to the internet for information and support. Objective: This review aimed to: 1) Identify the key components of existing internet-based interventions designed to support family caregivers of people with dementia 2) Develop an understanding of which components are most valued by caregivers 3) Consider the evidence of effectiveness of internet-based interventions designed to support family caregivers of people with dementia Methods: A systematic search was conducted of online databases in May 2017. Reference lists were searched and citations tracked. All study designs were included. A narrative synthesis approach was adopted with thematic analysis and tabulation as tools. Results: 2035 studies were identified and 37 were included. The interventions varied in the number and types of components, duration and dose, and in the outcomes used to measure effectiveness. The interventions focussed on: 1) contact with health or social care providers; 2) peer interaction; 3) provision of information; 4) decision support and 5) psychological support. The overall quality of the studies was low, making interpretation and generalizability of the effectiveness findings difficult. However, the majority of studies suggested that interventions may be beneficial to family caregiver well-being, including positive impacts on depression, anxiety and burden. Particular benefit came from psychological support provided online, where several small randomised controlled trials suggested improvements in caregiver mental health. Provision of information online was most beneficial when tailored specifically for the individual and used as part of a multi-component intervention. Peer support provided in online groups was appreciated by most participants and showed positive effects on stress. Finally, online contact with a professional was appreciated by caregivers, who valued the easy access to personalised practical advice and emotional support, leading to a reduction in burden and strain. Conclusions: Although mixed, the results indicate a positive response for the use of internet-based interventions by caregivers. More high quality studies are required to identify the effectiveness of internet interventions aimed at supporting family caregivers, with particular focus on meeting the needs of caregivers during the different stages of dementia. Clinical Trial: N/A

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

    From: Journal of Medical Internet Research

    Date Submitted: Dec 1, 2017

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

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

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

  • Development of an online formative self-assessment tool for physicians to practice breaking bad news: the BReaking bAD NEws Tool (BRADNET)

    From: Journal of Medical Internet Research

    Date Submitted: Dec 1, 2017

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

    Background: Although most physicians in a medical setting have to deliver bad news, the skills of delivering bad news to patients have been given insufficient attention. Delivering bad news is a compl...

    Background: Although most physicians in a medical setting have to deliver bad news, the skills of delivering bad news to patients have been given insufficient attention. Delivering bad news is a complex communication task that includes verbal and non-verbal skills, the ability to recognise and respond to patients’ emotions and the importance of considering the patient environment such as culture and social level. How bad news is delivered can have consequences that may affect patients sometimes definitively. Objective: The goal of the project was to develop an online formative self-assessment tool for physicians to practice delivering bad news so as to minimize the deleterious effects of a poor way of disclosing bad news about a disease, whatever the disease. Methods: BReaking bAD NEws Tool (BRADNET) items were developed by using a review of the existing protocols and recommendations for delivering bad news and patient–physician communication assessment instruments and semi-structured interviews with patients and physicians. From this step, the themes were selected and then pooled before consensus on a good practices communication framework list. Items were then created from this list. To ensure that physicians found the BRADNET acceptable, understandable and relevant to their condition, the tool was refined by a working group of clinicians familiar with delivering bad news. The think-aloud approach was then used to explore the impact of the items and messages and why and how these messages could change physicians’ relations with patients or how to deliver bad news. Finally, formative self-assessment sessions were constructed according to a double perspective of progression: a chronological progression of the disclosure of the bad news and the growing difficulty of items (difficulty concerning the expected level of self-reflection). Results: The good practices communication framework list consisted of 70 specific issues in breaking bad news pooled in 8 main domains: opening, preparing for the delivering bad news consultation, communication techniques, consultation content, attention, physician emotional management, shared decision making and relationship between the physician and the medical team. Following the construction of the items from this list, the items were extensively refined to make it more useful to the target audience. The BRADNET contains 71 items, each including a question, response options and a corresponding message. These 71 items were divided into 8 domains and assessed with 12 self-assessment sessions. Conclusions: The self-assessed training tool is Web-based. Its objective is to create a “space” for reflection. It contains items leading to self-reflection and messages introducing recommended communication behaviors. The interest in our approach lies in providing a distance-learning self-assessment tool that is not expensive and is more manageable and less time-consuming for physicians with often overwhelming schedules.

  • Cost- analysis of prenatal remote monitoring of women with gestational hypertensive diseases

    From: Journal of Medical Internet Research

    Date Submitted: Dec 2, 2017

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

    Background: Remote monitoring (RM) in obstetrics is relatively new; its effectiveness for both mother and child has been shown in some trials. However, few studies evaluated the economic impact of RM...

    Background: Remote monitoring (RM) in obstetrics is relatively new; its effectiveness for both mother and child has been shown in some trials. However, few studies evaluated the economic impact of RM compared to conventional care (CC), and no cost-analysis of a RM prenatal follow-up program for women diagnosed with gestational hypertensive diseases has been published today. Objective: The aim of this study was to assess the costs of RM versus CC, relative to reported benefits. Methods: Patient data from the reported Pregnancy Remote Monitoring (PREMOM) study was used. Health care costs were calculated from patient-specific hospital bills of Ziekenhuis Oost Limburg (Genk Belgium) in 2015. Cost comparison was made from three perspectives: the Belgian national health care system (HCS), which combines costs for the National Institution for Insurance of Disease and Disability (RIZIV), and costs for individual patients. The calculations were made for four major domains: prenatal follow-up, prenatal admission to the hospital, maternal and neonatal care at and after delivery, and total amount of costs. A simulation exercise is made in which is calculated how much can be demanded to RIZIV for funding the RM service. Results: A total of 140 pregnancies were included, of which 43 RM (30.71%) and 97 CC (69.29%) received. From the three perspectives, there were no differences in costs for prenatal follow-up. Compared to CC, RM patients had 34.51% less HCS and 41.72% les RIZIV costs for labs (€0.00 ± €55.34 vs. €38.28 ± € 44.08, P < 0.01; and €21.09 ± €27.94 vs. €36.19 ± €41.36 , P < 0.01 respectively) and a reduction of 47.16% in HCS and 48.19% in RIZIV costs for neonatal care (€989.66 ± €3020.22 vs. €1872.92 ± €5058.31, P < 0.01; and €872.97 ± €2761.64 vs. €1684.86 ± €4702.20, P < 0.01). HCS costs for medication were 1.92% lower in RM than in CC (€209.22 ± €213.32 vs. €231.32 ± 67.09, P = 0.02), but were 0.69% higher for RIZIV (€122.60 ± €92.02 vs. €121.78 ± €20.77; P < 0.01). Overall HCS costs for RM were €4233.31 ± €3463.31 pp and €4973.69 ± €5219.00 pp for CC (P = 0.82), which means a reduction of €740.38 (14.89%) pp, with savings mainly for RIZIV of €848.97 pp (23.18%; €2797.42 ± €2905.18 vs. €3646.39 ± €4878.47, P = 0.19). When an additional fee of €525.07/month/pregnant woman for funding RM costs is owned, RM is acceptable in their costs for HCS, RIZIV and individual patients. Conclusions: In the current organization of Belgian health care, a RM prenatal follow-up of women with GHD is cost-saving for the global health care system, mainly via savings for the insurance institution RIZIV. Clinical Trial: /

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

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 1, 2017

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

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

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

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

    From: Journal of Medical Internet Research

    Date Submitted: Dec 2, 2017

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

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

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

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

    From: Journal of Medical Internet Research

    Date Submitted: Dec 4, 2017

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

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

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

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

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 3, 2017

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

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

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

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

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 3, 2017

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

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

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

  • Amelioration of severity in Obsessive-Compulsive Disorder from a Randomized Controlled Trial of therapist-assisted Internet-based treatment: Comparison of Cognitive-behavioral Therapy and Progressive Relaxation

    From: Journal of Medical Internet Research

    Date Submitted: Dec 4, 2017

    Open Peer Review Period: Dec 4, 2017 - Dec 14, 2017

    Background: Obsessive Compulsive Disorder (OCD) is a highly disabling psychological disorder with a chronic course if left untreated. Cognitive-behavioral therapy (CBT) has been shown to be an effecti...

    Background: Obsessive Compulsive Disorder (OCD) is a highly disabling psychological disorder with a chronic course if left untreated. Cognitive-behavioral therapy (CBT) has been shown to be an effective treatment, but access to face-to-face CBT is not always possible. Internet-based CBT (iCBT) has become an increasingly viable option. However, no study has compared iCBT to an analogous control condition using a Randomized Controlled Trial (RCT). Objective: A two-armed RCT was used to compare a therapist-assisted 12-module iCBT to an analogous active attention control condition (Internet-based standard progressive relaxation training, iPRT) in adult OCD. Methods: In total, 179 participants (117 females; 65.7%) were randomized (stratified by gender) into iCBT or iPRT. The iCBT intervention included psychoeducation, mood and behavioral management, exposure and response prevention (ERP), cognitive therapy and relapse prevention; the iPRT intervention included psychoeducation, and relaxation techniques as a way of managing OCD-related anxiety but did not incorporate ERP or other CBT elements. Both treatments included audiovisual content, case stories, demonstrations of techniques, downloadable audio content and worksheets, and expert commentary. All participants received one weekly email, with a maximum 15-minute preparation time per client from a remote therapist trained in e-therapy. Emails aimed to monitor progress, review homework, provide support and encouragement, and assist in individualizing the treatment. Participants were assessed for baseline and post-treatment OCD severity with the telephone-administered clinician-rated Yale-Brown Obsessive-Compulsive Scale (YBOCS) and other measures by assessors who were blinded to treatment condition allocation. Results: No pre-treatment differences were found between the two conditions. Intention-to-treat analysis (ITT) revealed significant pre-post improvements in OCD symptom severity for both conditions (P < .001). However, relative to iPRT, iCBT showed significantly greater symptom severity improvement (P = .001); Cohen’s d for iCBT was 1.05 (95% confidence interval: 0.72, 1.37), whereas for iPRT it was 0.48 (95% confidence interval: 0.22, 073). The iCBT condition was also superior in regards to reliable improvement (49% vs 29.1%; P = .04) and clinically significant pre-post-treatment changes (33.3% vs 10.9%; P = .005). Furthermore, those undertaking iCBT post completion of iPRT showed further significant symptom amelioration (P < .001), although the sequential treatment was no more efficacious than the iCBT alone (P = .63). Conclusions: This study is the first to compare an online therapist-assisted CBT program (iCBT) for OCD to an analogous active attention control condition using Internet-based progressive relaxation training (iPRT). The current findings demonstrate the large magnitude efficacy of iCBT for OCD; interestingly, the analogous active attention control (iPRT) was also moderately efficacious, albeit significantly less so than the iCBT intervention. The findings are compared to previous Internet-based and face-to-face CBT treatment programs for OCD. Future directions for technology-enhanced programs for the treatment of OCD are outlined. Clinical Trial: ACTRN12611000321943

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

    From: Journal of Medical Internet Research

    Date Submitted: Dec 4, 2017

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

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

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

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

    From: Journal of Medical Internet Research

    Date Submitted: Dec 4, 2017

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

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

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

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

    From: JMIR Serious Games

    Date Submitted: Dec 4, 2017

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

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

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

  • Reliability of web information about palliative care

    From: Journal of Medical Internet Research

    Date Submitted: Dec 5, 2017

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

    Background: Patients and their families are able to easily obtain information about palliative care online nowadays. However, there are concerns that some information is inaccurate or has not been upd...

    Background: Patients and their families are able to easily obtain information about palliative care online nowadays. However, there are concerns that some information is inaccurate or has not been updated for a long time. Objective: The purpose of this study is to elucidate various problems with palliative care and medical information obtained from the web. Methods: We evaluated the top 50 palliative care websites that appeared in the Google Japan and Google USA search results using DISCERN or LIDA instruments. Results: We found that Japanese websites were given a lower evaluation on reliability compared with US websites. Conclusions: Our study suggested that there was not enough information provided on the websites to assess their reliability.

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

    From: Interactive Journal of Medical Research

    Date Submitted: Dec 5, 2017

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

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

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

  • Effects of Treatment Length and Chat-Based Counselling in a web-based Intervention for Cannabis Users. Randomized Controlled Non-Inferiority Trial

    From: Journal of Medical Internet Research

    Date Submitted: Dec 6, 2017

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

    Background: Digital interventions show promise in reducing problematic cannabis use. However, little is known about effect moderators in such interventions. The therapist-guided Internet intervention...

    Background: Digital interventions show promise in reducing problematic cannabis use. However, little is known about effect moderators in such interventions. The therapist-guided Internet intervention “Quit the Shit” (QTS) provides 50 days of chat-based (synchronous) and time-lagged (asynchronous) counselling. Objective: In the study, we examined whether the effectiveness of QTS is reduced by shortening the program or removing chat-based counselling option. Methods: Purely web-based randomized controlled non-inferiority trial using a two-factorial design (factor 1: real time-counselling via text-chat: yes vs. no; factor 2: intervention duration: 50 days vs. 28 days). Participants were recruited online on the QTS-website. Follow-ups were conducted 3, 6 and 12 months after randomization. Primary outcomes were cannabis use days, quantity and use events during the past 30 days using a Timeline Followback procedure. Secondary outcomes were cannabis dependency (SDS), treatment satisfaction (CSQ-8) and working alliance (WAI-sr). Results: 534 participants were included in the trial. Follow-up rates were 47.2% after 3 months, 38.2% after 6 months and 25.3% after 12 months. The lower bounds of the CIs for all between-group effect sizes are well within the non-inferiority margin of d=0.21, pointing to non-inferiority in both factors and for all outcomes. Provision of chat-based counselling was significantly associated with higher treatment satisfaction (P=.001, d=0.33) and stronger working alliance (P=.01, d=0.36). However, these results are also within the predefined range of non-inferiority. Conclusions: The reduction of program length and the waiver of synchronous communication have no meaningful impact on the effectiveness of “Quit the Shit”. It therefore seems tenable to abbreviate the program and to offer a self-guided start into QTS. Due to its positive impact on treatment satisfaction and working alliance, chat-based counselling nevertheless should be provided in QTS. Clinical Trial: ISRCTN99818059; http://www.isrctn.com/ISRCTN99818059 (Archived by WebCite at http://www.webcitation.org/6uVDeJjfD)

  • Detecting collaboration characteristics and topic burst on international mobile health research through visualization

    From: Journal of Medical Internet Research

    Date Submitted: Dec 7, 2017

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

    Background: In the last few decades, mobile technology has been widely employed in healthcare service field in order to improve the accessibility and quality of health services. Thereby mobile health...

    Background: In the last few decades, mobile technology has been widely employed in healthcare service field in order to improve the accessibility and quality of health services. Thereby mobile health (mHealth) emerged at the right time and was paid increasing attention by scientific researchers with a rapid increase in the related literature. Objective: The purpose of this article is to analyze research status and publication outputs in mHealth field in order to uncover in depth collaboration characteristics and topic burst of international mHealth research. Methods: The authors collected literature during the past 20 years, indexed by Thomson Reuters Web of Science Core Collection (WoSCC). Various statistical techniques and bibliometric measures, including publication growth analysis, journal distribution, subject distribution, and collaboration network analysis at the author, institution and country collaboration level, had been employed. The temporal visualization map of burst terms was drawn, and the co-occurrence matrix of these burst terms was analyzed by hierarchical cluster analysis and social network analysis. Results: A total 2,704 bibliographic records on mHealth were collected. The earliest article on mHealth was published in 1997. And the number of articles has risen continually since then. The output on mHealth was published in 1,008 journals. The publication output on mHealth was distributed in 162 subject categories. The total number of authors on mHealth research is 10,895, 21.3% (2,318) of which is first author. However, only 141 (1.3%) authors have just published one article. The total collaborative degree of author was 4.42, and the collaborative degree of authors per year is on the rise in general. The core authors group basically forms. Nevertheless, the collaboration of core author is not tight and stable. The publications on mHealth are distributed among 3,040 research institutions. University Michigan ranks the top one on most publications, but less collaboration among institutions exits. Scholars from 111 countries have contributed on mHealth research. The USA is the most productive country and plays an irreplaceable leading role in the collaboration network of mHealth research. However, the country collaboration is relatively scarce. There are 5,543 different keywords in all 2,704 articles, and the number of keyword frequency obeys power law distribution. The temporal bar graph clearly presents overall topic evolutionary process over time. There are 12 important research directions identified, which are in the imbalanced development. Moreover, the density of the network was 0.007, a relatively low level. These 12 topics basically locate in four different areas, namely patient engagement and patient intervention, health monitoring and self care, mobile device and mobile computing, and security and privacy. Conclusions: This study provides important insights into the collaboration status, topic burst and trends on mHealth research, which might provide a potential guide for the future research.

  • Increasing interest of mass communication media and general public in the distribution of Tweets about mental diseases

    From: Journal of Medical Internet Research

    Date Submitted: Dec 5, 2017

    Open Peer Review Period: Dec 5, 2017 - Dec 15, 2017

    Background: The contents of classical communication media and new Internet social media reflect the interests of society. Barriers and a lack of attention for mental diseases have been previously obse...

    Background: The contents of classical communication media and new Internet social media reflect the interests of society. Barriers and a lack of attention for mental diseases have been previously observed. Objective: To measure the relevance given by the main American social communication media (ASCM) to psychiatric information and the interest generated in their Twitter followers. Methods: We investigated the tweets generated about mental health conditions and disease by 15 main United States of America (USA) general communication media from January 2007 to December 2016. Our study strategy focused on identifying several psychiatric terms of main interest. The number of retweets generated by the selected tweets was also investigated. For a control, we used tweets generated about the main causes of death in the USA, the main chronic neurological degenerative diseases and infection by the human immunodeficiency virus (HIV). Results: In total, 13,119 tweets sent by the ASCM about mental health disorders show a heterogeneous distribution with preferential accumulation in a reduced number of conditions. Suicide and gender dysphoria accumulated half of the number of sent tweets. Variability in the number of tweets related to each control disease was also found (5,998). The number of tweets sent regarding each different psychiatric or organic disease analyzed was significantly correlated with the number of retweets generated by followers (1,030,974 and 424,813 responses to metal health disorders and organic diseases, respectively). However, the probability of a tweet being retweeted was statistically different between the conditions and diseases analyzed. Furthermore, the retweeted/tweet ratio was significantly higher in psychiatric diseases than in the control organic diseases (OR=1.11 [1.07- 1.14], p<0.001). Conclusions: According to the use of Twitter, the ASCM and the general public demonstrate a preferential interest for psychiatric diseases. The heterogeneous weight given by the ASCM to the different mental health disorders and conditions is reflected in the response of Twitter followers.

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

    From: Journal of Medical Internet Research

    Date Submitted: Dec 6, 2017

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

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

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

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

    From: Journal of Medical Internet Research

    Date Submitted: Dec 7, 2017

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

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

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

  • Emerging Technology and Data Analytics for Behavioral Health

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 6, 2017

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

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

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

  • Effectiveness of a Digital Therapeutic in Adults with Type 2 Diabetes: A Pilot Study

    From: Journal of Medical Internet Research

    Date Submitted: Dec 7, 2017

    Open Peer Review Period: Dec 8, 2017 - Dec 18, 2017

    Background: Intensive lifestyle change can treat and even reverse type 2 diabetes. Digital therapeutics have the potential to deliver lifestyle as medicine for diabetes at scale. Objective: This 12-w...

    Background: Intensive lifestyle change can treat and even reverse type 2 diabetes. Digital therapeutics have the potential to deliver lifestyle as medicine for diabetes at scale. Objective: This 12-week pilot study investigates the effects of a novel digital therapeutic on Hemoglobin A1c (HbA1c) and diabetes medication use. Methods: Adults with type 2 diabetes and a smartphone were recruited throughout the United States using Facebook advertisements. The intervention aim was to effect a sustainable shift to a plant-based dietary pattern and regular exercise by advancing culinary literacy and lifestyle skill acquisition. The intervention was delivered by an app paired with specialized human support, also delivered digitally. Health coaching was provided every 2 weeks by telephone, and a clinical team was available for participants requiring additional support. Participants self-reported current medications and HbA1c at the beginning and end of the 12-week program. Self-efficacy related to managing diabetes and maintaining dietary changes was assessed via survey. Engagement was recorded automatically through the app. Results: We enrolled 118 participants with a baseline HbA1c > 6.5%. Participants were 81.4% female, resided in 38 U.S. states, with a mean age of 50.7 years (SD 9.4), baseline Body Mass Index (BMI) of 38.1 kg/m2 (SD 8.8) and baseline HbA1c of 8.1% (SD 1.6). At 12-weeks, 86.2% (n=94) of participants were still using the app. Mean change in HbA1c was -0.8% (n=97, SD 1.3, P <.001) for those reporting end-study data; and, for participants with a baseline HbA1c >7.0% who did not change medications mid-study, HbA1c change was -1.1% (n=65, SD 1.4, P < .001). The proportion of participants with an end-study HbA1c < 6.5% was 22.7% (n=22). After completion of the intervention, 16.5% (n=16) of participants reported a decrease in diabetic medication while 8.3% (n=8) reported an increase. 56.7% (n=55) of participants achieved a composite outcome of reducing HbA1c, reducing diabetic medication use or both. 91.8% (n=90) reported greater confidence in their ability to manage their diabetes compared to before the program, and 90.8% (n=89) reported greater confidence in their ability to maintain a healthy dietary pattern. Participants engaged with the app an average of 4.3 times per day. We observed a significantly greater decrease in HbA1c amongst participants in the highest tertile of app engagement compared to those in the lowest tertile of app engagement (P = .03). Conclusions: The FareWell digital therapeutic produced clinically meaningful reductions in HbA1c. Greater glycemic control was observed with increasing app engagement. Engagement and retention were both high in this widely distributed sample.

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

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 6, 2017

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

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

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

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

    From: Journal of Medical Internet Research

    Date Submitted: Dec 7, 2017

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

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

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

  • Prototype Testing of BreatheFree: A Videogame-based Smoking Cessation Smartphone Application

    From: JMIR Serious Games

    Date Submitted: Dec 7, 2017

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

    Background: Cigarette smoking is the leading preventable cause of death in the United States, causing an estimated 438,000 deaths each year. Researchers have developed many efficacious smoking-cessati...

    Background: Cigarette smoking is the leading preventable cause of death in the United States, causing an estimated 438,000 deaths each year. Researchers have developed many efficacious smoking-cessation interventions, yet ample room remains for improvement upon not only their efficacy, but also their effectiveness. One of the most effective smoking cessation interventions is contingency management (CM). Objective: There are two barriers to CM, which involves delivering monetary incentives for objective evidence of health behavior, including the cost of incentives and sustainability of treatment outcomes. The goal of the present study was to evaluate the feasibility of a videogame-based smartphone application, BreathFree, to replace monetary incentives used in CM with videogame-based incentives. Methods: Twenty-one smokers participated in this study. Participants were given an overview of the goals of the BreathFree game and were trained to submit a carbon monoxide (CO) sample via an Android tablet. After playing several levels of the game participants were told that they could continue and play one extra level, or they could stop and complete an outcome survey, receive payment, and be dismissed. Results: When asked with a multiple choice question whether the game was fun, 52% said "Yes," 29%" said "Maybe, it has the potential to be fun," and 19% said "No." Fifty-eight percent of participants, given the option to play an extra level of the game, chose to do so, and 86% signed up to be notified when the full version of the game was released. Conclusions: This was the first study to evaluate a smartphone-delivered, videogame-based CM application for smoking cessation. The prototype of BreathFree was highly endorsed on multiple dimensions from a group of treatment-seeking smokers. More than half of participants decided to play the extra level, which meant they delayed smoking their next cigarette, as well as getting paid, by at least a few minutes. These results are promising and we are now fully developing the game to test in the context of a clinical trial. Clinical Trial: Not Applicable

  • Implementing Internet-Based Self-Care Programs in Primary Care: A Qualitative Analysis of Patient and Provider Determinants of Practice

    From: JMIR Mental Health

    Date Submitted: Dec 7, 2017

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

    Background: Access to evidence-based therapies for common mental health conditions is limited due to travel, scheduling, stigma, and provider availability. Internet-based self-care programs (ISPs) may...

    Background: Access to evidence-based therapies for common mental health conditions is limited due to travel, scheduling, stigma, and provider availability. Internet-based self-care programs (ISPs) may mitigate these barriers; however, little is known about ISP implementation in integrated U.S. healthcare systems. Objective: The objective of this study was to elicit perspectives on implementing ISPs in primary care settings at the point of care with patients and providers in an integrated healthcare system. Methods: The objective was explored through qualitative analysis of semi-structured interviews with Veterans Health Administration (VHA) primary care and primary care mental health providers and administrators. Participants were identified using a reputation-based snowball design. Interviews focused on identifying determinants of practice for the use of ISPs at the point of care in VHA primary care. Investigators utilized thematic analysis to code interview transcripts and reach consensus on key themes through group discussion. Results: Twenty interviews with physicians, psychologists, social workers, and nurses were conducted and analyzed. Among this group, ISP use was low, but enthusiasm for the platform was uniformly high. Themes were organized into patient and provider level determinants of practice. Patient level determinants included literacy, age, Internet access, patient expectations, ISP fit with patient experiences, interest/motivation, and face-to-face human contact. Provider level themes included familiarity with ISPs, changes to traditional care delivery, face-to-face human contact, competing demands, and age. Conclusions: This exploration of perspectives on ISP implementation among VHA providers and administrators revealed key determinants of practice, which can be used to develop comprehensive strategies for the implementation of ISPs in primary care settings. Clinical Trial: none

  • The impact of a mobile application for cognitive stimulation of healthy older adults: Pilot Studies and validation

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 8, 2017

    Open Peer Review Period: Dec 8, 2017 - Dec 20, 2017

    Background: Cognitive impairment is a chronic condition that is considered one of the most feared by the older adult population, since its incidence is approximately twice more frequent than dementia....

    Background: Cognitive impairment is a chronic condition that is considered one of the most feared by the older adult population, since its incidence is approximately twice more frequent than dementia. Objective: The objective of this study was to analyze the impact of a mobile application for cognitive stimulation implemented among a group of elderly adults over the age of 60, from the state of Hidalgo, Mexico. Methods: A pilot study consisted in integrating memory, attention, comprehension, perception and visual-spatial exercises, which were specially designed for the older adult population. The study was carried out during a period of 12 weeks. In order to know the viability and impact of the application, the intervention was implemented among a group of 22 older adults between the ages of 60 and 80. This group was then divided into an experimental and a control group. Results: After the intervention, 6 out 11 older adults who used the application presented an improvement in their neuropsychological evaluation with the MMSE test. Furthermore, 13 of 22 older adults from the group showed an improved perception of their cognitive state, as reported by themselves, and 7 of 22 indicated that their cognitive state remained without change after the intervention. Regarding validation of the application, all the participants evaluated its pertinence positively. Conclusions: The results of the study suggest that, despite the improvement of some older adults, a more extended intervention is required. Additionally, we concluded that ICT use, especially for aspects related to cognitive stimulation and general health care, represents an important benefit and a source of interest for older adults.

  • Non-Traditional Electrocardiogram and Algorithms for Inconspicuous In-Home Monitoring

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 8, 2017

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

    Background: Wearable and connected in-home medical devices are typically utilized in uncontrolled environments and often measure physiologic signals at suboptimal locations. Motion artifacts and reduc...

    Background: Wearable and connected in-home medical devices are typically utilized in uncontrolled environments and often measure physiologic signals at suboptimal locations. Motion artifacts and reduced signal-to-noise ratio, compared to clinical grade equipment, results in highly variable signal quality that can change significantly from moment to moment. To address concerns with measurement accuracy, confidence, and clinical validity, these devices can benefit from the use of signal quality classification algorithms and robust feature delineation algorithms, designed to achieve high accuracy on poor quality physiologic signals. Objective: The objective of the present work was to demonstrate the successful extraction of clinical grade measures using a custom signal quality classification algorithm for the rejection of poor quality regions and a robust QRS delineation algorithm from a non-standard electrocardiogram integrated into a toilet seat; a device which is plagued by many of the same challenges as wearable technologies and other Internet of Things based medical devices. Methods: The present algorithms were validated using a study of 25 normative subjects and 29 heart failure subjects. Measurements captured from a toilet seat based buttocks ECG (bECG) were compared to a simultaneously captured 12-lead clinical grade ECG. The ECG lead with the highest morphological correlation to the bECG was used to determine the accuracy of the heart rate (HR), heart rate variability (HRV), QRS duration, and the corrected QT (QTc) interval. The algorithms were also benchmarked using the MIT-BIH Arrhythmia Database (MITDB) and European ST-T Database (EDB), which are standardized databases commonly used to test QRS detection algorithms. Results: Clinical grade accuracy was achieved for all bECG measures when compared to standard Lead II. The accuracy of the HR is -0.0±0.3 bpm (mean±sd) (N=250) and the accuracy of the HRV is -3.4±9.4 ms (N=234). The QRS duration and the corrected QT interval have an accuracy of 0.9±9.1 ms (N=144) and 13.2±15.0 ms (N=143) respectively. When tested on the MITDB and EDB the algorithms presented herein have an overall sensitivity and positive predictive value of over 99.8% (N=868107), which is comparable to best in-class algorithms tuned specifically for use with these databases. Conclusions: The present algorithmic approach to data analysis of noisy physiologic data has been successfully demonstrated using a toilet seat based ECG remote monitoring system. This approach to the analysis of physiologic data captured from wearable and connected devices has future potential to enable new types of monitoring devices, providing new insights through daily, inconspicuous, in-home monitoring.

  • Measuring the Effectiveness of the Hello Sunday Morning Blog Platform in Reducing Alcohol Consumption amongst a Web-Based Supportive Community: An Observational Study

    From: Journal of Medical Internet Research

    Date Submitted: Dec 8, 2017

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

    Background: Alcohol use is a major social and public health issue in Australia, with an estimated cost to the community of $30 billion per annum. Until recently, a major barrier in addressing this sig...

    Background: Alcohol use is a major social and public health issue in Australia, with an estimated cost to the community of $30 billion per annum. Until recently, a major barrier in addressing this significant public health issue is the fact that the majority of individuals with alcohol use disorders are not receiving treatment. Objective: To assess whether alcohol consumption changes as a result of participation in Hello Sunday Morning (HSM), an online forum discussing experiences in abstaining from alcohol. Methods: The study reports on HSM participants who signed up for a three-month period of abstinence from November 2009 to November 2016. The sample was made up of 1,917 participants (63.7% female, 36.3% male). Main outcome measures were AUDIT scores, mood, program engagement metrics and slip-ups. Results: Individuals engaged in the HSM program reported a significant decrease in alcohol consumption, moving from harmful, high-risk or dependent drinking levels to risky or almost low-risk levels, four months following program commencement (p < .001). This reduction in risk was maintained seven months following program commencement. Furthermore, those who engaged in the program more (as defined by more sign-in’s, blogs posted, check-ins completed, engagement with the community through likes and following), had lower alcohol consumption. Lastly, those who experienced more slip ups had lower alcohol consumption. Conclusions: Participation in an online forum can support long-term behaviour change in individuals wishing to change their drinking behaviour. This has promising implications for future models of alcohol reduction treatment, as online forums are anonymous, accessible and cost-effective alternative or adjunct to treatment-as-usual. Further research is needed into the specific mechanisms of change within an online supportive community, as well as the role of specific mood states in predicting risky drinking behaviour.

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

    From: Journal of Medical Internet Research

    Date Submitted: Dec 8, 2017

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

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

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

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

    From: JMIR mHealth and uHealth

    Date Submitted: Dec 8, 2017

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

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

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

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

    From: Journal of Medical Internet Research

    Date Submitted: Dec 8, 2017

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

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

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

  • Virtual Antenatal Encounter and Standardized Simulation Assessment (VANESSA): A Pilot Study

    From: JMIR Serious Games

    Date Submitted: Dec 8, 2017

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

    Background: Prenatal counseling at the limits of viability involves sensitive interactions between neonatal providers and families. Empathetic discussions are currently learned through practice in tim...

    Background: Prenatal counseling at the limits of viability involves sensitive interactions between neonatal providers and families. Empathetic discussions are currently learned through practice in times of high stress. Decision aids may help improve provider communication but have not been universally adopted. Virtual standardized patients are increasingly recognized as a modality for education, but prenatal counseling simulations have not been described. To be valuable as a tool, a virtual patient would need to accurately portray emotions and elicit a realistic response from the provider. Objective: To determine if neonatal providers can accurately identify a standardized virtual prenatal patient’s emotional states, and examine the frequency of empathic responses to statements made by the patient. Methods: A panel of Neonatologists, Simulation specialists, and Ethicists developed a dialogue and identified empathic responses. VANESSA, a screen-based simulation of a woman at 23 weeks gestation, was capable of displaying anger, fear, sadness, and happiness through animations. 24 neonatal providers, including a subgroup with an ethics-interest, were asked to identify VANESSA’s emotions 28 times, respond to statements, and answer open ended questions. The emotions were displayed: without dialogue, with text dialogue, and with audio dialogue. Participants completed a post-encounter survey describing demographics and experience. Data was reported using descriptive statistics. Qualitative data from open ended questions e.g. “What would you do?” was examined using thematic analysis. Results: Half of our participants had over 10 years of clinical experience (Table 1). Most participants reported using medical research (n=18, 78.3%) and mortality calculators (n=17, 73.9%). Only the ethics interested subgroup (n=10, 41.6%), listed counseling literature (n=7, 70.0%). Of 672 attempts, participants accurately identified VANESSA’s emotions (n=523, 77.8%) of the time, and most (n=14, 61.11%) reported that they were confident in identifying these emotions (Fig 1). The ethics interest group were more likely to choose empathic responses (p= 0.002) (Fig 2). Participants rated VANESSA as easy to use (n=22, 91.20%), and reported that she had realistic dialogue (n=15, 65.22%). Conclusions: This pilot study shows that a prenatal counseling simulation is feasible and can yield useful data on prenatal counseling communication. Our participants showed a high rate of emotion recognition and empathy in their responses.

  • Self-directed Engagement with the Mobile Application Sinasprite and its Effects on Confidence in Coping Skills, Depression, and Anxiety

    From: Journal of Medical Internet Research

    Date Submitted: Dec 8, 2017

    Open Peer Review Period: Dec 9, 2017 - Dec 20, 2017

    Background: Inadequacies in mental healthcare coverage remain an enormous problem in the United States. Barriers to care include geographical and financial limitations, and a scarcity of accessible me...

    Background: Inadequacies in mental healthcare coverage remain an enormous problem in the United States. Barriers to care include geographical and financial limitations, and a scarcity of accessible mental healthcare professionals. Use of a mobile application may improve early access to healthcare for individuals who may benefit from tools to reduce stress as well as improve management of anxiety and depression. It is unknown how self-directed use of a mental health mobile application improves coping skills and its effects on self-reported depression and anxiety. Objective: The objective of this study was to evaluate self-directed engagement of the mobile application Sinasprite and how use can impact self-reported confidence in coping skills, and depression and anxiety severity. Methods: This retrospective longitudinal study involved users who were recruited via clinician referral and self-referral through social media and news media. Questionnaires were utilized to record demographic, medical and prescription medication histories. Mental health status was assessed via Patient Health Questionnaire 8 (PHQ-8), General Anxiety Disorder Item 7- (GAD-7) and the Coping Self-Efficacy Scale (CSE) questionnaires. Mobile use data were provided by the application development team. Individuals with verifiable usage data and at least one completed questionnaire at six weeks of use were included. Mann-Whitney U and Kruskal-Wallis tests were used to assess whether demographic data and psychotherapy were related to baseline questionnaire scores and usage. A Spearman Rho test was used to assess the relationship between improvement in the CSE and GAD-7 and PHQ-8 questionnaires. Changes in mental health status were assessed at baseline and again six weeks after via Wilcoxon signed-rank test. A mixed effects repeated measures regression model assessed the main effects of time, concomitant counseling and psychotropic prescription medication use on mental health status. Results: Thirty-four users were eligible for the analysis. Users were more commonly female, Caucasian, and college educated. At baseline, 35% of respondents reported use of individual/group counseling and 38% reported using prescription medications for their mental health. The median user completed 5.7 (interquartile range 2.7-14.1) trackable activities per week. After six weeks of engagement statistically significant improvements using a Wilcoxon signed-ranked test were observed in the PHQ-8 (p<0.001), GAD-7(p= 0.002), and CSE (p= 0.011) questionnaire scores. A strong, positive correlation between improvement in the GAD-7 and CSE questionnaire scores (r= 0.581 p= 0.007, n= 20) was observed. The mixed effects repeated measures regression model revealed a statistically significant effect of time on improvements in the PHQ-8 (p< 0.001), GAD-7 (0.007) and CSE (p= 0.003) questionnaire scores while controlling for concomitant therapies. Conclusions: This six-week retrospective study showed that self-directed use of a mental health-related mobile application, Sinasprite, resulted in significant improvements in self-reported questionnaire scores reflecting depression, anxiety, and confidence in coping skills.

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