JMIR Publications

Latest Submissions Open for Peer-Review:

• Remotely supervised home-based intensive exercise intervention to improve balance, functional mobility and physical activity in survivors of moderate or severe TBI: a mixed-method study protocol

  From: JMIR Research Protocols

  Date Submitted: Jun 11, 2019

  Open Peer Review Period: Jun 14, 2019 - Jun 28, 2019

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  Background: Traumatic brain injury may impact an individual physically, cognitively, socially and emotionally. Poor balance, reduced mobility and low daily physical activity often will require ongoing...

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  Background: Traumatic brain injury may impact an individual physically, cognitively, socially and emotionally. Poor balance, reduced mobility and low daily physical activity often will require ongoing physical rehabilitation intervention. Face-to-face specialized physiotherapy is not always accessible for individuals living in rural settings. Objective: We will answer four questions: (1) What is the feasibility of a remotely supervised home-based intensive exercise intervention with survivors of moderate and severe TBI? (2) Does the frequency of remote supervision have an impact on the feasibility of completing a home-based intensive exercise program? (3) Does the frequency of remote supervision impact balance, functional mobility and physical activity? (4) What is the lived experience of remote supervision for both survivors and caregivers? Methods: Four participants will complete two intensive, 4-week, five day-per-week, home-based exercise interventions remotely supervised via synchronous video-conference. Each exercise intervention will have a goal of 160-300 repetitions or 60 minutes of tailored exercises to promote neuroplasticity and be defined as an intensive home-based exercise intervention. An alternating single subject design will allow for the comparison between two frequencies of remote supervision, once weekly and five times weekly. Daily repeated outcome measures, pre-and post-intervention outcome measures, and 1- month follow-up outcome measures will be collected to explore the impact on feasibility and physical variables. Daily outcome measures include step count and Five Time Sit to Stand. Pre-post measures include assessment of quiet stance and the Community Balance and Mobility Scale. A semi-structured interview will be completed at the end of each intervention segment to document the lived experience of both survivors and their study partners. Finally, five questionnaires will be used to understand the overall experience: The Mayo-Portland MPAI-4, the Satisfaction with Life Scale, the Fall Efficacy Scale-International, the Interpersonal Behaviour Questionnaire and the System Usability Scale. Data will be analyzed following traditional single subject methods of analysis. Results: Ethics approval was received from both Bruyère Research Institute and University of Ottawa review board in March 2019. Recruitment is underway. Conclusions: The proposed intervention is complex in nature due to the involvement of multiple technology sources and the inclusion of a complex dyad (survivors and caregivers) in a community setting. This type of research is timely given that alternative methods of physical intervention delivery are needed to facilitate gains in balance, mobility, physical activity among traumatic brain injury survivors with limited access to clinical care, and the quality of the patients’ experience.

• Exploring Factors Influencing Patients’ Intention to Use Diabetes Management Mobile Apps Based on an Integrated Theoretical Model—a Web-Based Survey in China

  From: Journal of Medical Internet Research

  Date Submitted: Jun 13, 2019

  Open Peer Review Period: Jun 13, 2019 - Jun 21, 2019

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  Background: Diabetes poses heavy social and economic burdens on the world. Diabetes management mobile apps show great potential for diabetes self-management. However, the uptake of diabetes apps among...

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  Background: Diabetes poses heavy social and economic burdens on the world. Diabetes management mobile apps show great potential for diabetes self-management. However, the uptake of diabetes apps among diabetes patients is poor. The factors influencing patients’ intention to use these apps are unclear. Understanding patients’ behavioral intention is necessary to support the development and promotion of diabetes app use. Objective: To identify the determinants of patients’ intention to use diabetes apps based on an integrated theoretical model. Methods: The hypotheses of our research model were developed based on the Unified Theory of Acceptance and Use of Technology (UTAUT) integrated with context-related hypotheses. From 20 April to 20 May 2019, adult diabetes patients across China who were familiar with diabetes management mobile apps were surveyed using the web-based survey tool Sojump (Changsha ran Xing InfoTech Ltd). Structural equation modeling was used to analyze the data. Results: A total of 746 qualified questionnaires were collected. The fitness indices suggested that the collected data fit well with the research model. The model explained 62.6% of the variance in performance expectancy and 57.1% of the variance in behavioral intention. Performance expectancy and social influence had the strongest total effects on behavioral intention (β=.482 p=0.001). Performance expectancy (β=.482 P=.001), social influence (β=.223 P=.003), facilitating conditions (β=.17 P=.006), perceived disease threat (β=.073 P=.005) and perceived privacy risk (β=-.073 P=.012) had direct effects on behavioral intention. Additionally, social influence, effort expectancy and facilitating conditions had indirect effects on behavioral intention that were mediated by performance expectancy. Social influence had the highest indirect effects among the three constructs (β=.259 P=.001). Conclusions: Performance expectancy and social influence are the most important determinants of the intention to use diabetes apps. Healthcare technology companies must improve the usefulness of apps and carry out research to provide clinical evidence for the apps’ effectiveness, which will benefit the promotion of these apps. Facilitating conditions and perceived privacy risk also have an impact on behavioral intention. Therefore, it is necessary to improve facilitating conditions and provide solid privacy protection. Our study supports the use of UTAUT in explaining patients’ intention to use diabetes management mobile apps. Context-related determinants should also be taken into consideration.

• Understanding drivers of resistance towards implementation of online self-management tools in routine cancer care among oncology nurses

  From: Journal of Medical Internet Research

  Date Submitted: Jun 10, 2019

  Open Peer Review Period: Jun 13, 2019 - Aug 8, 2019

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  Background: Supporting patients to engage in (online) self-management tools is increasingly gaining in importance, but the engagement of healthcare professionals lags behind. This can partly be explai...

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  Background: Supporting patients to engage in (online) self-management tools is increasingly gaining in importance, but the engagement of healthcare professionals lags behind. This can partly be explained by resistance among healthcare professionals. Objective: The objective of this study was to investigate drivers of resistance among oncology nurses towards online self-management tools in cancer care. Methods: Drawing from earlier research, combining clinical and marketing perspectives, we developed the Resistance to Innovation model (RTI-model). The RTI-model distinguishes between passive and active resistance, which can be enhanced or reduced by functional drivers (incompatibility, complexity, lack of value, risk) and psychological drivers (role ambiguity, social pressure from the institute, peers, and patients). Both types of drivers can be moderated by staff-, organization-, patient- and environment-related factors. We executed a survey covering all components of the RTI-model on a cross-sectional sample of nurses working in oncology in the Netherlands. Structural equation modelling was used to test the full model, using a hierarchical approach. Results: The goodness of fit statistic of the uncorrected base model of the RTI-model (n=239) was acceptable (χ2(df) = 9.243 (1); CFI=0.95; TLI=0.21; RMSEA=0.19; SRMR=0.016). In line with the RTI-model we indeed found that passive and active resistance among oncology nurses towards (online) self-management tools were driven by both functional and psychological drivers. Passive resistance was enhanced by complexity, lack of value, and risk, and reduced by institutional social pressure. Active resistance was enhanced by complexity, lack of value, and social pressure from peers, and reduced by social pressure from the institute and patients. Nurses’ expertise regarding (online) self-management moderated the effects of complexity, lack of value, risk, role ambiguity, and social pressure from thePassive and active resistance are driven by functional and psychological drivers, and these drivers are moderated by expertise, managerial support and governmental influence. institute, peers, and patients (P=.030). Managerial support moderated complexity, lack of value, role ambiguity, and social pressure from peers and the institute (P=.004). Governmental influence moderated the effects of complexity, lack of value, risk, role ambiguity, and social pressure from peers and the institute (P=.037). Conclusions: Passive and active resistance are driven by functional and psychological drivers, and these drivers are moderated by expertise, managerial support and governmental influence.

• Mobile apps in rheumatology: review and analysis using the Mobile App Rating Scale (MARS)

  From: JMIR mHealth and uHealth

  Date Submitted: Jun 10, 2019

  Open Peer Review Period: Jun 13, 2019 - Aug 8, 2019

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  Background: Chronic rheumatic diseases need long-term treatment and professional supervision. Mobile applications promise to improve the lives of patients as well as physicians. In routine practice, h...

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  Background: Chronic rheumatic diseases need long-term treatment and professional supervision. Mobile applications promise to improve the lives of patients as well as physicians. In routine practice, however, rheumatology apps are largely unknown and little is known about their quality and safety. Objective: The aim of this study was to provide an overview of the mobile rheumatology applications currently available in the German app stores, to evaluate the app quality using the Mobile App Rating Scale (MARS) and to compile brief, ready-to-use descriptions for patients as well as rheumatologists. Methods: The German Google Play and Apple app stores were systematically searched to identify German rheumatology mobile applications applying to patients as well as physicians. MARS was used to independently assess app quality by a total of 8 physicians, 4 using Android and 4 using iOS smartphones. Apps were randomly assigned so that 4 apps were rated by all raters and the remaining apps were rated by two Android and two iOS users. Furthermore, brief app descriptions including app developers, app categories and features were compiled to inform potential users and developers. Results: In total, 128 and 63 apps were identified in the German Google Play and Apple app stores, respectively. After removing doublets and only including apps that were available in both stores, 28 apps remained. Sixteen apps met the inclusion criteria, which were: (1) German language; (2) availability in both app stores; (3) targeting patients or physicians as users; and (4) clearly including rheumatology or rheumatic diseases as subject matter. Exclusion criteria were: (1) congress apps and (2) company apps with advertisements. Nine apps addressed patients and 7 apps addressed physicians. No clinical studies to support the effectiveness and safety of these apps could be found. Pharmaceutical companies were the main developers of two apps. Rheuma-Auszeit was the only app mainly developed by a patient organisation. This app, had the highest overall MARS score (4.19/5). Three out of nine patient apps featured validated questionnaires. The median overall MARS score was 3.85/5, ranging from 2.81/5 to 4.19/5. One patient targeted app and one physician-targeted app had a MARS score >4/5. No significant gender or platform (iOS/Android) differences could be observed. The overall correlation between app store ratings and MARS scores was low and inconsistent between platforms. Conclusions: This is the first study, which systematically identified and evaluated mobile applications in rheumatology for patients, as well as physicians, available in German app stores. We found a lack of supporting clinical studies, use of validated questionnaires and involvement of academic developers. Overall app quality was very heterogeneous. To create high-quality apps a closer cooperation lead by patients and physicians is vital.

• Influences of eHealth Literacy on Obtaining Knowledge about Colorectal Cancer among Internet Users Accessing a Reputable Cancer Website: Web-Based Survey Study

  From: Journal of Medical Internet Research

  Date Submitted: Jun 10, 2019

  Open Peer Review Period: Jun 13, 2019 - Aug 8, 2019

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  Background: To develop websites that enhance Internet users’ health knowledge, it is important to identify relevant factors associated with obtaining health knowledge via the Internet. Although an a...

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  Background: To develop websites that enhance Internet users’ health knowledge, it is important to identify relevant factors associated with obtaining health knowledge via the Internet. Although an association between eHealth literacy (eHL) and knowledge of colorectal cancer (CRC) has been reported, little is known whether eHL is associated with obtaining knowledge of CRC via the Internet. Objective: This study aimed to compare the results obtained from Internet users with high or low eHL in searching and using a reputable cancer website to gain CRC knowledge. Methods: This study used respondents to Internet based pre-and post-surveys conducted in 2012. Potential respondents (n = 3,307) were identified from registered individuals aged 40–59 years (n = 461,160) in a Japanese Internet survey company. A total of 1,069 participants responded (response rate: 32.3%), and these pre-survey responders were then divided into high or low eHL groups using the Japanese eHealth Literacy Scale median score (23.5 points). From each group, 130 randomly selected individuals were invited to review the contents of a reputable CRC website, the Cancer Information Service managed by the National Cancer Center, and to respond to a post-survey via e-mail; responses were obtained from 107 individuals from each group. Twenty responses to knowledge statements regarding the definition, risk factors, screening prevention and symptoms of CRC were obtained at pre- and post-surveys, and differences in the correct responses between high and low eHL groups compared using the McNemar test. Results: The mean age of the participants was 49.1 (5.5) years. Four statements showed a significant increase in correct responses in both eHL groups pre- and post-survey: “S4. The risk of CRC is greater as a person gets older” (high eHL: P = 0.039, low eHL: P = 0.012), “S8. Cigarette smoking is a risk factor for CRC” (high eHL: P < 0.001, low eHL: P = 0.020), “S11. Obesity is a risk factor for CRC” (high eHL: P = 0.030, low eHL: P = 0.047), and “S12. Excess alcohol consumption is a risk factor for CRC” (high eHL: P = 0.002, low eHL: P = 0.003). Three statements showed a statistically significant increase in correct responses in the high eHL group only: “S1. CRC is cancer of the colon or rectum” (P = 0.003), “S5. The risk of CRC is the same between men and women” (P = 0.041), and “S9. Red meat intake is a risk factor for CRC” (P = 0.002), whereas only one response did in the low eHL group: “S17. Bloody stools are a symptom of CRC” (P = 0.004). Conclusions: Low eHL Internet users appeared less capable of obtaining knowledge of CRC through searching and understanding information from a reputable cancer website than high eHL Internet users.

• Examining Variations of Digital Behavior Change Techniques for Physical Activity Using an Adaptive Intervention Design

  From: JMIR mHealth and uHealth

  Date Submitted: Jun 10, 2019

  Open Peer Review Period: Jun 13, 2019 - Aug 8, 2019

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  Background: To foster physical activity behavior, technology often incorporates evidence-based behavior change techniques (BCTs). However, a gap exists on how to apply BCTs for optimal behavior change...

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  Background: To foster physical activity behavior, technology often incorporates evidence-based behavior change techniques (BCTs). However, a gap exists on how to apply BCTs for optimal behavior change, and do so in time-varying adaptive interventions. Objective: This study evaluated BCT variations using an adaptive intervention design that randomly assigned participants to a different intervention version based on whether participants met a self-determined physical activity goal. Methods: The study contained three intervention versions (individual pursuit, community comparison, and team competition). Each version included variations of 4 BCTs (goal setting, action planning, feedback, and prompts & cues). The individual pursuit version was the control, while versions two and three received variations of the social competition/comparison BCT. BCTs were delivered via phone app, phone texts, and a Garmin vivofit 3™. Participants who did not increase physical activity in the first 21 days as compared to their baseline were re-randomized into a different intervention version, reassessed at 42 days, and re-randomized again if physical activity did not increase. Ecological momentary assessments were conducted for secondary measures of self-efficacy, barriers, expectations, motivation, mood, social support, and well-being. Results: A total 158 adults in central Florida with low to moderate levels of physical activity, were randomized into one of three intervention versions. Based on a subsample analysis of 87 participants, those who received the team competition intervention version first, followed by community comparison, and individual pursuit, saw the greatest increase in their overall physical activity as compared to other intervention orders. In addition, five distinct behavioral pattern subgroups were identified. We also predicted the likelihood of a participant being active or inactive 14 days into observation and with >80% precision. There was also evidence that app usage in the first 21 days of observation was positively associated with physical activity behavior at study conclusion. Conclusions: The way BCTs are designed and the sequence in which they are delivered can impact physical activity behavior. Additional work is needed on determinants of physical activity behavior, as well as longevity of BCT novelty and user engagement. Clinical Trial: N/A

• Cardiology Handbook Application: A Pilot Study to Improve Medical Education

  From: JMIR mHealth and uHealth

  Date Submitted: Jun 9, 2019

  Open Peer Review Period: Jun 12, 2019 - Aug 7, 2019

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  Background: At most institutions, internal medicine residents struggle with balancing clinical duties and learning opportunities, particularly during busy cardiology ward rotations. To improve learni...

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  Background: At most institutions, internal medicine residents struggle with balancing clinical duties and learning opportunities, particularly during busy cardiology ward rotations. To improve learning experiences for residents, the authors helped develop a cardiology handbook application (app) to supplement cardiology education. Objective: The aim of this study was to report the development, implementation, and preliminary impact of a cardiology reference app in graduate medical education. Methods: In June 2017, 122 residents at Indiana University were invited to download the digital handbook in the Krannert app. The Krannert app featured a total of thirteen chapters which were written by cardiology fellows and faculty at Indiana University. Residents were surveyed on their self-reported improvement in cardiology knowledge and in their satisfaction after using the handbook app. Residents were also surveyed regarding their preference for a digital handbook app versus a paper handbook. Results: Thirty-eight trainees (31%) participated in survey evaluations. Among all respondents, 82% of app users reported the app helped improve their cardiology knowledge base. The handbook app had an overall favorable response. Conclusions: The Krannert cardiology app shows promise in augmenting clinical education in cardiology with mobile learning. Future work includes adding new topics, updating the content, comparing the app to other learning modalities.

• Trends in scientific reports on cartilage bioprinting: A scoping review

  From: JMIR Formative Research

  Date Submitted: Jun 12, 2019

  Open Peer Review Period: Jun 12, 2019 - Jun 20, 2019

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  Background: Satisfactory therapeutic strategies for cartilaginous lesion repair do not yet exist, creating a challenge for surgeons and biomedical engineers, and leading them to investigate the role o...

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  Background: Satisfactory therapeutic strategies for cartilaginous lesion repair do not yet exist, creating a challenge for surgeons and biomedical engineers, and leading them to investigate the role of bioprinting and tissue engineering as viable treatments through orthopedic surgery, plastic surgery, and otorhinolaryngology. Recent increases in related scientific literature suggest that bioprinted cartilage may develop into a viable solution. Objective: The objectives of this review were a) synthesize the scientific advances published to date, b) identify unresolved technical problems regarding human application, and (c) identify more effective ways for the scientific community to transfer their findings to clinicians. Methods: This scoping review considered articles published between 2011 and 2019 that were identified through searching PubMed, Science Direct, Web of Science, and Google Scholar. Arksey and O'Malley’s five-step framework was used to delimit and direct the initial search results, from which we established the following research questions: What do the authors say about current research on potential human applications? What improvements are needed in the technical aspects? On which issues do the authors agree? What proposals prioritize the authors’ next steps? We used Cohen's kappa to validate the interrater reliability. Results: The 13 articles included in the review demonstrated the feasibility of cartilage bioprinting in live animal studies. Some investigators are already considering short-term human experimentation, although technical limitations still need to be resolved. Both the use and manufacturing process of stem cells need to be standardized, and a consensus is needed regarding the composition of hydrogels. Using on-site printing strategies and pre-designed implants may allow techniques to adapt to multiple situations. In addition, the predictive capacity of implant behavior may lead to optimal results. Conclusions: Cartilage bioprinting for surgical applications is nearing initial use in humans. Current research suggests that soon surgeons will be able to replace damaged tissue with bioprinted material. Clinical Trial: Not applicable

• Evaluation of the demographic representativeness and health outcomes of users of SiSU Health Stations

  From: Journal of Medical Internet Research

  Date Submitted: Jun 9, 2019

  Open Peer Review Period: Jun 12, 2019 - Aug 7, 2019

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  Background: SiSU Wellness health check stations collect data on a range of self-reported and machine measured health indicators, including diabetes status, physical activity levels, waist circumferenc...

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  Background: SiSU Wellness health check stations collect data on a range of self-reported and machine measured health indicators, including diabetes status, physical activity levels, waist circumference, dietary practices, heart rate, blood pressure, weight, Body Mass Index (BMI) and body fat percentage. Users of the health stations are able to monitor their progress and changes to health over time by connecting their health check station profile to a free application downloadable from Google Play or the iTunes store. The stations and associated application are intended to assist consumers by allowing them to monitor their health status over time and providing alerts to consumers when follow up with a General Practitioner (GP) is recommended. Objective: To assess the demographic representativeness of SiSU Health Station users, identify the factors associated with repeat utilisation stations, and determine whether the health status of repeat users changed between their baseline and final health checks. Methods: SiSU Health Station users were compared with 2014-2015 Australian National Health Survey participants on key demographic and health characteristics to determine representativeness. Binary logistic regression analyses were used to compare demographic and health characteristics of repeat and one-time users. Baseline and final health checks of repeat users were compared using McNemar’s Tests and Wilcoxon Signed Rank Tests. The relationship between number of checks and final health scores was investigated using generalised linear models. Results: Data from 180,442 SiSU Health Station health checks conducted at 192 locations across Australia between October 2017 and June 2018, including 8,441 repeat users. SiSU Health Stations located in Priceline Pharmacies accounted for 98.4% of checks. The demographic profile of SiSU Health Station users differs from that of the general population. A larger proportion of SiSU users were female (55.87% vs 50.72%), younger (47.87% vs 34.49% under 35 years) and socio-economically advantaged (35.68% vs 20.325. When considering the gender profile of Priceline Pharmacy customers, males were found to be substantially over-indexed on health station usage, accounting for 44.10% of health checks but only 3.00% of customers. Compared with NHS participants, a smaller proportion of SiSU Health Station users were overweight or obese, were smokers, had high blood pressure or had diabetes. When data were weighted for demographic differences, only rates of high blood pressure were found to be lower for SiSU users compared to National Health Survey participants (OR=1.26, p<0.001). Repeat users were more likely to be female (OR=1.37, p<0.001), younger (OR=0.99, p<0.001), and from high socio-economic status areas - those residing in SEIFA quintiles 4 and 5 were significantly more likely to be repeat users compared to those residing in quintile 1 (OR=1.243, p<0.001 and OR=1.151, p<0.001 respectively). Repeat users were more likely to have higher body mass index (OR=1.02 p<0.001), high blood pressure (OR=1.15, p<0.001), and less likely to be smokers (OR=0.77, p<0.001). Significant improvements in health status were observed for repeat users. Mean BMI decreased by 0.97kg/m2 from baseline to final check (z=-14.24, p<0.001), while the proportion of people with high blood pressure decreased from 15.8% to 12.9% (2=38.21, p<0.001). The proportion of smokers decreased from 11.9% to 10.1% (2=48.39, p<0.001). The number of repeat health checks was found to be significantly associated with smoking status (OR=0.96, p<0.048), but not with higher blood pressure (p=0.142) or BMI (p=0.225). Conclusions: These findings provide valuable insight into the health benefits of health stations for self-monitoring and partially support previous research regarding the effect of demographics and health status on uptake of self-management of health.

• Development and Implementation of a Nurse-Led Model of Care Coordination to Provide Health-Sector Continuity of Care for People with Multimorbidity: Protocol for a Mixed Methods Study

  From: JMIR Research Protocols

  Date Submitted: Jun 12, 2019

  Open Peer Review Period: Jun 12, 2019 - Jun 20, 2019

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  Background: Innovative strategies are required to reduce care fragmentation for people with multimorbidity. In response, coordinated models of health care delivery need to be adopted to deliver consum...

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  Background: Innovative strategies are required to reduce care fragmentation for people with multimorbidity. In response, coordinated models of health care delivery need to be adopted to deliver consumer-centred continuity of care. Nurse-led services have emerged over the past 20 years as evidence-based structured models of care delivery, providing a range of positive and coordinated healthcare outcomes. Although Nurse-led services are effective in a range of clinical settings, strategies to improve continuity of care across the secondary and primary health care sectors for people with multimorbidity have not been examined. Objective: To implement a nurse-led model of care coordination from a multi-disciplinary outpatient setting and provide continuity of care between the secondary and primary health care sectors for people with multimorbidity. Methods: This action research mixed methods study will have two phases. Phase one includes a systematic review, stakeholder forums and validation workshop to collaboratively develop a model of care for a nurse-led care coordination service. The second phase, through a series of iterative action research cycles, will implement a nurse-led model of care coordination in a multidisciplinary outpatient setting. Three to five iterative action research cycles will allow the model to be refined and further developed with multiple data collection points throughout. Results: Pilot implementation of the model of care coordination commenced in October 2018. Formal study recruitment commenced in May 2019 and the intervention and follow-up phases are ongoing. The results of the data analysis are expected to be available by March 2020 Conclusions: Nursing, clinician and patient outcomes and experiences with the nurse-led model of care coordination will provide a template to improve continuity of care between the secondary and primary healthcare systems. The model template may provide a future pathway for implementation of nurse-led services both nationally and internationally.

• Growing disparities in Patient-Provider Messaging Following Supportive Public Policy: A Trend Analysis using Health Information National Trends Survey Data

  From: Journal of Medical Internet Research

  Date Submitted: Jun 8, 2019

  Open Peer Review Period: Jun 11, 2019 - Aug 6, 2019

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  Background: Under the HITECH Act, public policy introduced since 2011 has supported provider adoption of electronic medical records and patient-provider messaging. It is unclear how disparities in use...

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  Background: Under the HITECH Act, public policy introduced since 2011 has supported provider adoption of electronic medical records and patient-provider messaging. It is unclear how disparities in use of policy-influenced online health tools have changed over time relative to use of online tools that were not targeted by policy. Objective: To characterize the impact of public policy on disparities in patient-provider messaging by comparing its use with rates of looking for health information online, which was not targeted by public policy. Methods: We used nationally representative Health Information National Trends Survey data from 2003-2018 (N=37,300) to describe disparities in patient-provider messaging and looking for health information online. We first reported the percentage of individuals across education and racial/ethnic groups who reported using these tools in each survey year. We then compared changes in unadjusted disparities during pre-policy (2003-2011) and post-policy (2011-2018) periods. Using multivariable linear probability models, we examined adjusted effects of education and race/ethnicity in three periods: pre-policy (2003-2005), early-policy (2011-2013) and post-policy (2017-2018). Models controlled for sociodemographic factors and general health. In the post-policy period, an additional model tested whether access to the internet, healthcare providers, or providers that used an electronic medical record explained remaining disparities. Results: From 2003-2018, overall rates of provider messaging increased from 4% to 36%. The gap between the highest and lowest education groups increased by 10 percentage points from 2003-2011 (p<.001), and 22 additional points from 2011-2018 (p<.001). The gap between Hispanics and non-Hispanic whites increased by 3.2 points from 2003-2011 (p=.42) and an additional 11 points from 2011-2018 (p=.01). Trends for Blacks resembled those for Hispanics, while trends for Asians resembled non-Hispanic Whites. In contrast, education-based disparities in looking for health information did not significantly change from 2003-2011 or 2011-2018. Racial disparities narrowed by 15 percentage points from 2003-2011 (p=.008) and did not significantly change from 2011-2018. Results of adjusted models were similar to unadjusted associations, though smaller in magnitude. Including access to the internet, providers, and providers with electronic medical records in the model attenuated, but did not eliminate, disparities based on education. However, disparities by race/ethnicity were no longer statistically significant when accounting for access. Conclusions: Disparities in provider messaging widened over time, particularly after the introduction of supportive public policy. Meanwhile, disparities in looking for health information online have remained stable or narrowed. Public policy aimed at increasing provider messaging may have disproportionately benefited socioeconomically advantaged groups. Future policy could address disparities by incentivizing providers treating these populations.

• Headache and Rhinitis: A 15-Year Long Content Analysis in a Search Engine Query Data

  From: Journal of Medical Internet Research

  Date Submitted: Jun 8, 2019

  Open Peer Review Period: Jun 11, 2019 - Aug 6, 2019

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  Background: There has been an increase in search engine data being used in healthcare research being an important tool for a better understanding of the epidemiology of diseases, a guide for public po...

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  Background: There has been an increase in search engine data being used in healthcare research being an important tool for a better understanding of the epidemiology of diseases, a guide for public policies and increasingly inserted in decision making. Our study aims to study the relationship between headache and rhinitis, through Google Trends, a Google search tool, seeking to better understand the temporal distribution of these pathologies in Brazil during the last 15 years. In addition, we sought to analyze the correlation between these conditions. Objective: : Headaches and sinus disorders have been linked in several ways. Rhinitis – commonly referred to as hay fever - and chronic headaches are both highly common conditions that coexist in the general world population. In order to shed light into the mechanisms between headache and rhinitis, using a digital epidemiology methodology, we aimed to investigate the correlation between the two terms and their temporal pattern in a search engine database. Methods: On January 8th, 2019, we queried the Google Trends website for the terms ‘rinite’ and ‘dor de cabeça,’limiting the search region to Brazil and other Portuguese-speaking countries. Data was obtained for every month from January 2004 to December 2018, and then extracted to a csv, Microsoft Excel file. After the descriptive analysis by dispersion diagrams, the Pearson test was performed to evaluate the correlation between the volume of research on rhinitis, headache and Alzheimer's disease, which was included as a control group. A linear regression model was used to predict the volume of searches for the term headache from the term rhinitis, with a 95% confidence interval. Finally, we analyzed the seasonality of rhinitis research volume. Results: : As a result, we found that the Pearson coefficient for rhinitis and headache was 0.80 indicating a strong correlation in the time interval analyzed. On the other hand, the test result for Alzheimer's and headache and rhinitis was respectively -0.18 and -0.09, indicating a very low correlation. The regression model showed that the increase in rhinitis volume increased by 2.69 the volume of headache. In addition we note seasonality in the volume of research of the term rhinitis, we noticed that the peaks of research volume tend to concentrate in the month of May, with the smaller volumes of research concentrating during the months of spring and early summer, and in the autumn (months of May and June) this volume of research increases. Finally, we note an increase in the research volume of the term headache, which may suggest an increase in the burden of this pathology. Conclusions: Headaches and rhinitis were significantly correlated in 15 years of Google Search query data, where a circannual variation could be observed with both conditions. Further studies using digital search engine query data may be useful for better understanding of comorbidity in headache disorders and possible treatments.

• Exploiting Machine Learning Algorithms and Methods for the Prediction of Agitated Delirium after Cardiac Surgery

  From: Journal of Medical Internet Research

  Date Submitted: Jun 11, 2019

  Open Peer Review Period: Jun 11, 2019 - Jun 19, 2019

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  Background: Delirium is a temporary mental disorder that occurs frequently among patients undergoing cardiac surgery. It is strongly associated with major adverse events, which in turn leads to increa...

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  Background: Delirium is a temporary mental disorder that occurs frequently among patients undergoing cardiac surgery. It is strongly associated with major adverse events, which in turn leads to increased cost and poor outcomes (e.g.: need for nursing home due to cognitive impairment, stroke, and death). The ability to foresee patients at risk of delirium will guide the timely initiation of multi-modal preventive interventions, which will aid in reducing the burden and negative consequences associated with delirium. Several studies have focused on the prediction of delirium. However, the number of studies in cardiac surgical patients that have used machine learning methods is very limited. Objective: Hence, we sought to explore the application of several machine learning predictive models that can pre-emptively predict delirium in patients undergoing cardiac surgery and compare their performance. Methods: We investigated a number of machine learning methods to develop models that can predict delirium after cardiac surgery. A clinical dataset comprising over 5000 actual patients who underwent cardiac surgery in a single center was used to develop the models using: Logistic Regression, Artificial Neural Networks, Support Vector Machines, Bayesian Belief Networks, Naïve Bayesian, Random Forrest, and Decision Trees Results: Since only 11.4% patients developed delirium, we addressed the underlying class imbalance, using random under-sampling, in the training dataset. The final prediction performance was validated on a separate test dataset. Due to the target class imbalance, several measures were used to evaluate algorithms performance for the “Delirium” class on the test dataset. Out of the selected algorithms, the Support Vector Machines algorithm had the best F1-Score for positive cases, Kappa, and positive predictive value (40.2%, 29.3%, 29.7%; respectively). The Artificial Neural Networks had the best receiver-operator area-under the curve (78.2%). The Bayesian Belief Networks had the best precision-recall area-under the curve for detecting positive cases (30.4%). Conclusions: Although, delirium is inherently complex, preventive measures to mitigate its negative effect can be applied proactively if patients at risk are prospectively identified. Our results highlight two important points: 1) addressing class imbalance on the training dataset will enhance machine learning model’s performance in identifying patients likely to develop post-operative delirium, 2) When it comes to complex medical problems, like delirium, increasing the complexity by using machine learning methods will improve the prediction, which will lead to reduction of cost by prevention of complications and better patients outcomes.

• Digital health transformation of integrated care in Europe: an overarching content analysis of 17 integrated care programmes

  From: Journal of Medical Internet Research

  Date Submitted: Jun 6, 2019

  Open Peer Review Period: Jun 11, 2019 - Aug 6, 2019

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  Background: Digital health tools comprise a wide arrange of technologies to support health processes. The potential of these technologies to effectively support healthcare transformation is widely acc...

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  Background: Digital health tools comprise a wide arrange of technologies to support health processes. The potential of these technologies to effectively support healthcare transformation is widely accepted. However, wide scale implantation is uneven among countries/regions. Identification of common factors facilitation and hampering the implementation process may be useful for future policy recommendations. Objective: To analyse the implementation of digital health tools to support healthcare and social care services, as well as to facilitate the longitudinal assessment of the services, in 17 selected integrated chronic care (ICC) programmes from 8 European countries. Methods: A programme analysis based on thick descriptions - including document examinations and semi-structured interviews with relevant stakeholders - of ICC programmes in Austria, Croatia, Germany, Hungary, The Netherlands, Norway, Spain and United Kingdom was performed. The overarching analysis focused on the use of digital health tools and programme assessment strategies. Results: Supporting digital health tools are implemented in all countries, but different levels of maturity were observed among the programmes. Only few ICC programmes have well-established strategies for a comprehensive longitudinal assessment. There is a strong relationship between maturity of digital health and proper evaluation strategies of integrated care. Conclusions: Notwithstanding the heterogeneity of the results across countries, most programmes aim to evolve towards a digital transformation of integrated care, including implementation of comprehensive assessment strategies. It is widely accepted that the evolution of digital health tools alongside clear policies towards their adoption will facilitate regional uptake and scale-up of services with embedded digital health tools.

• Title: A Randomized Trial Comparing an Adaptive Self-Help Mobile App to a Standard Self-Monitoring App for the Treatment of Eating Disorders

  From: JMIR Mental Health

  Date Submitted: Jun 10, 2019

  Open Peer Review Period: Jun 11, 2019 - Jun 18, 2019

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  Background: Eating disorders severely impact psychological, physical and social functioning and yet the majority of individuals with eating disorders do not receive treatment. mHealth apps have the po...

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  Background: Eating disorders severely impact psychological, physical and social functioning and yet the majority of individuals with eating disorders do not receive treatment. mHealth apps have the potential to decrease access barriers to care and reach individuals who have been underserved by traditional treatment modalities. Objective: This study evaluates the effectiveness of an adaptive, fully automated self-help version of Recovery Record, an app developed for eating disorder management. We examined differences in eating disorder symptom change in app users that were randomized to receive either a standard, Cognitive Behavioral Therapy (CBT) based version of the app or an adaptive version that included algorithmically determined clinical content aligned with baseline and evolving user eating disorder symptom profiles. Methods: Participants were recruited via the open-access Recovery Record app to participate in this randomized trial. We examined both continuous and categorical clinical improvement outcomes (measured with the self-report Eating Disorder Examination Questionnaire [EDE-Q]) in both intervention groups. Results: Between December 2016 and August 2018, 3,294 Recovery Record app users were recruited into the study, of whom 959 were considered engaged, completed follow-up assessments and were included in the analyses. Both study groups achieved significant overall outcome improvement, with 61.6% of the adaptive group and 55.4% of the standard group achieving a clinically meaningful change in the EDE-Q, on average. There were no statistically significant differences between randomized groups for continuous outcomes, but a pattern of improvement being greater in the adaptive group was evident. The rate of remission on the EDE-Q at 8 weeks was significantly greater in the group receiving the adaptive version (d = 0.22; P= <0.001). Conclusions: This is the first report to compare the relative efficacy of two versions of a smartphone app for eating disorders. The data suggest that tailoring app content to specific clinical presentations may be more effective in promoting symptomatic remission on the EDE-Q than content that offers a generic approach. Clinical Trial: ClinicalTrials.gov NCT02503098

• An Integrative Model for the Effectiveness of Biofeedback Interventions for Anxiety Regulation

  From: Journal of Medical Internet Research

  Date Submitted: Jun 6, 2019

  Open Peer Review Period: Jun 10, 2019 - Aug 5, 2019

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  Biofeedback has shown to be a promising tool for the treatment of anxiety however several theoretical as well as practical limitations have prevented widespread adaptation until now. With current tech...

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  Biofeedback has shown to be a promising tool for the treatment of anxiety however several theoretical as well as practical limitations have prevented widespread adaptation until now. With current technological advances and the increasing interest in the use of self-monitoring technology to improve mental health we argue that this is an ideal time to launch a new wave of biofeedback training. In this review we reflect on the current state of biofeedback training including the more traditional mechanisms that have been thought to explain the effectiveness of biofeedback such as: changes in interoceptive awareness, changes in physiology and the implementation of operant learning and mindfulness techniques. Subsequently, we propose a new integrative model that includes a set of cognitive appraisals as potential determinants of adaptive trajectories within biofeedback training such as: growth mindset, self-efficacy, perceived control and threat-challenge appraisals. Finally, we present a set of detailed guidelines based on the integration of our model with the mechanics and mechanisms offered by emerging interactive technology to encourage a new phase of research and implementation using biofeedback. We believe that there is a great deal of promise for future biofeedback interventions that harness the power of wearables and video games, as well as adopt a user-centred approach to help people regulate their anxiety in a way that feels engaging, personal and meaningful.

• Design, development and usability of the Narcolepsy Monitor: a mobile app for long-term subjective symptom monitoring in narcolepsy patients

  From: Journal of Medical Internet Research

  Date Submitted: Jun 5, 2019

  Open Peer Review Period: Jun 10, 2019 - Aug 5, 2019

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  Background: Narcolepsy is a debilitating sleep disorder with a broad variety of symptoms. It is primarily characterized by excessive daytime sleepiness and cataplexy (partial or total loss of muscle c...

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  Background: Narcolepsy is a debilitating sleep disorder with a broad variety of symptoms. It is primarily characterized by excessive daytime sleepiness and cataplexy (partial or total loss of muscle control, often triggered by emotions). Beside these core symptoms, narcolepsy patients may suffer from hypnagogic hallucinations, sleep paralysis and fragmented night sleep. However, the spectrum of narcolepsy also includes several symptoms not related to sleep, such as cognitive or psychiatric problems. The symptoms vary greatly among patients and even within patients day-to-day variance can be significant. Current diagnostic tests focus primarily on daytime sleepiness and cataplexy, although these symptoms do not fully account for the experienced burden of the disorder. Questionnaires to monitor narcolepsy symptoms also not cover the whole symptom spectrum and may not capture symptom variability. Objective: To describe the development and evaluation process of the Narcolepsy Monitor: a companion app for long term subjective symptom monitoring in narcolepsy patients. Methods: After several iterations during which content, interaction design, data management and security were critically evaluated, a complete version of the app was built. The Narcolepsy Monitor allows patients to report a broad spectrum of experienced symptoms and rate their severity based on the level of burden each symptom imposes. The app emphasizes reporting of changes in relative severity of the symptoms. Seven narcolepsy patients were recruited and asked to use the app for thirty days. Evaluation was done using in depth interviews and the User Experience Questionnaire. Results: Patients used the app on average for 45.3 (± 19.2) days. The app was opened in 34.9% of those days. ‘Daytime sleepiness’ was the most dynamic symptom with a mean number of changes of 5.5 ± 3.7 per month, in contrast to ‘feelings of anxiety or panic’, which was only moved 0.3 ±0.7 times per month. Mean symptom scores were highest for ‘daytime sleepiness’ (1.8 ± 1.0). Patients reported ‘feelings of anxiety or panic’ as the least bothering, scoring 0.1 ± 0.22. The personal in-depth interviews revealed three major themes: (1) Reasons to use, (2) Usability and (3) Features. Overall patients appreciated the concept of ranking symptoms on subjective burden and found the app easy to use. Conclusions: The Narcolepsy Monitor appears to be a helpful tool to gain more insight in the individual burden of narcolepsy symptoms over time. Clinical Trial: Not applicable

• Effects of a Socially Assistive Robot on Psychosocial and Physical Outcomes of Persons With Dementia Living at Home including Caregivers and Dementia Trainers: A Mixed Method Study

  From: JMIR Research Protocols

  Date Submitted: Jun 5, 2019

  Open Peer Review Period: Jun 10, 2019 - Jun 24, 2019

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  Background: New technologies, like socially assistive robots (SAR) may have the potential to support caregivers at home, but the evidence for people with dementia (PWD) in home care is unclear, becaus...

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  Background: New technologies, like socially assistive robots (SAR) may have the potential to support caregivers at home, but the evidence for people with dementia (PWD) in home care is unclear, because a lot of studies are performed in laboratory- or institutional settings mainly using robots in prototype stages. Objective: The aim of this study is to explore the effects of the commercially available SAR Pepper on psychosocial and physical outcomes of PWD living at home, including caregivers and dementia trainers. Methods: A mixed method study will be performed, including a randomized controlled parallel 2 arm study with a complementary qualitative part. The sample includes 40 PWD living at home and 40 relatives each complemented with five professional caregivers and dementia trainers. The intervention group will receive Coach Pepper (an SAR connected with a theratainment app on a Tablet-PC) and the control group will receive the theratainment app without the SAR. The duration of the intervention will be 3 weeks per household. Data will be collected baseline, during and after the intervention by standardized questionnaires, sensor data of the robot and theratainment app as well as semi-structured interviews, focus groups and observation. Results: This study started in May 2019. There are no results. Conclusions: The intervention of this study can be seen as a non-pharmacological intervention including cognitive and physical training by a robot. We hypothesize that the robot has a positive effect on the primary outcome motivation (stable or decreased apathy) of PWD. The study will help to further refine SAR for the specific needs of PWD living at home. Clinical Trial: ClinicalTrial.gov Identifier: NCT03818217 (https://clinicaltr ials.gov); Registered and last update, 28 January 2019. If there are main changes in the study plan the information in the register will be updated. The principal investigator of the study is Sandra Schüssler.

• Augmented Reality learning environment for basic life support and defibrillation Training: a feasibility and acceptability study.

  From: Journal of Medical Internet Research

  Date Submitted: Jun 5, 2019

  Open Peer Review Period: Jun 10, 2019 - Aug 5, 2019

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  Background: Being sudden cardiac arrest still a major cause of death, basic life support with defibrillation (BLSD) is crucial in the emergency response system. Unfortunately, only a minority of victi...

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  Background: Being sudden cardiac arrest still a major cause of death, basic life support with defibrillation (BLSD) is crucial in the emergency response system. Unfortunately, only a minority of victims receive bystanders cardiopulmonary resuscitation (CPR). In this context, training could be helpful to save more lives and technology-enhanced simulation is one possible solution. Objective: The aim of this study is to assess feasibility and acceptability of an Augmented Reality (AR) prototype system as a tool for training CPR, AED use, and emergency response system activation. Methods: Holo-BLSD is an AR self-instruction training system, developed using a standard CPR mannequin which is “augmented” by an interactive virtual environment reproducing realistic scenarios. Learners can use natural gestures, body movements and spoken commands to perform their tasks, with virtual 3D objects anchored to the manikin and to the environment. During the experience, users were trained to use the device, guided through an emergency simulation and, at the end, asked to complete a survey rating a number of statements using a five-point Likert scale. Results: The system was found easy to use (average value(AV) 4.00) and trainees stated that most people would learn to use it very quickly (AV 4.00). Voice (AV 4.48), gaze (AV 4.12) and gesture interaction (AV 3.84) were evaluated positively, although some hand recognition errors reduced the feeling of having the right level of control over the system (AV 3.40). Conclusions: We found Holo-BLSD application feasible and acceptable as an augmented reality tool for BLSD training.

• Health professions digital education for antibiotic management: systematic review and meta-analysis by the Digital Health Education Collaboration

  From: Journal of Medical Internet Research

  Date Submitted: Jun 10, 2019

  Open Peer Review Period: Jun 10, 2019 - Jun 18, 2019

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  Background: Inappropriate antibiotic prescribing is one of the key contributors to antibiotic resistance and could potentially be resolved with appropriate health professions education. Digital educat...

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  Background: Inappropriate antibiotic prescribing is one of the key contributors to antibiotic resistance and could potentially be resolved with appropriate health professions education. Digital education has the potential to improve the quality of healthcare professionals’ antibiotic management. Objective: The objectives of this systematic review were to evaluate the effectiveness of digital education for antibiotic management compared with various controls in improving healthcare professionals’ knowledge, skills, attitudes, satisfaction, clinical practice, economic outcomes and patient-related outcomes. Methods: Seven electronic databases and two trial registries were searched for randomized controlled trials (RCTs) and cluster RCTs published between January 1, 1990 and September 20, 2018. There were no language restrictions. We followed Cochrane methods to select studies, extract data and to appraise and synthesize eligible studies. Results: Six cluster RCTs and two RCTs with 655 primary healthcare practices, 1392 primary care physicians and 485,632 patients were included. The interventions included personal digital assistants, short text messages, online digital education including emails and websites, and online blended education which used a combination of online digital education and traditional education materials. The control groups received traditional education. Six studies assessed post-intervention clinical practice. The majority of the studies (4 out of 6 studies) reported greater reduction in antibiotics prescription or dispensing rate with digital education compared to traditional education. Two studies showed significant difference in post-intervention knowledge scores in favour of mobile education compared with traditional education [standardized mean difference (SMD)=1.09, 95% CI 0.90 to 1.28, I2=0%, large effect size, 491 participants (2 studies)]. The findings about healthcare professionals’ attitudes and patient-related outcomes were mixed or inconclusive. Three studies found digital education to be more cost-effective than traditional education. None of the included studies reported on skills, satisfaction or adverse effects. Conclusions: Our findings suggest that mobile digital education and/or online digital education (standalone or in blended format) on antibiotic management could improve primary care physicians’ post-intervention knowledge, clinical practice and be cost-effective particularly in post-registration scenarios. Future research should focus on the use of emerging technologies (such as serious games, virtual reality, and virtual patient simulations) in training healthcare professionals, within a range of settings (including low- and middle-income countries) and report on outcomes such as attitudes, skills, adverse effects, patient outcomes and economic impact.

• The burden of incontinence in a real-world data environment – insights from a digital patient companion

  From: JMIR mHealth and uHealth

  Date Submitted: Jun 7, 2019

  Open Peer Review Period: Jun 10, 2019 - Aug 5, 2019

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  Background: Urinary Incontinence (UI) can have a potentially devastating effect on women’s quality of life (QoL) in the physical, social, sexual, and psychological spheres. During pregnancy and afte...

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  Background: Urinary Incontinence (UI) can have a potentially devastating effect on women’s quality of life (QoL) in the physical, social, sexual, and psychological spheres. During pregnancy and after delivery, the strength of the pelvic floor muscle may decrease, resulting in a high rate of UI. Conservative treatment by means of pelvic floor muscle training is the first-choice treatment modality. Nowadays, this can be supported by digital apps. Those apps have the advantage of giving insights into real-world data on UI. Objective: The aim of the present study was to analyze the impact of UI on QoL using the app pelvina. Methods: We analyzed data from pelvina - a digital health companion pelvic floor course. This course regularly examines incontinence symptoms through “The Questionnaire for Urinary Incontinence Diagnosis” (QUID) and QoL through SF-6D. Subsequently, we analyzed the incidence and degree of incontinence in a real-world environment and determined the influence of different demographic factors. In addition, the impact of UI on the QoL was evaluated in more detail. Results: In all, 293 patients with a median age of 36 years and a median of 2 deliveries could be included in this study. Patients were slightly to moderately affected by UI with a QUID of 6 (2 - 11, max: 24). Age and parity were independently associated with the incidence of UI with an adjusted odds ratio (aOR) of 1.06 (95% CI 1.01 – 1.12) and aOR of 1.86 (95% CI 1.12 – 3.08), respectively. The severity of incontinence symptoms strongly correlated with impairment in QoL ( = 0.489, P < 0.001). Conclusions: The use of real-world data, as generated by digital health solutions such as pelvina, gives us, for the first time, the opportunity to gain insight into the reality of patients' lives outside of classical clinical studies. In this paper we can corroborate the known associations between parity and UI known from the literature and the great influence UI has on QoL on a daily basis. This study shows that, in the future, the use of digital apps can make an important contribution to scientific data acquisition and, for example, therapy monitoring.

• An App Predicting Peritoneal Dialysis Appropriate Dwell Volume for Patients in Daily Practice

  From: JMIR mHealth and uHealth

  Date Submitted: Jun 4, 2019

  Open Peer Review Period: Jun 7, 2019 - Aug 2, 2019

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  Background: Few studies mention how to objectively adjust peritoneal dialysis (PD) dwell volume (DV) for adult continuous ambulatory peritoneal dialysis patients. It requires a great deal of physician...

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  Background: Few studies mention how to objectively adjust peritoneal dialysis (PD) dwell volume (DV) for adult continuous ambulatory peritoneal dialysis patients. It requires a great deal of physicians’ precious time to determine the appropriate DV during daily practice. An app with evidence is required to solve this problem independently and efficiently. Objective: This study aims to determine a method for fluid control that can reduce fluid overload-related complications. We proposed a reference equation composed of parameters from the peritoneal equilibration test (PET) for adjusting daily dialysate DV to obtain more ultrafiltration volume. Methods: Ninety PD patients being treated at one medical center were enrolled, with laboratory data collected during half-yearly PET evaluations. The instilled dialysate was composed of 2.57% glucose PD fluid, either 1500 ml or 2000 ml for two groups in DV. We measured intraperitoneal pressure (IPP) before dialysate instilled (P0) and drained in the supine position after four hours (P4), effluent volume (ml), body mass index (BMI), waist circumference, and other parameters, including social demographics, to predict the appropriate DV. Exploratory factor analysis (EFA) was performed to extract independent domains. Statistical multivariate techniques of discrimination analysis and logistic regression (LR) to verify the most feasible and optimal formula were applied to determine infill volumes for patients. A final equation for fine-tuning daily DV was proposed with an app to be used for physicians and patients in clinical settings. Results: Two domains were observed by using EFA: (1) P0, and P4, and effluent volume and (2) BMI and wais circumference. We determined a formula for calculating daily dialysate DV, derived from L to obtain an accurate prediction rate of 94.44% higher than the previous study at 80.68%: Z = 4.32974 + 3.85477 * F1 + 3.83008 * F2. An app was created to easily adjust the DV in the daily procedure. Conclusions: The novel formula, combined with an app using objective, real-time parameters for predicting appropriate DVs, was proposed for PD patients to optimize maximal ultrafiltration volumes and reduce subjective abdominal discomfort. DV is easy to calculate using the app, which makes it possible for physicians or patients to make frequent adjustments. Clinical Trial: Not available

• Reliability of virtual audits using Google Earth to characterize the rural opioid use environment in Kentucky

  From: Journal of Medical Internet Research

  Date Submitted: Jun 3, 2019

  Open Peer Review Period: Jun 6, 2019 - Aug 1, 2019

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  The opioid epidemic has ravaged rural communities in the United States. Despite extensive literature relating the physical environment to substance use in urban areas, little is known about the role o...

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  The opioid epidemic has ravaged rural communities in the United States. Despite extensive literature relating the physical environment to substance use in urban areas, little is known about the role of the physical environment on the opioid epidemic in rural areas. We examined the reliability of Google Earth to collect data on the physical environment related to substance use in rural areas. Systematic virtual audits were performed in five rural Kentucky counties using Google Earth between 2017 and 2018 to capture land use, health care facilities, entertainment venues and businesses. In-person audits were performed for a subset of the census blocks. We captured 533 features, most of which were images taken before 2015 (72%). Reliability between the virtual auditors and the gold standard was high for health care facilities (>83%), entertainment venues (>95%) and businesses (>61%), but poor for land use features (>18%). Reliability between the virtual audit and in-person audit was high for health care facilities (83%) and entertainment venues (62%) but was poor for land use (0%) and businesses (12.5%). Poor reliability for land use features may reflect difficulty characterizing features that require judgement, or natural changes in the environment that are not reflective of the Google Earth imagery because it was captured earlier years before the audit was performed. Virtual Google Earth audits were an efficient way to collect rich neighborhood data that are generally not available from other sources. However, these audits should use caution when the images in the observation area are dated.

• Physical activity, gaming and virtual reality: the views of parents of adolescents

  From: JMIR Serious Games

  Date Submitted: Jun 3, 2019

  Open Peer Review Period: Jun 6, 2019 - Aug 1, 2019

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  Background: Virtual reality (VR) exergaming may be a promising avenue to engage adolescents with physical activity (PA). Since parental support is a consistent determinant of adolescent PA, it is cruc...

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  Background: Virtual reality (VR) exergaming may be a promising avenue to engage adolescents with physical activity (PA). Since parental support is a consistent determinant of adolescent PA, it is crucial to gather the views of parents of adolescents about this type of intervention. Objective: The aim of this study was to interview parents of adolescents (13-17 year olds) about PA, gaming and VR. Methods: Semi-structured interviews were conducted with 18 parents of adolescents aged 13-17 years. Data was synthesized using framework analysis. Results: Parents believed encouraging PA in adolescents was important (particularly for mental health benefits) and most thought their child was not active enough. Parents reported their adolescents gamed regularly, with perceptions of gaming mostly negative due to violent content of the games and a potential for addiction. However, parents were permissive of gaming mainly because they wanted children to have autonomy of choice in leisure time and because they used screens frequently and did not want to appear hypocritical. Parents discussed an inability to relate to gaming due to ‘generational differences’ but an exception was exergaming, which they had played with their children in the past (e.g. Wii Fit). They commented that adolescents are ‘tough consumers’ who would only engage with high-end graphics and high game quality. Specific recommendations for promoting a VR exergaming intervention were provided, but ultimately parents strongly supported harnessing gaming for any positive purpose. Conclusions: The current study suggests promise for a VR exergaming intervention, but this must be framed in a way that it addresses parental concerns, particularly around addiction, violence and safety, without actively involving them participating. While parents would rather their children performed ‘real world’ PA, they believed the key to engaging them was through technology. Overall, there was the perception that harnessing gaming and sedentary screen-time for a positive purpose would be strongly supported.

• The integration and evaluation of a mobile application into Dialectial Behaviour Therapy (DBT) for persons with Borderline personality Disorder: A qualitative and quantitative study

  From: JMIR mHealth and uHealth

  Date Submitted: Jun 3, 2019

  Open Peer Review Period: Jun 6, 2019 - Aug 1, 2019

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  Background: The advancement and access to technology such as smartphones has potential implications in the provision of psychotherapeutic interventions for a range of mental health disorders. Objectiv...

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  Background: The advancement and access to technology such as smartphones has potential implications in the provision of psychotherapeutic interventions for a range of mental health disorders. Objective: To describe service-users’ experiences of the integration of a mobile phone application (app) to enhance and support Dialectial Behavior Therapy (DBT) for personality disorders. Methods: A combination of indepth interviews and questionnaires were used to capture service- users’ experience of using the app during DBT treatment. Qualitative data from the interviews was analyzed using thematic analysis and combined with quantitative data from the questionniares in a mixed method approach. Results: The app was trialled with 24 service-users receiving DBT. All partipants completed an evaluation questionnaire and a subset of this group (n=8) participated in semi-structured interviews. Major themes identified from the interviews included an overall positive experience of using the app, where users perceived that the app faciltitiated the access and implementation of DBT strategies to regulate mood and behavior in challenging situations. Other themes identified included the app providing a common source of information for patient/therapist interactions where app based interactions were perceived to facilitate therapeutic alliance. Qualitative themes from the interviews were largely congruent with the quantitative responses from the questionnaires. Conclusions: : Service users welcomed the integration of technology as a supplement to clinical treatment. The app was seen to facilitate and support many of the therapeutic techniques associated with DBT treatment. The incorporation of technology into psychotherapeutic interventions may facilitate the transfer of knowledge and strategies learnt in therapy to use in real world settings thereby promoting recovery from mental health problems.

• Utilisation, safety, and technical performance of a worldwide unique telemedicine system for prehospital emergency care: An analysis of 6,265 teleconsultations during the initial three operational years

  From: Journal of Medical Internet Research

  Date Submitted: Jun 2, 2019

  Open Peer Review Period: Jun 5, 2019 - Jul 31, 2019

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  Background: As a consequence of increasing Emergency Medical Service (EMS) missions requiring an EMS physician on-site, we had implemented a unique prehospital telemedical emergency service as a new s...

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  Background: As a consequence of increasing Emergency Medical Service (EMS) missions requiring an EMS physician on-site, we had implemented a unique prehospital telemedical emergency service as a new structural component to the conventional physician-based EMS in Germany. Objective: We sought to assess the utilisation, safety, and technical performance of this telemedical emergency service. Methods: We conducted a retrospective analysis of all primary emergency missions with telemedical consultation of an EMS physician in the City of Aachen (250.000 inhabitants) during the first three operational years of our tele-EMS system. Main outcome measures were the number of teleconsultations, number of complications, and number of transmission malfunctions during teleconsultations. Results: The data of 6,265 patients were analysed. The number of teleconsultations increased during the run-in period of four quarters towards full routine operation from 152 to 420 missions per quarter. When fully operational, around the clock and providing teleconsultations to 11 mobile ambulances, the number of teleconsultations further increased by 25.9 per quarter (95%CI 9.1–42.6; p < 0.01). Only six of 6,265 patients (0.1%; 95%CI 0.04–0.21%) experienced adverse events, all of them not inherent in the system of teleconsultations. Technical malfunctions of single transmission components occurred from as low as 0.3% (95%CI 0.2–0.5%) during two-way voice communications to as high as 1.9% (95%CI 1.6–2.3%) during real-time vital data transmissions. Complete system failures occurred in only 0.3% (95%CI 0.2–0.6%) of all teleconsultations. Conclusions: The Aachen prehospital emergency medical service is a frequently used, safe and technically reliable system to provide medical care for emergency patients without an EMS physician physically present. Non-inferiority of the tele-EMS physician compared to an on-site EMS physician needs to be demonstrated in a randomised trial.

• Implementing a digital Care Pathway Tool in community-based mental health services: A qualitative evaluation

  From: Journal of Medical Internet Research

  Date Submitted: Jun 5, 2019

  Open Peer Review Period: Jun 5, 2019 - Jul 31, 2019

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  Background: Mental health services aim to provide recovery-focused care and facilitate co-produced care planning. In practice, mental health professionals can find balancing administrative and perfor...

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  Background: Mental health services aim to provide recovery-focused care and facilitate co-produced care planning. In practice, mental health professionals can find balancing administrative and performance demands, whist supporting individualised co-produced care with servcice users, difficult. To help meet this aim and using principles of co-production, an innovative mobile digital Care Pathway Tool was developed to be used on a tablet computer and piloted in the West of England. Objective: To examine mental health care professionals’ views of and experiences with the Care Pathway Tool during the pilot implementation phase and identify factors influencing its implementation. Methods: Twenty in-depth telephone interviews with professionals participating in the pilot, and managers in the host organisation. Interviews were audio-recorded, transcribed, anonymised and thematically analysed guided by the Consolidated Framework for Implementation Research. Results: The tool was thought to facilitate co-produced recovery-focused care planning, a policy and organisational, as well as professional priority. Internet connectivity issues, system inter-operability and access to service users’ health records affected use of the tool during mobile working. The organisation’s resources such as IT infrustructure and staff time, and IT culture influenced implementation. Participants’ levels of use of the tool was dependent on knowledge of the tool and self-efficacy; perceived service-user needs and characteristics; and perceptions of impact on the therapeutic relationship. Training and preperation time influenced participants’ confidence in using the tool. Conclusions: Findings highlight the importance for congruence between staff, organisation and external policy priorities and digital technologies to aid intervention engagement; and need for ongoing training and support of those intended to use the technology during and after the end of implementation interventions.

• An international ResearchKit app-based pragmatic randomized control trial for women with menstrual pain (primary dysmenorrhea): development, access and engagement

  From: Journal of Medical Internet Research

  Date Submitted: Jun 1, 2019

  Open Peer Review Period: Jun 4, 2019 - Jul 30, 2019

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  Background: Primary dysmenorrhea is a common condition in women of reproductive age. A previous app-based study undertaken by our group demonstrated that a smartphone app supporting self-acupressure i...

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  Background: Primary dysmenorrhea is a common condition in women of reproductive age. A previous app-based study undertaken by our group demonstrated that a smartphone app supporting self-acupressure introduced by a healthcare professional can reduce menstrual pain. Objective: The objective of this study is to evaluate whether a specific smartphone app is effective in reducing menstrual pain in 18 to 34-year-old women with primary dysmenorrhea in a self-care setting. One group of women has access to the full-featured study app and will be compared with two control groups who have access to fewer app features. Here, we report the trial design, app development, user access and participant engagement. Methods: Based on the practical implications of the previous app-based study, we revised and re-engineered the study app and included the Apple ResearchKit framework. Behavior Change Techniques (BCTs) were implemented in the app and validated by expert ratings. User access was estimated by assessing recruitment progress over time. User evolution and baseline survey respondent rate were assessed to evaluate user engagement. Results: The development of the study app for a three-armed randomized controlled trial required a multidisciplinary team. The app is accessible for the target population free of charge via the Apple App Store. In Germany, within 9 months, the app was downloaded 1,458 times and 328 participants were recruited using it without external advertising. A total of 98% of the app-based baseline questions were answered. The correct classification of BCTs used in the app required psychological expertise. Conclusions: Conducting an innovative app study requires multidisciplinary effort. Easy access and participant engagement with such an app can be achieved by recruitment via the App Store. Future research is needed to investigate the determinants of participant engagement, optimal BCT application, and potential clinical and self-care scenarios for app use. Clinical Trial: ClinicalTrials.gov NCT03432611; https://clinicaltrials.gov/ct2/show/NCT03432611 (Archived by WebCite at http://www.webcitation.org/75LLAcnCQ)

• Smartphone apps for the treatment of mental disorders: a systematic review.

  From: Journal of Medical Internet Research

  Date Submitted: Jun 3, 2019

  Open Peer Review Period: Jun 4, 2019 - Jul 30, 2019

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  Background: Smartphone apps are an increasingly popular means for providing psychological interventions to patients suffering from a mental disorder. In line with this popularity, there is a need to a...

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  Background: Smartphone apps are an increasingly popular means for providing psychological interventions to patients suffering from a mental disorder. In line with this popularity, there is a need to analyse and summarize the state of the art, both from a psychological and technical perspective. Objective: This systematic review focuses on the use of smartphones for psychological interventions. We aim to: (i) analyze the evolution of research over time as well as the covered mental disorders; (ii) study the characteristics of assessments that were performed; (iii) map the use of advanced technical features, such as sensors, and novel software features, such as personalization and social media; and (iv) provide an overview of developed smartphone apps per mental disorder. Methods: The PRISMA guidelines for systematic reviews were followed. We performed searches in Scopus, Web of Science, APA PsycNET and MEDLINE, covering a period of over five years (2013+). We included papers that describe the use of smartphone apps to deliver psychological interventions for known mental disorders. We formed multidisciplinary teams, comprising experts in psychology and ICT, to select and classify articles based on psychological and technical features. Results: 111 articles met the inclusion criteria. We observed an increasing interest in this field. More and more studies are focusing on clinical effects in addition to (only) usability/UX, but Randomly Controlled Trials (RCT) are still a small minority (16,2%). Around 70% of the papers focus on 6 mental disorders: depression, anxiety, trauma and stressor-related, substance-related and addiction, schizophrenia spectrum and other psychotic disorders, or a combination of disorders. More than half of known mental disorders are not or very scarcely (<3%) represented. Whereas interventions are leveraging the improved modalities (screen, sound) and interactivity of smartphones, their truly novel capabilities, such as sensors, alternative delivery paradigms and analytical methods, are only sparingly exploited. Conclusions: We found an overall increase in smartphone-based interventions over time. Most research targets disorders with high prevalence, i.e., depressive (19,8%) and anxiety disorders (12,6%). Hence, there is a need for designing interventions that focus on disorders with high severity as well, such as personality disorders, which are currently only scarcely found. The majority of assessments evaluated usability/UX, and we found only a limited number of RCT. We contend that, to improve the robustness and trustworthiness of assessments, an increasingly systematic focus is needed as to effect on clinical symptomatology. Regarding technical aspects, most studies rather conservatively transfer traditional ICT interventions to smartphones. We argue that more innovative use of their novel capabilities is needed to fully realize promising treatments, such as Ecological Momentary Interventions, as they require context-awareness, though the use of sensors and analytics, to determine the need for interventions at times that patients need them most.

• Improving Pacific adolescents’ physical activity towards international recommendations: exploratory study of a digital education app coupled with activity trackers

  From: JMIR mHealth and uHealth

  Date Submitted: May 29, 2019

  Open Peer Review Period: Jun 3, 2019 - Jul 29, 2019

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  Background: The prevalence of overweight and obesity in children and adolescents has dramatically increased in the Pacific region over the last decade. Childhood overweight and obesity are likely to l...

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  Background: The prevalence of overweight and obesity in children and adolescents has dramatically increased in the Pacific region over the last decade. Childhood overweight and obesity are likely to lead to noncommunicable diseases (NCDs) in adulthood. A major contributing factor to the rising prevalence is the insufficient amount of daily moderate to vigorous physical activity (MVPA). In the Pacific region, less than 50% of children and adolescents meet the recommendations of 11000 steps and 60 minutes of MVPA per day. Whilst studies have shown the potential of digital technologies to change behaviours, none has been proposed to guide adolescents towards achieving these international recommendations. Objective: We propose a technology-supported educational program that includes objective measures of physical activity (PA) components and self-assessment of goal achievement, helps Pacific adolescents to meet the international PA recommendations. We also created data-mining techniques to provide a more detailed analysis of PA behaviour changes. Methods: Twenty-four adolescents, 12-14 years old, participated in a 4-week program comprising eight 1-hour modules to develop health literacy and physical skills. This self-paced user-centred program was delivered via an app and provided learning content and goal-setting and self-assessment tasks. PA performed during the 4-week program was captured with an activity tracker to support learning and help the adolescents self-assess their achievements against personal goals. The data were analysed using a consistency rate and daily behaviour clustering to reveal any PA changes, particularly regarding adherence to international recommendations. Results: The consistency rate of daily steps revealed that the adolescents reached 11,000 steps per day 48.1% of the time in the first week of the program (~3.4 days per week) and this peaked at 59% (~4.1 days per week) toward program end. PA showed an overall increase during the program, particularly in the less active adolescents, who increased their daily steps by 15.6% and ultimately reached 11,000 steps more frequently. The consistency of daily behaviour clustering showed a 27% increase in adherence to international recommendations in the least active adolescents. Conclusions: Technology-supported educational programs that include self-monitored PA via activity trackers can be successfully delivered to adolescents in schools in remote Pacific areas. New data-mining techniques enable innovative analyses of PA engagement based on the international recommendations. Clinical Trial: The protocol was approved by the ethics committee of the University of New Caledonia and the consultative ethics committee for New Caledonia (CEC-NC03-2016).

• Deaf Adults’ Health Literacy and Access to Health Information: Protocol for a Multi-Center Mixed Methods Study

  From: JMIR Research Protocols

  Date Submitted: May 31, 2019

  Open Peer Review Period: Jun 3, 2019 - Jun 17, 2019

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  Background: Deaf American Sign Language (ASL) users often struggle with limited health literacy compared to their hearing peers. Yet, the mechanisms driving limited health literacy and how this may im...

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  Background: Deaf American Sign Language (ASL) users often struggle with limited health literacy compared to their hearing peers. Yet, the mechanisms driving limited health literacy and how this may impact access to and understanding of health information for Deaf individuals have not been determined. Deaf individuals are more likely than hearing individuals to use the Internet yet they continue to report significant barriers to health information. This study presents an opportunity to identify key targets that impact information access for a largely marginalized population. Objective: The study objectives are to elucidate the role of information marginalization on health literacy in Deaf ASL users and to better understand the mechanisms of health literacy in this population for the purpose of identifying viable targets for future health literacy interventions. Methods: This is an exploratory mixed methods study to identify predictors and moderators of health literacy in the Deaf. These predictors of health literacy will be used to inform the second step that qualitatively explains the findings, including how Deaf individuals access and understand health information online. Multiple interviewer and computer based instruments underwent translation and adaptation, from English to ASL, to make them accessible for the Deaf participants in our study. A planned sample of 450 Deaf ASL users and 450 hearing native English speakers, aged 18 to 70, will be recruited from three partnering sites, Rochester, NY; Flint, MI and Chicago, IL. These individuals will participate in a single data collection visit. A subset of participants (30 total) with key characteristics of interest will be invited for a second data collection visit to observe and inquire more about their ability to directly access, navigate and comprehend health information information online. The study will help assess how health literacy and how information is visulalized may differ from Deaf individuals compared to hearing individuals. The study will also survey participants’ ownership and use of computer and mobile devices and their level of online information use, including health information. Results: Adaptation and translation of protocols and instruments has been completed and are now in use for the study. Recruitment is underway and will continue until late 2020. Results from this study will be used to provide a guide on how to structure health information online in a way that maximizes accessibility and to improve health literacy for Deaf individuals. Conclusions: Conclusions: The results from this mixed methods proposal will advance what is known about health literacy and health information accessibility for Deaf individuals. This innovative study will generate rich data on how to formulate health information and health literacy interventions more accurately to take advantage of visual learning skills.

• Influenza Vaccination Coverage among Registered Nurses in China during 2017-2018: an Internet Panel Survey

  From: Journal of Medical Internet Research

  Date Submitted: May 30, 2019

  Open Peer Review Period: Jun 3, 2019 - Jul 29, 2019

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  Background: Influenza vaccination is recommended for nurses in China but is not mandatory or offered free of charge. Identifying factors that impact seasonal influenza vaccine acceptance among nurses...

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  Background: Influenza vaccination is recommended for nurses in China but is not mandatory or offered free of charge. Identifying factors that impact seasonal influenza vaccine acceptance among nurses in China may inform strategies to increase vaccination coverage in this high priority group. Objective: To determine influenza vaccination coverage and the principal factors influencing influenza vaccination among nurses in China. Methods: During March 22-April 1, 2018, we conducted an opt-in internet panel survey among registered nurses in China. Respondents were recruited from an internet-based training platform for nurses. We assessed influenza vaccination status and factors influencing influenza vaccine acceptance and refusal. Results: Among 22,888 nurses invited to participate, 4,706 responded, and 4,153 were valid respondents. Overall, 257 (6%) nurses reported receiving the seasonal influenza vaccine during the 2017/18 season. Vaccination coverage was highest among nurses working in Beijing (10%, P<.001) and nurses working in primary care (12%, P=.023). The top three reasons for not being vaccinated were lack of time (28%), not knowing where and when to get vaccinated (14%), and lack of confidence in the vaccine’s effectiveness (12%). Overall, 41% of nurses reported experiencing at least one episode of influenza-like illness (ILI) during the 2017/18 season; 87% of nurses kept working while sick, and 25% of nurses reported ever recommending influenza vaccination to patients. Compared with nurses who did not receive influenza vaccination in the 2017/18 season, nurses who received influenza vaccination were more likely to recommend influenza vaccination to patients (67% vs. 22%, P<.001). Conclusions: Influenza vaccination coverage among nurses was low, and only a small proportion recommended influenza vaccine to patients. Our findings highlight the need for a multi-pronged strategy to increase influenza vaccination among nurses in China.

• Valuable Genomes: A Taxonomy and Archetypes of Business Models in Direct-to-Consumer Genetic Testing

  From: Journal of Medical Internet Research

  Date Submitted: May 30, 2019

  Open Peer Review Period: Jun 3, 2019 - Jul 29, 2019

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  Background: Recent progress in genome data collection and analysis technologies has led to a surge of direct-to-consumer genetic testing services. Due to the clinical value and sensitivity of genomic...

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  Background: Recent progress in genome data collection and analysis technologies has led to a surge of direct-to-consumer genetic testing services. Due to the clinical value and sensitivity of genomic data, as well as uncertainty and hearsay surrounding business practices of direct-to-consumer genetic testing service providers, direct-to-consumer genetic testing has faced significant criticism by researchers and practitioners. Research in this area has centered on ethical and legal implications of providing genetic tests directly to consumers, but we still lack a more profound understanding of how business in the direct-to-consumer genetic testing markets will work and provide value to different stakeholders. Objective: We address the lack of knowledge concerning business models of direct-to-consumer genetic testing services by systematically identifying salient properties of various direct-to-consumer genetic testing service business models as well as discerning dominant business models in the market. Methods: We employ a three-phased research approach. In phase one, we set up a database of 277 direct-to-consumer genetic testing services. In phase two, we draw on this data as well as conceptual models of direct-to-consumer genetic testing services and iteratively develop a taxonomy of direct-to-consumer genetic testing service business models., In phase three, we use a two-stage clustering method in order to cluster the 277 services that we identified during phase one and derive six dominant archetypes of direct-to-consumer genetic testing service business models. Results: The contributions of this research are twofold. First, we provide a first of its kind, systematically developed taxonomy of direct-to-consumer genetic testing service business models consisting of 15 dimensions in four categories. Each dimension comprises two to five characteristics and captures relevant aspects of direct-to-consumer genetic testing service business models. Second, we derive six archetypes of direct-to-consumer genetic testing service business models called: (1) Low Cost DTC Genomics for Enthusiasts; (2) High Privacy DTC Genomics for Enthusiasts; (3) Specific Information Tests; (4) Simple Health Tests; (5) Basic Low Value DTC Genomics; (6) Comprehensive Test, Low Data Processing. Conclusions: Our analysis paints a much more complex business landscape in the direct-to-consumer genetic testing markets than previously anticipated. This calls for further research on business models and their effects that underlie direct-to-consumer genetic testing services and invites specific regulatory interventions to protect consumers and level the playing field.

• Bridging the Gap in Community Care for Patients with Borderline Personality Disorder: A Protocol to Explore Patient, Caregiver, and Clinician Perspectives on Service Gaps and Potential Solutions for Severe Emotion Dysregulation

  From: JMIR Research Protocols

  Date Submitted: May 30, 2019

  Open Peer Review Period: Jun 3, 2019 - Jun 17, 2019

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  Background: Individuals diagnosed with Borderline Personality Disorder (BPD) are not well served by current healthcare systems. Barriers include ineffective service utilization, system constraints, co...

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  Background: Individuals diagnosed with Borderline Personality Disorder (BPD) are not well served by current healthcare systems. Barriers include ineffective service utilization, system constraints, comorbid diagnoses, stigma, and high risk of suicide. Patients with BPD tend to get “lost to the system” or become frequent users of emergency departments and crisis teams. To better support individuals with severe emotion dysregulation, it is necessary to gain better understandings of patient, caregiver, and clinician perspectives and experiences with the healthcare system. Objective: To explore patient, caregiver, and clinician perspectives on the current care pathways for those with severe emotion dysregulation within a large Canadian metropolitan city (Edmonton, Alberta). Methods: Using qualitative methodology, 3-6 patients with a diagnosis of BPD, 3 caregivers of individuals with BPD, and 3 clinicians of patients diagnosed with BPD will be invited to share their experiences of the healthcare system’s response to individuals with BPD. Results: We expect that the findings of the study will illuminate the perspectives of patients with BPD, their caregivers, and their clinicians. We expect to gain a better understanding of the perceived gaps in services and potential solutions. The findings of the study are expected to be available in 12 months. Conclusions: The findings of the study have the potential to inform training, practice, policy, and future research in this area. The aim of this exploratory research is to develop better understandings that can lead to helpful action with this population.

• A psychometric analysis of the Polish version of the eHealth Literacy Scale (P-eHEALS) among social media users

  From: Journal of Medical Internet Research

  Date Submitted: May 30, 2019

  Open Peer Review Period: Jun 3, 2019 - Jul 29, 2019

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  Background: Social media have become mainstream online tools that allow individuals to connect and share information. Such platforms also influence people’s health behavior in the way they communica...

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  Background: Social media have become mainstream online tools that allow individuals to connect and share information. Such platforms also influence people’s health behavior in the way they communicate about personal health, treatments or physicians. But little is known about individuals’ ability to find and apply online health information to specific health problems. The eHealth Literacy Scale (eHEALS) is an instrument developed to measure these skills but it is not available in Polish and there is no evidence on its validity. Objective: The objective of our study was to examine the psychometric aspects of the Polish version of eHealth Literacy Scale (P-eHEALS) among Polish social media users. Methods: We examined the translated version of the scale in a representative sample of Polish social media users (n = 1527). P-eHEALS was a part of a web-based survey and CAWI was the method used to gather data. We examined the reliability of the P-eHEALS by calculating Cronbach alpha coefficients and analyzing the principal components. The exploratory factor analysis was used to assess the theoretical validity of the instrument. Results: The internal consistency of the P-eHEALS was sufficient: Cronbach alpha = .84. Item-total correlations ranged from r = .514 to .666. Exploratory factor analysis revealed a single structure explaining 47.42% of the variance, with high factor loadings of the item, ranging from .623 to .769. Conclusions: The study results showed that the items of the Polish version of eHEALS were equivalent to the original instrument developed by Norman and Skinner in 2006 and can be used in measuring the level of eHealth literacy among social media users.

• Title: A new treatment modality to reduce acute tonsillitis healing time

  From: Interactive Journal of Medical Research

  Date Submitted: May 29, 2019

  Open Peer Review Period: Jun 3, 2019 - Jul 29, 2019

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  Background: Acute tonsillitis is the most common reason for ear, nose and throat services. The infectious factors of tonsillitis are shown in detail in the studies. in the treatment of acute tonsillit...

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  Background: Acute tonsillitis is the most common reason for ear, nose and throat services. The infectious factors of tonsillitis are shown in detail in the studies. in the treatment of acute tonsillitis, supportive therapies are mostly used. As antibiotic therapy; Penicillin V if allergy is given Erythromycin-estolate. Objective: The aim of this study is to accelerate the clinical recovery by providing parenteral treatment and daily cleaning of tonsillar lesions in patients who were admitted to the otolaryngology because of acute tonsillitis. Methods: Patients in the age range 15-60 are included the study. The patients were divided into two groups. To the 1st group i.v. With the combination of ampicillin + sulbactam and i.v clindamycin, the tonsillar membrane was cleaned daily.21 In the second group only i.v. In combination with ampicillin + sulbactam and i.v clindamycin combination. Results: Patients who received antibiotherapy and debridement had clinical improvement at 90% on day 2 and 95% on 5 days. Only patients receiving antibiotics had a clinical improvement of 65% at day 5 and 75% at day 7. The recovery time of both groups was statistically significant. (P <0.05) Conclusions: The solution and technique used in this clinical study showed that patients with acute tonsillitis could recover in a very short time without any complications.

• Digital cognitive behaviour therapy for insomnia (CBTi) for adolescents with mental health problems. Results from a feasibility open trial.

  From: Journal of Medical Internet Research

  Date Submitted: May 29, 2019

  Open Peer Review Period: Jun 3, 2019 - Jul 29, 2019

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  Background: Insomnia in adolescents is common, persistent, and associated with poor mental health including anxiety and depression. Insomnia in adolescents attending child mental health services is se...

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  Background: Insomnia in adolescents is common, persistent, and associated with poor mental health including anxiety and depression. Insomnia in adolescents attending child mental health services is seldom directly treated and the effects of digital CBTi on the mental health of adolescents with significant mental health problems is unknown. Objective: This paper reports an open study assessing the feasibility of adding supported online CBT for insomnia to the usual care of young people aged 14-17 years attending specialist child and adolescent mental health services. Methods: Thirty-nine adolescents aged 14-17 attending specialist child and adolescent mental health services with insomnia were assessed and offered digital CBTi. The digital intervention was Sleepio, an evidence based, self-directed, fully automated CBTi that has proven effective in multiple randomized controlled trials with adults. Self-report assessments of sleep (Sleep Condition Indicator, Insomnia Severity Scale, online sleep diaries), anxiety (Revised Child Anxiety and Depression Scale) and depression (Mood and Feelings Questionnaire) were completed at baseline and post-intervention. Post-use interviews assessed satisfaction with digital CBTi. Results: Average baseline sleep efficiency was very poor (52.9%) with participants spending an average of 9.6 hrs in bed but only 5.1 hrs asleep. All scored <17 on the Sleep Condition Indicator with 36/39 (92.3%) scoring ≥15 on the Insomnia Severity Scale, suggesting clinical insomnia. 36 (92.3%) scored ≥ 27 on the Mood and Feelings Questionnaire for major depression and 20 (51.3%) had clinically elevated symptoms of anxiety. The majority (76%) were not having any treatment for their insomnia, with the remaining 24% receiving medication. Sleepio was acceptable with 77% (30/39) activating their account and 67% (21/30) completing the program. Statistically significant pre-post improvements were found in weekly diaries of sleep efficiency (p=.005) and sleep quality (p=.001) and on measures of sleep (SCI; p=.001: ISI; p=.001), low mood (MFQ; p=.024) and anxiety (RCADS; p=.015). Satisfaction was high; with 89% finding Sleepio helpful, 94% would recommend it to a friend with 39% expressing a definite preference for a digital intervention. Conclusions: Our study has a number of methodological limitations, particularly the small sample size, absence of a comparison group and follow-up assessment. Nonetheless, our findings are encouraging and suggest that digital CBTi for young people with mental health problems might offer an acceptable and an effective way to improve both sleep and mental health. Clinical Trial: N/a

• The Flipside Of Work Engagement: A Qualitative Evaluation Of A Stress Management Intervention In The Workplace

  From: JMIR Human Factors

  Date Submitted: May 29, 2019

  Open Peer Review Period: Jun 3, 2019 - Jun 17, 2019

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  Studies on the effectiveness of Stress Management Interventions (SMIs) currently lack long-term evaluations. Accordingly, this article addresses questions of how workers who experience SMIs evaluate c...

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  Studies on the effectiveness of Stress Management Interventions (SMIs) currently lack long-term evaluations. Accordingly, this article addresses questions of how workers who experience SMIs evaluate change after the intervention as well as how SMIs’ implementation can be improved. By processing 50 semi-structured interviews by a qualitative analysis, results indicate that participants perceive themselves as highly engaged and motivated at work. Attributing their engagement at work as a positive coping strategy, the in depth qualitative analysis reveals forms of over-engagement: temporary over-engagement is considered a positive reaction to an increased work demand in the past, it fails to work for the new cumulative stress that workers face. Additionally, identifying four different groups of SMI utilizers, we conclude that specific groups of participants benefit from individualized intervention strategies. SMIs effectiveness increases, both for the individual productivity and for the corporate productivity, when focusing on the individual work engagement and providing individualized interventions.

• Clinical validation of an independent online tool for measuring visual acuity and refractive error: the Manifest vs. Online Refractive Evaluation (MORE) trial

  From: Journal of Medical Internet Research

  Date Submitted: May 29, 2019

  Open Peer Review Period: Jun 3, 2019 - Jul 29, 2019

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  Background: Digital tools provide a unique opportunity to increase access to eye care. We developed an online test that measures visual acuity and both spherical and cylindrical refractive errors. Thi...

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  Background: Digital tools provide a unique opportunity to increase access to eye care. We developed an online test that measures visual acuity and both spherical and cylindrical refractive errors. This test is CE-marked and available at easee.online. The purpose of this study was to compare the efficacy of this online tool with traditional manifest subjective refraction in a prospective open-label non-inferiority clinical trial. Objective: Evaluate the outcome of an online refraction compared to a manifest refraction (golden standard) Methods: Healthy volunteers 18-40 years of age with a refraction error between -6 and +4 diopters (D) were eligible. Each participant performed the online test, and the reference test was performed by an optometrist. An absolute difference in refractive error of <0.5 D was considered non-inferior. Reliability was assessed using an intraclass correlation coefficient (ICC). Both uncorrected and corrected visual acuity were measured. Results: Two-hundred eyes in 100 healthy volunteers were examined. The online assessment of refractive error had excellent correlation with the reference test (ICC =0.92) and was considered non-inferior to the reference test. Uncorrected visual acuity was similar with the online test and the reference test (P=.21). Visual acuity was significantly improved using the prescription obtained using the online tool (P<.01). The online test provided the best results in participants with mild myopia (i.e. less than 3D), with a mean difference of 0.02±0.49 D (P=.48) and yielding a corrected visual acuity of >1.0 in 90% of participants. Conclusions: Our results indicate that online eye testing is a valid and safe method for measuring visual acuity and refractive error in healthy eyes, particularly for mild myopia. This tool can be used for screening purposes and is an easily accessible alternative to the subjective manifest refraction test. Clinical Trial: NCT03313921

• Validity and reliability of the 2kmFIT smartphone app for measuring cardiorespiratory fitness

  From: JMIR mHealth and uHealth

  Date Submitted: May 29, 2019

  Open Peer Review Period: Jun 3, 2019 - Jul 29, 2019

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  Background: There is strong evidence suggesting that higher levels of CRF are associated with a healthier metabolic profile and is a powerful predictor of morbidity and mortality. In this context, a s...

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  Background: There is strong evidence suggesting that higher levels of CRF are associated with a healthier metabolic profile and is a powerful predictor of morbidity and mortality. In this context, a smartphone app based on UKK-Test would provide the possibility to assess CRF remotely in individuals geographically distributed around a country, or continent or inter-continent with minimal equipment and low-costs involved. Objective: The overall aim of this study was to evaluate the validity and reliability of 2kmFIT-App developed for Android and iOS mobile operating systems to estimate cardiorespiratory fitness (CRF). The specific aims of the study were to determine the validity of 2kmFIT-App to track distance and calculate heart rate (HR). Methods: Twenty participants were included for field-testing validation and reliability analysis. The participants completed twice the 2-km walk test (UKK-Test) using the 2kmFIT-App and CRF, distance and HR were collected. Results: The validity results showed that the mean difference was: distance (-70.40 ± 51.47 m), criterion time (-0.59 ± 0.45 min), criterion HR (-16.75 ± 9.96 bpm) and criterion VO2max (3.59 ± 2.01 ml/kg/min). There was a moderate validity for HR (ICC=0.731, CI=-0.211 to 0.942) and good for VO2max (ICC=0.878, CI =-0.125 to 0.972). The reliability results showed that the mean difference was: app distance (25.99 ± 43.21 m), app time (-0.15 ± 0.94 s), pace (-0.18 ± 0.33 min/km), app HR (-4.5 ± 13.44 bpm) and app VO2max (0.92 ± 3.04 ml/kg/min). There was a good reliability as revealed by the ICC for app HR (ICC=0.897, CI=0.742 to 0.959), and excellent for app VO2max (ICC=0.932, CI=0.830 to 0.973). Conclusions: The present study finds 2kmFIT-App to be a new and scientifically valid and reliable tool able to objectively and remotely estimate CRF, HR, and distance in Android but not in the iOS mobile operating system.

• The Ethics and Design Principles of an Online Social Therapy System

  From: JMIR Mental Health

  Date Submitted: May 30, 2019

  Open Peer Review Period: May 31, 2019 - Jul 26, 2019

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  The modern omnipresence of social media and social networking sites (SNS) brings with it a range of important research questions. One of these concerns the impact of SNS use on mental health and wellb...

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  The modern omnipresence of social media and social networking sites (SNS) brings with it a range of important research questions. One of these concerns the impact of SNS use on mental health and wellbeing; a question that has been pursued in depth by scholars in the psychological sciences and the field of human-computer interaction. Despite this attention, the design choices made in the development of SNS and the notion of wellbeing employed to evaluate such systems require further scrutiny. In this paper we examine the strategic design choices made in developing an enclosed SNS for young people experiencing mental ill-health; in terms of ethical, persuasive design and in terms of how it fosters wellbeing. In doing so, we come to critique the understanding of wellbeing that is used in much of the existing literature to make claims about the impact of a given technology on wellbeing. We also demonstrate how the holistic concept of eudaimonic wellbeing and ethical design of SNS can complement one another.

• Step-based metrics and overall physical activity in children with overweight/obesity: Cross-sectional study

  From: JMIR mHealth and uHealth

  Date Submitted: May 28, 2019

  Open Peer Review Period: May 31, 2019 - Jul 26, 2019

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  Background: Best practice early interventions to increment physical activity in children with overweight/obesity should be both feasible and evidence-based. Walking is a basic human movement pattern t...

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  Background: Best practice early interventions to increment physical activity in children with overweight/obesity should be both feasible and evidence-based. Walking is a basic human movement pattern that is practical, cost-effective and does not require complex movement skills. However, there is still a need to investigate how much walking is performed by children with overweight/obesity (as proportion of total PA level) in order to determine its utility as a public health strategy. Objective: This study aimed to: 1) investigate the proportion of overall physical activity (PA) indicators that are explained by step-based metrics; and, 2) to study step accumulation patterns relative to achievement of public health recommendations in children with overweight/obesity. Methods: One-hundred and five overweight/obese children (10±1 year, 43 girls) were assessed with hip-worn accelerometers for 7 days. Counts/15s were used to derive overall PA indicators (i.e., daily average of counts/15s, light-to-vigorous PA [LMVPA], and moderate-to-vigorous PA [MVPA]). Step-based metrics included volume (steps/day) and intensity (cadence bands and peak 1, 30 and 60-min cadences). Results: Steps/day explained 66%, 40% and 74% of variance for counts/15s, LMVPA and MVPA, respectively. The variance explained was increased up to 80%, 92% and 77% by including specific cadence bands and peak cadences. Children who achieved the recommended 60 min/day of MVPA spent less time in zero cadence and more time in cadence bands representing sporadic movement to brisk walking (20-120 steps/min) than their less-active peers. Conclusions: Step-based metrics, including steps/day and various cadence-based indicators, seem to capture a large proportion of PA for children with overweight/obesity. Given the affordability of pedometers, step-based metrics could be useful for discriminating between those children who do or do not achieve MVPA recommendations. Clinical Trial: NCT02295072

• Towards early detection of outbreaks of infectious diseases: development of a mobile app and dashboard for accurate, complete and timely (ACT) outbreaks reporting and analysis

  From: JMIR mHealth and uHealth

  Date Submitted: May 28, 2019

  Open Peer Review Period: May 31, 2019 - Jul 26, 2019

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  Background: Outbreaks of infectious diseases pose great risks, including hospitalisation and death, to public health. Improving the management of outbreaks is therefore important for preventing widesp...

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  Background: Outbreaks of infectious diseases pose great risks, including hospitalisation and death, to public health. Improving the management of outbreaks is therefore important for preventing widespread infection and mitigating associated risks. Mobile health (mHealth) technology provides new capabilities that can help better capture, monitor and manage infectious diseases, including the ability to quickly identify potential outbreaks. Objective: To develop a new infectious disease surveillance (IDS) system comprising of a mobile app for accurate data capturing and dashboard for better healthcare planning and decision making. Methods: Literature review on available and similar disease surveillance systems was conducted to understand the fundamental functional-requirements. We then derived the specific scope and requirements of the system by consulting the local public health unit (PHU) team from the Nepean hospital, Nepean Blue Mountains Local Health District (NBMLHD), New South Wales (NSW), Australia. Results: We identified 3 fundamental requirements when designing an electronic IDS system, which are the ability to 1) accurately, 2) completely and 3) timely (ACT) capture and report outbreak data. We then developed our IDS system based on the workflow, scope and specific requirements gathered from the PHU team. We also produced detailed design and requirement guidelines. In our system, the outbreak data is captured and sent from anywhere using a mobile device or desktop PC (web interface). The data are processed using a client-server architecture and therefore can be analysed in real-time. Our dashboard is designed to provide a daily, weekly, monthly and, historical summary of outbreaks information, which can be potentially used to develop a future intervention plan. Specific information about certain outbreaks can also be visualised interactively to understand the unique characteristics of emerging infectious diseases. Conclusions: We demonstrate the development of our IDS system. We suggest that the use of a mobile app and dashboard will simplify the overall data collection, reporting and analysing processes, and thereby improving the public health responses and providing accurate registration of outbreak information. The accurate data reporting and collection are a major step forward to creating a better intervention plan for a future outbreak of infectious diseases.

• User experience of a post-TBI sexuality information toolkit

  From: Journal of Participatory Medicine

  Date Submitted: May 29, 2019

  Open Peer Review Period: May 31, 2019 - Jul 26, 2019

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  Background: After having sustained a traumatic brain injury (TBI), individuals are at risk of impairments in information processing, abstract reasoning, executive functioning, attention, and memory. T...

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  Background: After having sustained a traumatic brain injury (TBI), individuals are at risk of impairments in information processing, abstract reasoning, executive functioning, attention, and memory. This affects different aspects of communicative functioning. Specific strategies can be adopted to improve the provision of health information to individuals with TBI, including the development of written material and non-written media. Objective: A user-centered design was adopted to codevelop five audiovisual presentations, a double-sided information sheet and a checklist aimed at informing individuals about post-TBI sexuality. The last phase of the project consisted of the assessment of the user experience of the information toolkit, based on the User Experience Honeycomb model. Methods: Two focus groups and one individual semi-structured interview were conducted with individuals with moderate to severe TBI. Results: The participants mentioned that the toolkit was easily usable, and would have fulfilled a need for information on post-TBI sexuality during or after rehabilitation. They mostly agreed that the minimalist visual content was well organized, attractive and relevant. The information was easily located, and the tools were accessible in terms of reading and visioning. The content was also considered credible. Conclusions: These results confirmed the assumption that this patient-oriented project led to the development of a usable toolkit, matching the needs for adapted

• Mobile phone usage and willingness to receive mental health support through mobile phones among perinatal mothers in rural Bihar, India: A community survey

  From: JMIR Mental Health

  Date Submitted: May 30, 2019

  Open Peer Review Period: May 31, 2019 - Jul 26, 2019

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  Background: The increasing usage of mobile phones has created unique opportunities to provide health information dissemination and other interventions even to the remote places. Objective: The aim of...

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  Background: The increasing usage of mobile phones has created unique opportunities to provide health information dissemination and other interventions even to the remote places. Objective: The aim of the current study as to examine the mobile phone usage among ante- and post- natal mothers in rural Bihar and their willingness to receive health information and mental health counseling through mobile phones. Methods: The current study was conducted in four village panchayats, selected by convenience sampling, in Dalsinghsarai Taluk, Samastipur district, Bihar. A total of 50 ante- and post- natal mothers were interviewed after obtaining a written informed consent. A semi-structed performa was developed, in consultation with the mental health professionals, community level workers, village heads and lay people, to gather relevant information from the study participants. Descriptive statistical tests were used to analyze the data. Results: Analysis shows that the study participants’ average years of education was 5.4±3.6. Nearly 98% of the households of the interviewed study participants had at least one mobile phone while 84% of the study participants had separate personal mobile phones for themselves and had autonomy to use. 90% of the mobile phones in use are modular type. Nearly 98% of the study participants reported willingness to receive health information and mental health counseling through mobile phones. Conclusions: The results of the current study indicate that there is high mobile phone usage in rural Bihar and majority of the ante- and post- natal mothers own and use them with autonomy. They have also shown interest in receiving heath interventions through mobile phones. Novel and innovative approaches could be developed to tap into this potential avenue to promote and deliver health information and could be scaled up for wider audience at low cost.

• Understanding Social Media Addiction Disorder Management via Online Intervention Features for Higher Education

  From: Journal of Medical Internet Research

  Date Submitted: May 27, 2019

  Open Peer Review Period: May 30, 2019 - Jul 25, 2019

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  Background: Social media addiction disorder has recently become a major concern and has been reported to have negative impacts on postgraduate studies, particularly addiction to Facebook. Although pre...

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  Background: Social media addiction disorder has recently become a major concern and has been reported to have negative impacts on postgraduate studies, particularly addiction to Facebook. Although previous studies have investigated the effects of Facebook addiction disorder in learning settings, yet there has been a lack of studies conducted on investigating the relationship between online intervention features for Facebook addiction focusing on postgraduate studies. Objective: In an attempt to understand this relationship, we carried out an investigation on online intervention features for effective management of Facebook addiction in higher education. Methods: This study was conducted quantitatively using surveys and partial least square-structural equational modelling (PLS-SEM). The study involved 200 postgraduates in a Facebook support group for postgraduates. In the study, Bergen’s Facebook Addiction test was used to assess postgraduates’ Facebook addiction level while online intervention features were used to assess postgraduates’ perceptions of online intervention features for Facebook addiction, which are: (i) self-monitoring features; (ii) manual control features; (iii) notification features; (iv) automatic control features; and (v) reward features. Results: The study discovered that six Facebook addiction factor (relapse, conflict, salience, tolerance, withdrawal, and mood modification) and five intervention features (notification, auto-control, reward, manual control, and self-monitoring) that could be used in management of Facebook addiction in postgraduate education. The study also revealed that the relapse is the most important factor and mood modification is the least important. Furthermore, findings indicated notification was the most important intervention feature while self-monitoring was the least important. Conclusions: This implies that findings (addiction factors and intervention features) could assist future developed and educators in development of intervention tools for Facebook addiction management in postgraduate education.

• A scale to assess the methodological quality of studies assessing usability of eHealth products: a delphi study followed by validity and reliability testing

  From: Journal of Medical Internet Research

  Date Submitted: May 27, 2019

  Open Peer Review Period: May 30, 2019 - Jul 25, 2019

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  Background: Usability of ehealth and mhealth applications is of paramount importance as it impacts the quality of care. Methodological quality assessment is common practice in the field of health for...

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  Background: Usability of ehealth and mhealth applications is of paramount importance as it impacts the quality of care. Methodological quality assessment is common practice in the field of health for for different designs and type of studies. However, we were unable to find a scale to assess the methodological quality of studies assessing usability of eHealth products or services. Objective: The aims of this study were to develop a scale to assess the methodological quality of studies assessing usability and to perform a preliminary analysis of its reliability and construct validity. Methods: A 3-rounds Delphi panel was used to generate a pool of items considered important when assessing the quality of studies on usability. These items were used to write the scale and the guide to assist its use. The scale was then used to assess the quality of studies on usability of mobile application for physical activity and assessed in terms of feasibility, inter-rater reliability and construct validity. Results: Twenty-five experts participated in the Delphi panel and a 15-iten scale was developed. This scale was shown to be feasible (mean±sd time of application=13.10±2.59 minutes), reliable (ICC=0.81; 95% CI=0.55-0.93) and able to discriminate between low- and high-quality studies (high quality: mean±sd= 9.22±0.36; low quality: mean±sd= 6.86±0.80; p=0.011). Conclusions: The scale developed can be used both to assess the methodological quality of usability studies as well as to inform its planning. Clinical Trial: not applicable

• Virtual Reality for Screening of Cognitive Function in Older Persons: Comparative Study

  From: Journal of Medical Internet Research

  Date Submitted: May 27, 2019

  Open Peer Review Period: May 30, 2019 - Jul 25, 2019

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  Background: Dementia, which presents as cognitive decline in one or more cognitive domains affecting function, is becoming more prevalent. Traditional cognitive screening tools for dementia have their...

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  Background: Dementia, which presents as cognitive decline in one or more cognitive domains affecting function, is becoming more prevalent. Traditional cognitive screening tools for dementia have their limitations, with emphasis on memory and to a lesser extent on the cognitive domain of executive function. The use of virtual reality (VR) in screening for cognitive function in older person is promising but evidence for its use is sparse. Objective: The primary aim is to examine the feasibility and acceptability of using VR for screening for cognitive impairment, through a VR module. The secondary aim is to assess the module’s ability to discriminate between cognitively normal and cognitively impaired participants. Methods: A comparative study was conducted at a public primary care clinic in Singapore, where 60 older persons were recruited based on a cut-off score of 26 using the Montreal Cognitive Assessment (MoCA) scale. They participated in the VR module to assess their learning and memory, perceptual-motor function and executive function. Each participant was evaluated by a total performance score (range: 0 – 700) upon completion. An assisted questionnaire was also administered to assess their perception of and attitude towards VR. Results: 37 participants in Group 1 (cognitively normal; MoCA>26) and 23 participants in Group 2 (cognitively impaired; MoCA<26) were assessed. All participants completed the study with a mean total time of 19.1±3.6 minutes in Group 1 and 20.4±3.4 minutes in Group 2. Mean feedback scores ranged from 3.80 to 4.48 (max=5) in favour of VR. The total performance score in Group 1 (552.0±57.2) was higher than in Group 2 (476.1±61.9) (P<.001), and exhibited moderate positive correlation with scores from other cognitive screening tools: Abbreviated Mental Test (AMT) (0.312), Mini-Mental State Examination (MMSE) (0.373) and MoCA (0.427). A ROC curve analysis, relating total performance score to the presence of cognitive impairment, showed an area under curve of 0.821 (95% confidence interval: 0.714 to 0.928). Conclusions: We demonstrated the feasibility of using an VR-based screening tool for cognitive function in older persons in primary care, who were largely in favour of this tool.

• Public Response to Privatization of Healthcare Services in Saudi Arabia on Twitter

  From: Interactive Journal of Medical Research

  Date Submitted: May 26, 2019

  Open Peer Review Period: May 29, 2019 - Jul 24, 2019

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  Background: The Saudi government has been providing free medical care for all Saudis in public healthcare facilities, with the Ministry of Health being the major financing, operating, and supervising...

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  Background: The Saudi government has been providing free medical care for all Saudis in public healthcare facilities, with the Ministry of Health being the major financing, operating, and supervising body. In July 2017, the Saudi government approved privatization of healthcare services. Objective: This study aimed to assess public reactions to this reform that have been shared on Twitter. Methods: All tweets that contained the hashtag “خصخصة_الصحة#” [i.e., #Healthcare_Privatization] between 9th and 16th July 2017 were collected. Manual content analysis of the tweets was carried out to identify sentiments, types of sources of the tweets and the general theme of each tweet. Association between the types of sources and sentiments delivered was tested using chi-square test. Results: Out of 12,430 tweets collected, 2,119 met the inclusion criteria and were included in the final analysis. Most tweets delivered neutral or undetermined sentiments [37.4%], followed by positive [35.2%] and then negative [27.4%] sentiments. Each tweet has been assigned to one out of nine themes that best fits. The most common theme of the tweets was ‘supportive and explanatory’ [24.6%] then ‘unsupportive and/or expecting failure’ [16.3%]. The majority of contributors were members of the public [85.1%] and the clinical and non-clinical healthcare workers [10.1%]. There was a significant association between the type of the source and the sentiments delivered 2 [6, N = 1740] = 82.1, P-value <0.0001] Conclusions: Our study has shown that Twitter data represents a possible rich source of information to be studied by decision makers to evaluate public responses to major reforms in healthcare systems worldwide. Studying such data provides an insight into common concerns and misunderstandings to be addressed.

• Dose-response relationship of a Web-based Tailored Intervention Promoting HPV Vaccination: Process Evaluation

  From: Journal of Medical Internet Research

  Date Submitted: May 26, 2019

  Open Peer Review Period: May 29, 2019 - Jul 24, 2019

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  Background: In the Netherlands, HPV vaccination uptake remains to be low. To improve informed decision making (IDM) and HPV vaccination acceptability, we systematically developed an interactive, Web-b...

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  Background: In the Netherlands, HPV vaccination uptake remains to be low. To improve informed decision making (IDM) and HPV vaccination acceptability, we systematically developed an interactive, Web-based tailored intervention for mothers of Dutch girls to-be-invited. Objective: The aim of this study is to provide insight into the intervention’s working mechanisms by evaluating (1) program use, (2) program acceptability, and (3) the relationship of program use with (a) program acceptability, and (b) intervention effects (i.e., dose-response). Methods: In total, 3,995 mothers were invited to visit the Web-based intervention between baseline (January 2015, just before access to the intervention) and follow-up (March 2015, prior to the first HPV vaccination). Indicators for program use were time (i.e., duration of intervention exposure) and completeness (i.e., the proportion of all available webpages visited). HPV vaccination uptake registered by Praeventis was used as the primary outcome. Secondary outcomes were informed decision-making (IDM), decisional conflict, and social psychological determinants of HPV vaccination uptake. Results: From the 3,995 (100.00%) invited mothers, 2,509 mothers (62.80%) logged in. Of these, 2,239 mothers (89.24%) visited at least one page of the intervention components. On average, mothers spent 21.39 minutes on the website (SD = 12.41 minutes) and completed 50.04% (SD = 26.18%) of the website. Participants rated the website with a 7.64 on a 10-point scale (SD = 1.39). Program acceptability was significantly associated with completeness (β = 4.36, P < .001), but not with time (β = -.07, P =.77). Intention-to-treat analysis (N = 3,995) showed a significant positive effect of completeness on all outcome measures (P’s <.003; Bonferroni corrected alpha=.05/15 factors), including on HPV vaccination uptake. Time had a significant positive effect on all outcomes (P’s <.003), except for uptake (P = .195), risk perception when not vaccinated (P = .144), subjective norms (P = .032), and habit (P = .013). Conclusions: Program use and acceptability of the intervention was adequate. Completeness was positively associated with acceptability. Furthermore, dose-response effects were found of completeness and time on the mothers IDM, decisional conflict, and almost all of the social-psychological determinants of HPV vaccination acceptability. In addition, the extent to which mothers completed the intervention had a positive impact on their daughters’ vaccination uptake. This indicates that the Web-based, tailored intervention fits well with the mothers’ needs, and that completeness of use is essential for improving HPV vaccination uptake, acceptability, and IDM. Program use should therefore be promoted. Clinical Trial: Trialregister.nl NTR4935; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4935

• Multi-dimensional cognitive behavior therapy for obesity applied by clinical psychologist using digital platform: an open-label, randomised controlled trial

  From: JMIR mHealth and uHealth

  Date Submitted: May 25, 2019

  Open Peer Review Period: May 29, 2019 - Jul 24, 2019

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  Background: Developing effective weight management programs that are widely useful is a priority for the healthcare industry because obesity is a major health problem. Objective: The aim of the presen...

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  Background: Developing effective weight management programs that are widely useful is a priority for the healthcare industry because obesity is a major health problem. Objective: The aim of the present study is to develop and validate the efficacy of a new, comprehensive multi-factorial, intensive, daily-based, clinical psychologist’ coaching based on cognitive behavioral therapy (CBT) modules via the digital healthcare mobile services Noom Coach and InBody. Methods: This was an open-label, active comparator randomised controlled trial. Seventy female participants whose body mass index (BMI) scores were above 24kg/m² and who had no other clinical problems except obesity were randomised into experimental and control groups. Forty-five people in the experimental group (digital CBT group) were connected with a therapist intervention using a digital healthcare service that provided daily feedback and assignments for 8 weeks. Twenty-five people in the control group also used the digital healthcare service, but they were asked to do self-care without therapist intervention. The main outcomes of this study were objectively measured: weight in kg as well as other body compositions at 0, 8, and 24 weeks. The differences between the groups were evaluated using independent t-test and per-protocol framework. Results: Weight loss at 8 weeks in the digital CBT group was significantly higher than in the control group (-3.1 (4.5%) vs. -0.7 (3.4%), P = 0.036). Fat mass in the digital CBT group at 8 weeks was also significantly decreased compared to that in the control group (-6.3 (8.8%) vs. -0.8 (8.1%), P = 0.021). Leptin and insulin resistance in the digital CBT group at 8 weeks significantly declined compared to the control group (-15.8 (29.9%) vs. 7.2 (35.9%), P = 0.013 and -7.1 (35.1%) vs. 14.4 (41.2%), P = 0.044). Emotional eating behavior measured by the questionnaire (Dutch Eating Behavior Questionnaire) at 8 weeks in the digital CBT group significantly recovered compared to the control group (-2.8 (34.4%) vs. 21.6 (56.9%), P = 0.048). Snack calorie intake in the digital CBT group during the intervention period was significantly lower than in the control group (135.9 (86.4 kcal) vs. 208.2 (166.3 kcal), P = 0.020). Last, the level of depression, anxiety, and self-esteem at the baseline could significantly predict clinical outcomes at long term (24 weeks), while the level of motivation at the baseline could significantly predict clinical outcomes at both short term (8 weeks) and long term. Conclusions: These findings lend further support to the notion that obesity is closely related to psychological problems that require psychological intervention to manage weight for a healthy lifestyle. This study is innovative in that it provides a new CBT approach with a multi-disciplinary team based on digital technologies rather than conventional methods by successfully developing and verifying its effects. Clinical Trial: The trial was registered with ClinicalTrials.gov NCT03465306.

• How do patients use hospital websites? A Bayesian Network-Based Browsing Model for Patients Seeking the Radiation-Related Information

  From: Journal of Medical Internet Research

  Date Submitted: May 24, 2019

  Open Peer Review Period: May 27, 2019 - Jul 22, 2019

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  Background: Today, patients use information obtained from hospital websites to select hospitals. Therefore, it is important that hospitals provide information to meet patient’s needs, on their websi...

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  Background: Today, patients use information obtained from hospital websites to select hospitals. Therefore, it is important that hospitals provide information to meet patient’s needs, on their websites. However, few studies have investigated whether hospital websites meet the needs of patients and conducted on the usefulness of hospital websites for patients, especially patients seeking radiology-related information. Objective: The purpose of this study is to visualize and propose methods of enhancing the radiology-related information provision on hospital websites by analyzing access logs and building browsing models of a radiology-related contents based on a Bayesian network. Methods: First, we followed the website access log of Hokkaido University Hospital which collected from September 1st, 2016, to August 31st, 2017 invoked from Google Analytics modules. Second, we specified the access records related to radiology from visitor browsing pages and keywords. Third, using these resources, we built three Bayesian network models based on specific patient needs: radiotherapy, nuclear medicine examination, and radiological diagnosis. Analyzing each model, we considered why some visitors could not reach their desired page and improvements. Results: The radiotherapy model showed that, 74% (accuracy=0.86, F-measure=0.92) of target viewers could reach their request page, but that of 2.7% could reach the Center page where inspection information, one of their request pages, is posted. Conclusions: The results of our study indicated that the radiology-related information provided on hospital websites meets the most of patients needs. We proposed the potential solutions of patient web-browsing accessibility based on Bayesian network.

• Self-assessment for risk on perinatal depression and Internet health literacy among expecting and nursing mothers in Japan: Web-based research

  From: Journal of Medical Internet Research

  Date Submitted: May 24, 2019

  Open Peer Review Period: May 27, 2019 - Jul 22, 2019

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  Background: Perinatal depression (PD) is one of the biggest causes of maternal mortality in Japan. Objective: To investigate the relationships between Internet health literacy among expecting and nurs...

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  Background: Perinatal depression (PD) is one of the biggest causes of maternal mortality in Japan. Objective: To investigate the relationships between Internet health literacy among expecting and nursing mothers regarding perinatal depression, health information acquisition behaviors, and anxiety about PD. Methods: Web-based open survey (30 items, about eight minutes) was conducted anonymously between November 19, 2018, and November 30, 2018. The participants are users of “Luna Luna Baby” (MTI Co Ltd), an app service for expecting and nursing mothers. All participants consented to the research. The Japanese version of eHealth Literacy Scale was measured. All statistical analyses were performed using Stata software, Version 15.0 (StataCorp LP, College Station, TX). This study was approved by the Ethics Committee (approval number: 2018-051). Results: Valid responses were received from 2,979 individuals (1,987 pregnant women, 969 post-childbirth, and 21 others). More than 50% of participants felt they have a risk of developing PD. Most information about PD was acquired from websites during pregnancy (40.1 to 52.0%), while only 15.0% came from the medical institutions. A high-eHealth Literacy Scale group had a significantly higher awareness about postpartum depression (74.7% vs 48.7%), and fewer feelings that they were developing PD (47.4% vs 58.5%). Conclusions: The result suggest that medical institutions may not provide adequate information about PD during pregnancy and the accurate knowledge of the disease might alleviate the anxieties.

• A Machine Learning Approach to Understanding HIV and Comorbidities in Electronic Health Record Data: A Cross-Sectional Study

  From: Journal of Medical Internet Research

  Date Submitted: May 23, 2019

  Open Peer Review Period: May 27, 2019 - Jul 22, 2019

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  Background: As people living with HIV age, it becomes increasingly important to understand aging-related outcomes. The analysis of electronic health data (EHR) can further the understanding of such ou...

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  Background: As people living with HIV age, it becomes increasingly important to understand aging-related outcomes. The analysis of electronic health data (EHR) can further the understanding of such outcomes to support HIV aging phenotype development and improved overall health. Objective: For further insight, we evaluated the performance of two machine learning models: deep learning, and logistic regression on electronic health record data, to identify predictors of medical resource utilization, represented by Charlson comorbidity scores. Diagnostic codes that comprise the factors of individual characteristics, chronic conditions, treatment, and high-risk behaviors served as predictors. Methods: Diagnostic codes (ICD 9/10) were extracted for HIV infected (N=786), and uninfected (N=100,000) patients. A data mining process was applied to build comorbidity prediction models for use with two machine learning algorithms: deep learning and logistic regression. Final models were based on the relationship strength between the outcome (Charlson score: high (>5), low (≤5), and predictors (diagnostic codes). Results: Mean Charlson scores were 7.45±4.01 for HIV infected and 3.18±3.3 for uninfected patients. Top diagnostic codes were chemotherapy, hypertension, heart failure and acute kidney disease for HIV infected and substance abuse, length of hospital stay and chemotherapy for uninfected patients. Deep learning model predictors for HIV infected were age (16.16%), chemotherapy (13.17%), noncompliance treatment/regimen (11.83%), and hypertension (10.52%). For uninfected were, age (91.39%), and substance abuse (4.99%). Machine learning logistic regression predictors for HIV infected were chemotherapy (30.3%; OR: 48.7), age (26.6%; OR: 1.03), malnutrition (15.8%; OR: 4.58), and heart failure (10.8%; OR: 4.18). For uninfected were, age (88.7%; OR: 0.89), and length of hospital stay (9.74%; OR: 0.97). Conclusions: Differences were observed for medical resource utilization by HIV status, and predictive models. Results contribute to the development of narrower HIV and aging phenotypes with greater clinical validity to improve interventions for optimal aging-related outcomes.

• Mobile Health Adoption by Hospital: Evidence from China

  From: JMIR Medical Informatics

  Date Submitted: May 23, 2019

  Open Peer Review Period: May 27, 2019 - Jul 22, 2019

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  Background: Although mobile health (or mHealth) has the potential to transform healthcare through delivering better outcomes at a much lower cost than traditional healthcare services, very little is k...

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  Background: Although mobile health (or mHealth) has the potential to transform healthcare through delivering better outcomes at a much lower cost than traditional healthcare services, very little is known on mHelath adoption by hospitals. Objective: Our study will explore the determinants of mHealth adoption by hospitals using Technology-Organisation-Environment (TOE) framework. Methods: We conducted interviewer-administered survey with hospital managers in China and we analysed data using logistic regression. Results: : The results of our survey indicate that perceived ease-of-use, system security, top management support, hospital size, and external pressure are significantly positively related to hospitals’ adoption of m-health, while IT infrastructure, system reliability, and government policy are significant but negatively related to hospitals’ adoption of m-health. Conclusions: We concluded that TOE works in the context of mHealth adoption by hospital. In addition to technological predictors, organizational and environmental predictors are critical for explaining mHealth adoption by Chinese hospitals.

• Machine Learning Algorithms in Cardiology Domain: A Systematic Review

  From: Journal of Medical Internet Research

  Date Submitted: May 22, 2019

  Open Peer Review Period: May 27, 2019 - Jul 22, 2019

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  Background: It has been shown in previous decades, that Machine Learning (ML) has a huge variety of possible implementations in medicine and can be very helpful. Neretheless, cardiovascular diseases c...

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  Background: It has been shown in previous decades, that Machine Learning (ML) has a huge variety of possible implementations in medicine and can be very helpful. Neretheless, cardiovascular diseases causes about third of of all global death. Does ML work in cardiology domain and what is current progress in that regard? Objective: The review aims at (1) identifying studies where machine-learning algorithms were applied in the cardiology domain; (2) providing an overview based on identified literature of the state of the art of the ML algorithm applying in cardiology. Methods: For organizing this review, we have employed PRISMA statement. PRISMA is a set of items for reporting in systematic reviews and meta-analyses, focused on the reporting of reviews evaluating randomized trials, but can also be used as a basis for reporting systematic review. For the review, we have adopted PRISMA statement and have identified the following items: review questions, information sources, search strategy, selection criteria. Results: In total 27 scientific articles or conference papers written in English and reporting about implementation of an ML-method or algorithm in cardiology domain were included in this review. We have examined four aspects: aims of ML-systems, methods, datasets and evaluation metrics. Conclusions: We suppose, this systematic review will be helpful for researchers developing machine-learning system for a medical domain and in particular for cardiology.

• A pilot study of DigiHelse – a web based communication platform to improve home care service in Norway

  From: Journal of Medical Internet Research

  Date Submitted: May 22, 2019

  Open Peer Review Period: May 27, 2019 - Jul 22, 2019

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  Background: The home care service in Norway still struggles to meet an increasing demand of health care under restricted budgets constraints, although about one fourth of municipal budgets are dedicat...

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  Background: The home care service in Norway still struggles to meet an increasing demand of health care under restricted budgets constraints, although about one fourth of municipal budgets are dedicated health services DigiHelse is a web based platform designed to reinforce the home care service in Norway, and is currently undergoing a development process to meet the predefined needs of the municipalities. The three main features of the platform are to enable digital messages between residents and the home care service, highlight information on planned and completed visits and provide an opportunity to cancel visits and final notifications of completed visits. Objective: The aim of the study was to test the usability and feasibility of adopting DigiHelse in four districts in Oslo applying registry and behavioural data collected throughout a one-year pilot. Early health technology assessment (HTA) was used to estimate the potential future value of DigiHelse, including the predictive value of behaviour data. Methods: Outcome measures identified in the project’s concept phase by stakeholder insights and scenario drafting, were used to assess quality gains and patient safety issues in a present value calculation on socioeconomic benefits. In this follow-up study, aggregated data was collected at baseline, 15 and 52 weeks after DigiHelse was introduced to assess changes in health consumption. To update the present value calculation, data from four intervention- and one control group was analysed using the quasi-experimental difference-in-difference design to estimate the casual effect. Descriptive behavioural data from the digital platform was applied to assess the usability of the platform. Results: A significant gap was found between the estimated value of DigiHelse in the concept phase of the project and after the one-year pilot. In the present pilot assessment costs are expected to exceed potential savings with 67 million Euro over ten years, as compared to the corresponding concept estimates with a potential gains of 172.6 million Euro. Interestingly, behavioural data from the digital platform revealed that only 3-4% of recipients used the platform actively after one year. Conclusions: Objective behavioural data provides an important source to assess usability. In this case study, the low adoption rate may, at least in part, explain the inability of the DigiHelse pilot to perform as expected: meet the citizens’ needs. This study points to early assessment of behavioural data as an opportunity to identify inefficiencies and direct digital development in the right direction. For DigiHelse, insight into why the recipients in Oslo have not made a greater use of the web based platform seems to be the next step in ensuring the right improvement measures for the home care service. Clinical Trial: The trial is reported in accordance with CONSORT-EHEALTH.

• Smartphone and app usage of orthopaedic and trauma surgeons in Germany- a survey of the acceptance and future prospects

  From: JMIR mHealth and uHealth

  Date Submitted: May 24, 2019

  Open Peer Review Period: May 27, 2019 - Jul 22, 2019

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  Background: In the course of digitalization, smartphones are affecting more and more areas of life giving the user mobile and almost ubiquitous access to the internet and other web applications. The a...

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  Background: In the course of digitalization, smartphones are affecting more and more areas of life giving the user mobile and almost ubiquitous access to the internet and other web applications. The advantages of Mobile Health (mHealth) are an integral part in some areas of patient care. In contrast to other disciplines, routine integration of mobile devices in orthopaedics and trauma surgery in Germany is still in its very infancy. Objective: Knowledge of the actual physicians´ state of opinion regarding acceptance, future prospects and risks is essential in order to develop a stringent but dynamic-adaptive mHealth strategy in the fields of German orthopaedics and trauma surgery in the future. Methods: Between September 2018 and February 2019, an online survey among orthopaedics and trauma surgeons in German-speaking countries on the use of medical apps in everyday clinical practice was conducted between September 2018 and February 2019. The survey consisted of 13 open- and closed-ended- or multiple-choice-questions. A logistic regression analysis was performed to ascertain the effects of inter-individual characteristics on the likelihood of participants´ app and smartphone usage behaviour. Results: A total of 206 physicians participated in the survey. All participants owned a mobile device 206/206 (100%) and used smartphones 159/201 (79.1%) or apps 130/201 (64.4%) regularly in everyday clinical practice. Benefits of medical apps were seen as highly promising for the future 181/201 (90.1%). However, 120/192 (62.5%) were not satisfied with the current supply of medical apps in the appstores. Desired specifications for future apps were “intuitive usability” 167/201 (83.1%), “no advertising” 145/201 (72.1%) and “free of app-charge” 92/201 (45.8%). The attributes "transparent app-development and -sponsoring" 75/201 (37.3%) and the existence of an "easy-to understand privacy statement" 50/201 (24.9%) were of minor relevance. In the field of “medical research” 162/194 (83.5%), future apps were considered to provide the greatest benefit. Greatest risks were predicted for “data-misuse” 147/189 (77.8%), the “usage of unserious Apps” 135/189 (71.4%) and the “alienation from patients” 51/189 (27.0%). Increasing age was significantly associated with a reduction in the likelihood of regular smartphone (odds ratio: 0.91, P= .002) and app (odds ratio: 0.90, P= .001) usage, while the grade of medical profession had no significant impact on the usage behaviour. Conclusions: The study demonstrates that German orthopedic and trauma surgeons already use smartphones and apps on a regular basis in everyday clinical practice. Medical apps are considered to play an important role in the future. But there is still a significant discrepancy between the supply of mHealth applications and the demand, which creates a (data protection) legal and ethical vacuum. Therefore, it is up to German clinicians to remain open to digital innovations, to question them critically and to define and actively shape the role of smartphones in the context of medicine.

• Continuous 7-month IoT-based Health Monitoring of Pregnant and Postpartum Women—Observational Pilot Study

  From: JMIR mHealth and uHealth

  Date Submitted: May 24, 2019

  Open Peer Review Period: May 27, 2019 - Jul 22, 2019

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  Background: Monitoring during pregnancy is vital to ensure mothers and their infants’ health. Remote and continuous monitoring provides health care professionals with significant opportunities to ob...

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  Background: Monitoring during pregnancy is vital to ensure mothers and their infants’ health. Remote and continuous monitoring provides health care professionals with significant opportunities to observe health-related parameters in their patients and to detect any pathological signs at an early stage of pregnancy, and thus it may partly replace traditional appointments. Objective: To continuously monitor health parameters (physical activity/step counts, sleep duration and heart rate) of nulliparous women throughout pregnancy and until one month postpartum by way of a smart wristband worn by the women and an IoT-based solution to understand the possibilities of continuous long-term monitoring. Methods: A prospective observational pilot study utilized a convenience sample of 20 nulliparous women from the Hospital District of Southwest Finland. Continuous monitoring of physical activity/step counts, sleep and heart rate (HR) was performed by way of a smart wristband for 24 hours a day, 7 days a week over a 7-month period (6 months during pregnancy and 1 month postpartum). The smart wristband was connected to a cloud server. Self-reported physical activity (PA), sleep, and pregnancy and birth-related data were collected using semi-structured phone interviews and patient records. Results: Valid PA data were available from a mean of 127 (SD 49) days and sleep data from a mean of 116 (SD 62) days per participant during pregnancy. During the postpartum period, a mean of 12 (SD 10) days of valid PA data and 12 (SD 11) days of valid sleep data were available. Both PA and sleep time decreased as pregnancy progressed, and the decrease continued through the postpartum period. The mean resting HR increased towards the third trimester and returned to the early pregnancy level during the postpartum period. Only a few pregnant women reached the global recommendation of weekly PA. The participants’ subjective evaluations on activity and sleep did not correlate with the objective values. Conclusions: The smart wristband with the IoT technology was an appropriate and useful device for continuous monitoring of health parameters during pregnancy and the postpartum period. Continuous monitoring provides real-time information between scheduled appointments and thus may be helpful for targeting and tailoring pregnancy follow-up. Clinical Trial: none

• The development of a drug classification system for antihypertensive medications utilizing electronic health record based data: A methodology comparison

  From: Journal of Medical Internet Research

  Date Submitted: May 21, 2019

  Open Peer Review Period: May 24, 2019 - Jul 19, 2019

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  Background: Computable phenotypes have the ability to utilize data within the electronic health record (EHR) in order to identify patients with certain characteristics. Many computable phenotypes rel...

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  Background: Computable phenotypes have the ability to utilize data within the electronic health record (EHR) in order to identify patients with certain characteristics. Many computable phenotypes rely on multiple types of data within the EHR including prescription drug information, which is the case for resistant hypertension (RHTN). RHTN is a phenotype that is dependent on the correct classification of antihypertensive prescription drug information, as well as corresponding diagnoses and blood pressure information. Objective: We sought to create an antihypertensive drug classification system to be utilized with EHR based data as part of our RHTN computable phenotype. Methods: We compared four different antihypertensive drug classification systems based off of four different methodologies and terminologies, including three RxNorm Concept Unique Identifier (RxCUI) based classifications, and one medication name based classification. The RxCUI based classifications utilized data from 1) the Drug Ontology (DrOn), 2) the new Medication Reference Terminology (MED-RT), and 3) the Anatomical Therapeutic Chemical (ATC) Classification System and DrugBank, while the medication name classification relied on antihypertensive drug names. Each classification system was applied to EHR based prescription drug data from hypertensive patients in the OneFlorida Data Trust. Results: We observed broad overlap between the four methods, with 84-95% of terms overlapping pairwise between the different classification methods. Key differences arose from drug products with multiple dosage forms (e.g. oral and ophthalmic, oral and topical), drug products with an indication of benign prostatic hyperplasia, drug products that contain more than one ingredient (combination products), and terms within the classification systems corresponding to retired or obsolete RxCUIs. Conclusions: We have constructed two antihypertensive drug classifications, one based on RxCUIs, and one based on medication name that can be used in future computable phenotypes that require anti-hypertensive drug classifications.

• Using Technology to Communicate Prenatal Health Messages to Pregnant Women: A Mixed Methods analysis of the Knowledge, Attitudes, and Perceptions of Text4Baby in Urban Immigrant Pregnant Women

  From: Journal of Medical Internet Research

  Date Submitted: May 17, 2019

  Open Peer Review Period: May 23, 2019 - Jul 18, 2019

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  Background: The Text4baby™ mobile health (mhealth) program has received national attention and is acclaimed to provide pregnant women with greater access to prenatal healthcare, resources, and infor...

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  Background: The Text4baby™ mobile health (mhealth) program has received national attention and is acclaimed to provide pregnant women with greater access to prenatal healthcare, resources, and information. However, without sufficient piloting, little is known whether urban and Afro-Caribbean immigrant pregnant women are open and receptive to such innovative health communication methods, or of the cultural and systematic barriers that inhibit their behavioral intent to use Text4baby. Objective: We aimed to understand the lived experiences of urban and immigrant pregnant women with accessing prenatal health care and information in Brooklyn New York; and to utilize behavioral and technology assimilation theoretical constructs to measure their knowledge, perceptions and behavioral intent to use the Text4baby program. Methods: This exploratory mixed methods study first used a phenomenological approach to explore and describe the lived experiences of pregnant women while receiving prenatal care at University Hospital of Brooklyn at Downstate prenatal health clinic. Data from the qualitative arm led to the development of a theoretically inspired survey instrument that was then used in a repeated measures pre-post test design to evaluate changes in participants’ knowledge, attitudes, beliefs and perceptions of Text4baby after a minimum of four weeks exposure to the program’s messages. Results: Three themes emerged during the focus groups and interviews and were major factors affecting participant experiences: (1) patient-provider engagement, (2) social support, and (3) acculturation. With time as a barrier to quality care; inadequate patient provider engagement often left many participants with feelings of indifference regarding the prenatal care and information they received in the clinical setting. However, pregnant women reported strongly positive attitudes towards the use of mobile health and Text4baby with 63% of survey respondents reporting strong agreement with Text4baby providing them extra support during their pregnancy. Overall, on a scale of 1 -5, participant perception of the usefulness of Text4baby ranked at 4.26, and their perception of the compatibility and relative advantage of using Text4baby ranked 4.41 and 4.15 respectively. There was a 14% increase in participants reporting their intent to use Text4baby; and a 28% increase from pre and post-test in pregnant women strongly agreeing to speak more with their doctor about the information learned through Text4baby. Conclusions: Urban and immigrant pregnant women in Brooklyn endure a number of social determinants of health that create barriers when accessing quality prenatal health care and information which negatively impacts prenatal outcomes. Low-income expecting mothers often lack access to vital information about pregnancy, preparation for birth, and best practices when caring for their newborn. Our study indicates a number of systematic, political, and other macrosystem-level factors that perpetuate health disparities in our study population. In addition, traditional, cultural, and environmental patterns also perpetuate suboptimal prenatal behaviors and practices that influence access to quality care and prenatal outcomes.

• Awareness of Diabetic Eye Diseases among Diabetic In-Patients at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, cross sectional study.

  From: JMIR Diabetes

  Date Submitted: May 20, 2019

  Open Peer Review Period: May 23, 2019 - Jul 18, 2019

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  Background: Background: Saudi Arabia is the second most common country affected by diabetes mellitus in the Middle East, and it is the seventh in the world. Approximately 10% of diabetic patients deve...

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  Background: Background: Saudi Arabia is the second most common country affected by diabetes mellitus in the Middle East, and it is the seventh in the world. Approximately 10% of diabetic patients develop visual impairment and blindness due to ocular complications. These could be prevented by increasing awareness. Objective: Aim: To assess the awareness of diabetic eye disease among diabetic in-patients. Methods: Methods: This cross-sectional study was conducted among 241 diabetic in-patients at treated between 2014 and 2017 at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. The data were collected through a telephone-based interview and analysis was performed using SPSS. The chi-square test was used to investigate the relationship between demographic data and awareness to diabetic eye disease. Results: Results: A total of 241 patients were included in the analyses. Of these, 140 (58.1%) were males. Approximately 80.9% of the patients knew about diabetic eye disease. Patients with a higher educational level and economic status were more aware about diabetic eye disease. A considerable proportion of the patients (79.7%) were aware that retinopathy could be caused by diabetes. Conversely, only 41.9% and 32.8% were aware that cataract and glaucoma could be caused by diabetes mellitus, respectively. Conclusions: Conclusion: Most patients were aware of the ophthalmologic complications of diabetes. Despite being aware of diabetic retinopathy, more than half of the patients did not know that it was curable; hence, more public health education is needed.

• Serious gaming during multidisciplinary rehabilitation for patients with chronic pain or fatigue symptoms: realistic process evaluation

  From: Journal of Medical Internet Research

  Date Submitted: May 20, 2019

  Open Peer Review Period: May 23, 2019 - Jul 18, 2019

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  Background: Serious gaming could support patients in learning to cope with chronic pain or functional somatic syndromes and reduce symptom burdens. Objective: To realize this potential, insight is nee...

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  Background: Serious gaming could support patients in learning to cope with chronic pain or functional somatic syndromes and reduce symptom burdens. Objective: To realize this potential, insight is needed into how this could work, why, for whom, and in what actual treatment circumstances. Methods: Inspired by a realist approach, process evaluation methods were embedded before, during, and after a two-armed natural quasi-experiment (n=275). Changes in health outcome over time were compared between two groups of patients with interfering chronic pain or fatigue symptoms: 1) those who received a short additional blended mindfulness-based serious gaming intervention during a regular multidisciplinary rehabilitation program and 2) those who did not. Prior to inspecting outcome data, stakeholder focus group and patient semi-structured interview data were coded for configurations of intervention characteristics (I) in context (C) that activate mechanisms (M) for producing outcomes (O). Subsequently, hypotheses were formulated that could be tested on quantitative data using multiple regression and (moderated) mediation models. Results: Qualitative methods showed that self-discrepancies perceived by patients during serious gaming were a necessary trigger (M) for learning results with respect to self-awareness in moments of daily social interaction (O). Characteristics of serious gaming intervention (I) in context (C) that recipients considered important for gaming acceptance or learning results included design qualities, the relative advantage of an experiential learning opportunity, compatibility within rehabilitation treatment with a consistent approach and distinctive modality, (limited) flexibility to adjust to the personal preferences and contexts of the users, patients’ age and styles of managing stress or pain, provider role perceptions, and local intervention planning and facilitating processes. Quantitative methods showed that very small study group differences in self-reported depression, pain and fatigue changes (-.07<β<-.17, all 95% confidence interval upper bounds <0) were mediated by group differences in mindfulness (β=.26, 95% CI=.02-.51). Mindfulness changes were also positively associated with patient involvement in serious gaming (n=114, β=.36, P=001). Acceptance of serious gaming was lower in older patients. Outcome changes were stronger in patients that reported lower active coping with stress and pain coping before serious gaming. Finally, learning results and acceptance varied by indicators of local planning and facilitation of serious gaming. Conclusions: This study developed a tentative program theory about how and why serious gaming can additionally support learning about coping for reducing burdens of chronic pain or fatigue symptoms in certain patients and actual intervention delivery conditions. Future research can elucidate which findings are fallible, extendable, and transferable across future serious gaming contexts. This supports decisions for designing, allocating and tailoring serious gaming for optimal patient chances of important health benefit. Clinical Trial: This study was registered in the Netherlands Trial Registry NTR6020 on June 10th, 2016.

• Escape Rooms as a method of clinical evaluation in Nursing Students: A quasi-experimental study

  From: JMIR Serious Games

  Date Submitted: May 20, 2019

  Open Peer Review Period: May 23, 2019 - Jul 18, 2019

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  Background: Gamification has been shown to be a positive learning tool for its use among nursing students, but there are currently no studies available about its possible implementation in the evaluat...

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  Background: Gamification has been shown to be a positive learning tool for its use among nursing students, but there are currently no studies available about its possible implementation in the evaluation of nursing students’ clinical skills. Objective: The aim of this study was to understand the gameful experience and satisfaction of nursing students in the evaluation of their clinical skills using an escape room, as opposed to the traditional method of objective structured clinical evaluation. Methods: A quasi-experimental study was carried out on 237 nursing students divided randomly into a control group (n=120) and an experimental group (n=117). The participants completed a questionnaire about their knowledge and then the experimental group also filled out a questionnaire about their game experience and their satisfaction with the game. Results: The finding showed higher than average scores in all the dimensions of the Gameful Experience Scale, except in the dimension of negative effects. Regarding satisfaction, the highest scores were found in the dimensions of activity duration (3.51±0.66); the organisers’ attentiveness to students (3.60±0.61) and applicability of content to their training (3.50±0.58). As for the final evaluation, statistically significant differences were found between both groups (U=759.500; Z=-11.878; p<0.05), and the experimental group had a final average score of 9.59±0.36, while the control group’s was 7.46±1.36. Conclusions: Escape rooms are a useful tool used for evaluation of nursing students as opposed to objective structured clinical evaluation.

• Analyzing the Performance of a Preeclampsia Prediction Software by Customization of Maternal Ethnicity: Cross Sectional Study

  From: Journal of Medical Internet Research

  Date Submitted: May 20, 2019

  Open Peer Review Period: May 23, 2019 - Jul 18, 2019

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  Background: There is a pioneer algorithm developed by Fetal Medicine Foundation (FMF) to predict preeclampsia based on maternal characteristics combined with biophysical and/or biochemical markers. T...

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  Background: There is a pioneer algorithm developed by Fetal Medicine Foundation (FMF) to predict preeclampsia based on maternal characteristics combined with biophysical and/or biochemical markers. The Afro-Caribbean ethnicity is the second risk factor, in magnitude, found in populations tested by FMF, which was not confirmed in a Brazilian scenario. Objective: This study aimed to analyze the performance of preeclampsia (PE) prediction software by customization of maternal ethnicity. Methods: It was an observational, cross-sectional study, with secondary evaluation of data from FMF first trimester screening tests of singleton pregnancies. Risk scores were calculated from maternal characteristics and biophysical markers and were presented as the risk for PE development before 34 and 37 weeks. The following steps were followed: (1)identification of women characterized as black ethnicity; (2)calculation of early and preterm PE risk, reclassifying them as white, which generated a new score; (3)comparison of the proportions of women categorized as high risk between the original and new scores; (4)construction of the receiver operator characteristic(ROC)curve; (5)calculation of the area under the curve(AUC), sensitivity and false positive rate(FPR); (6)comparison of the AUC, sensitivity and FPR of the original with the “new”risk by chi-square test. Results: A total of 1531 cases composed the final sample, with 14.3%(95%CI: 12.54-16.06) and 11.88%(95% CI: 10.26 - 13.51) were respectively classified as high risk for PE development, originally and after recalculating the new risk. The comparison of FMF2012 predictive model performance between the originally estimated risks and the estimated “new risks”, showed that the difference was not significant for sensitivity and AUC, but it was significant for FPR. Conclusions: We concluded that black ethnicity classification of Brazilian pregnant women by FMF2012 algorithm increases the false positive rate. Suppressing ethnicity effect didn’t improve the test sensitivity. By modifying demographic characteristics it is possible to improve some performance aspects of clinical prediction tests. Clinical Trial: No trial registration

• The effects of human behavior on tick exposure and the risk of Lyme disease: evaluation of the use and user demographic of The Tick App.

  From: JMIR mHealth and uHealth

  Date Submitted: May 20, 2019

  Open Peer Review Period: May 23, 2019 - Jul 18, 2019

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  Background: Mobile health technologies (mHealth) provide a unique opportunity to share and gather information about health and disease. In the context of public health, mHealth is particularly suited...

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  Background: Mobile health technologies (mHealth) provide a unique opportunity to share and gather information about health and disease. In the context of public health, mHealth is particularly suited for patient education, disease self-management, and remote monitoring of patients. mHealth also takes advantage of smartphone features to turn them into research tools, with the potential to reach a larger section of the population in a cost-effective manner compared to traditional epidemiological methods. However, although mHealth apps have been widely implemented in chronic diseases and psychology, their potential use for vector-borne diseases research has not been yet fully exploited. Objective: In this study, we report on the development and implementation of a smartphone application, The Tick App, which is the first tick research-focused app in the United States. Methods: We used an iterative mixed-methods approach, including qualitative and quantitative methods, to develop and evaluate the implementation of The Tick App. This app was designed as a survey tool to collect data on human behaviors and movements associated with tick exposure, while simultaneously raising awareness among the general public by engaging users in tick identification and reporting. It consists of an enrollment survey to identify general risk factors; daily surveys to collect data on human activities and tick encounters (“Tick Diaries”); a survey to enter the details of tick encounters coupled with tick identification services (“Report a Tick”); and educational material. Results: Between May and September 2018, 1468 adult users enrolled, and approximately half were recurring users of the app. They were equally represented in gender and age, peaking at 37 and 55 years old. Most users owned a pet, did frequent outdoor activities (occupational, recreational and/or peridomestic) and lived in the Midwest and Northeast regions, increasing significantly in counties with high Lyme incidence or with recent increase in the number of reported cases in low incidence counties. Recurring users had a similar demographic profile to all users but participated in outdoor activities more frequently. The number of active users peaked in June and July, consistent with Ixodes scapularis nymphal activity. Although the “Tick Diary” was the most frequently used feature, the median number of submissions per user was 2 (IQR=1–11), falling short of the target of 15. The number of “Tick Diaries” submitted per user was higher for older age groups and in the Midwest, while the number of tick reports increased with the frequency of outdoor activities. Conclusions: This assessment allowed us to identify what fraction of the population used The Tick App which would allow us for a better interpretation of the external validity of the findings derived from the app-collected data, as well as to tailor the design of potential future tick prevention interventions to the users’ characteristics.

• 1 Deadly Step – evaluation of a novel, community-based chronic disease prevention and management program for Aboriginal people in New South Wales, Australia

  From: JMIR mHealth and uHealth

  Date Submitted: May 20, 2019

  Open Peer Review Period: May 23, 2019 - Jul 18, 2019

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  Background: Chronic diseases account for over 70% of health gaps between Aboriginal people and the rest of the Australian population. 1 Deadly Step is a community-based program that uses a sporting pl...

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  Background: Chronic diseases account for over 70% of health gaps between Aboriginal people and the rest of the Australian population. 1 Deadly Step is a community-based program that uses a sporting platform and cultural ambassadors to improve chronic disease prevention and management in New South Wales (NSW). Objective: To evaluate the feasibility and acceptability of a community based chronic disease screening program for Aboriginal people. Methods: In 2015 the program was enhanced to include an iPad application for screening assessments, a results portal for nominated care providers, and a reporting portal for program administrators and implemented in nine NSW community events. A mixed methods evaluation comprising survey data, analytics obtained from iPad and web portal usage and key informant interviews was conducted. Results: 1046 people were screened between April 2015 and April 2016 (mean age 40.3 years, 61.2% female, 91.5% Aboriginal or Torres Strait Islander). High chronic disease rates were observed (22.1% participants at high cardiovascular disease (CVD) risk, 16.5% with diabetes, 17.3% with albuminuria). A minority at high risk of CVD (42.9%) and with diabetes (42.2%) were meeting guideline-recommended management goals. 297 participants completed surveys (response rate 37%) with 85% reporting satisfaction with event organisation and information gained, and 6% experiencing problems with certain screening activities. Twenty-one interviews were conducted. A strong local working group and processes that harnessed community social networks were key to implementation success. Although software enhancements facilitated screening and data management, some technical difficulties impeded smooth processing of information. Only 51.4% of participants had medical review recorded post-event with wide inter-site variability (10.5% - 85.6%). Factors associated with successful follow-up included clinic managers with overall program responsibility and availability of medical staff for immediate discussion of results on event day. The program was considered resource intensive to implement. Support from a central coordinating body and integration with existing operational processes was essential. Conclusions: 1 Deadly Step offers an effective and acceptable strategy to engage Aboriginal communities in chronic disease screening. High rates of risk factors and management gaps were encountered, including people with no prior knowledge of these issues. Strategies to improve linkage to primary care could enhance the program’s impact in reducing chronic disease burden. Clinical Trial: N/A

• Deep Learning Based Tobacco Products Classification

  From: JMIR Medical Informatics

  Date Submitted: May 19, 2019

  Open Peer Review Period: May 22, 2019 - Jul 17, 2019

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  Background: Various images and videos are uploaded every day or even every second on Instagram. These publicly available images are easily accessible as a result of uncontrolled Internet use by young...

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  Background: Various images and videos are uploaded every day or even every second on Instagram. These publicly available images are easily accessible as a result of uncontrolled Internet use by young people and children. Shared images include tobacco products and can be encouraging for young people and children when they are accessible. Objective: In this study, it is aimed to detect tobacco and tobacco products with various Convolutional Neural Networks (CNNs) and to limit the access of young users to these detected tobacco products over the Internet. Methods: A total of 1607 public images were collected from Instagram, and feature vectors were extracted with various CNNs, which proved to be successful in the competitions and CNN was determined to be proper for detect tobacco products. Results: MobileNet gave the highest results 99.1% as weighted average. The feature vector of the input images are extracted with CNNs and classified with the latest fully connected layer. Conclusions: The classification of the tobacco products of 4 different classes was studied by using the networks and the classification performance rate was obtained as 100% for 322 test images via MobileNet. In this way, the content that is encouraging for children can be censored or filtered with a high accuracy rate and a secure Internet environment can be provided.

• Young Persons’ Face IT (YP Face IT), a web-based self-help psychosocial intervention for adolescents distressed by appearance-altering conditions and injuries: a feasibility study for a parallel randomized controlled trial.

  From: JMIR Mental Health

  Date Submitted: May 21, 2019

  Open Peer Review Period: May 22, 2019 - Jul 17, 2019

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  Background: Disfigurement (visible difference) from wide-ranging congenital or acquired conditions, injuries or treatments can negatively impact adolescents’ psychological well-being, education and...

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  Background: Disfigurement (visible difference) from wide-ranging congenital or acquired conditions, injuries or treatments can negatively impact adolescents’ psychological well-being, education and health behaviours. Alongside medical interventions, appearance-specific cognitive behavioural and social skills training to manage stigma and appearance anxiety may improve psychosocial outcomes. YP Face IT (YPF), is a web-based seven session self-help program plus booster quiz, utilising cognitive behavioural and social skills training, for young people (YP) struggling with a visible difference. Co-designed by adolescents and psychologists, it includes interactive multi-media and automated reminders to complete sessions/homework. Adolescents access YPF via a health professional who determines its suitability and remotely monitors clients’ usage. Objective: To establish the feasibility of evaluating YPF for 12-17 year olds self-reporting appearance-related distress and/or bullying associated with a visible difference. Methods: Randomized controlled trial with nested qualitative and economic study evaluating YPF compared with usual care (UC). Feasibility outcomes included: viability of recruiting via GP practices (face to face and via patient databases) and charity advertisements; intervention acceptability and adherence; feasibility of study and data collection methods and health professionals’ ability to monitor users’ online data for safeguarding issues. Primary psychosocial self-reported outcomes collected online at baseline, 13, 26 and 52 weeks were: appearance satisfaction (Appearance Subscale from Mendleson et al’s (2001) Body Esteem Scale); social anxiety (La Greca’s (1999) Social Anxiety Scale for Adolescents). Secondary outcomes were; self-esteem; romantic concerns; perceived stigmatization; social skills and healthcare usage. Participants were randomised using remote web-based allocation. Results: Thirteen charities advertised the study yielding 11 recruits, 13 primary care practices sent 687 invitations to patients on their databases with a known visible difference yielding 17 recruits (2.5% response rate), four recruits came from GP consultations. Recruitment was challenging, therefore four additional practices mass-mailed 3,306 generic invitations to all 12-17 year old patients yielding a further 15 participants (0.5% response rate). Forty-seven YP with a range of socioeconomic backgrounds and conditions were randomised (26% male, 91% white, mean age 14 years (SD 1.7)); 23 to YPF, 24 to UC). At 52 weeks, 16 (70%) in the intervention and 20 (83%) in UC groups completed assessments. There were no intervention-related adverse events; most found YPF acceptable with three withdrawing because they judged it was for higher-level concerns; 12 (52%) completed seven sessions. The study design was acceptable and feasible, with multiple recruitment strategies. Preliminary findings indicate no changes from baseline in outcome measures among the UC group and positive changes in appearance satisfaction and fear of negative evaluation among the YPF group when factoring in baseline scores and intervention adherence. Conclusions: YPF is novel, safe and potentially helpful. Its full psychosocial benefits should be evaluated in a large-scale RCT, which would be feasible with wide-ranging recruitment strategies. Clinical Trial: ISRCTN40650639

• A cross-sectional study on quality of diabetes information identified from the Internet

  From: Journal of Medical Internet Research

  Date Submitted: May 19, 2019

  Open Peer Review Period: May 22, 2019 - Jul 17, 2019

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  Background: Increasingly people seek health information from the Internet, in particular, health information on diseases that require intensive self-management, such as diabetes. However, the Internet...

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  Background: Increasingly people seek health information from the Internet, in particular, health information on diseases that require intensive self-management, such as diabetes. However, the Internet is largely unregulated and the quality of online health information may not be credible. Objective: To assess the quality of online information on diabetes identified from the Internet. Methods: We used the single term “diabetes” or equivalent Chinese characters to search Google and Baidu respectively. The first 50 websites retrieved from each of the two search engines were screened for eligibility using pre-determined inclusion and exclusion criteria. Included websites were assessed on four domains: accessibility, content coverage, validity and readability. Results: We included 26 websites from Google search engine and 34 from Baidu search engine. There were significant differences in website provider (P<0.0001), but not in targeted population (P=0.832) and publication types (P=0.378), between the two search engines. The website accessibility was not statistically significantly different between the two search engines, although there were significant differences in items regarding website content coverage. There was no statistically significant difference in website validity between the Google and Baidu search engines (mean Discern score 3.3 vs 2.9, p=0.156). The results to appraise readability for English website showed that that Flesch Reading Ease scores ranged from 23.1 to 73.0 and the mean score of Flesch-Kincaid Grade Level ranged range from 5.7 to 19.6. Conclusions: The content coverage of the health information for patients with diabetes in English search engine tended to be more comprehensive than that from Chinese search engine. There was a lack of websites provided by health organisations in China. The quality of online health information for people with diabetes needs to be improved to bridge the knowledge gap between website service and public demand.

• Leaderboard Design Principles to Improve Motivation in a Gamified Learning Environment: Cases Analysis and Literature Review for Leaderboard Design

  From: JMIR Serious Games

  Date Submitted: May 19, 2019

  Open Peer Review Period: May 22, 2019 - Jul 17, 2019

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  Background: Gamification in education enhances learners’ motivation, problem-solving and decision making abilities, and social skills such as communication. Numerous on-going studies are examining t...

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  Background: Gamification in education enhances learners’ motivation, problem-solving and decision making abilities, and social skills such as communication. Numerous on-going studies are examining the application of gamification design methodology and game mechanics to a learning environment. Leaderboards are a type of game mechanic that assist learners in goal setting and unleash motivation for learning. Objective: This study suggests principles for leaderboard design to assist learners in efficient goal setting, improve learning motivation, and promote learning in gamified learning environments. Methods: This study analyze previous studies on leaderboards that focus on their educational effectiveness and influence on social interactions and apply our findings to leaderboard design principles. Results: This study determined four leaderboard design objectives from previous studies. Based on these objectives, we developed three leaderboard design principles. First, macro leaderboards and micro leaderboards should be designed and used together. Second, all the elements used to measure learners’ achievements in an educational environment should be incorporated into the micro leaderboard. Third, leaderboards should be designed and considered for application in contexts other than the learning environment. This study further analyzes best practices considering the three leaderboard design principles. Conclusions: This study helps to resolve the problems associated with leaderboard design for the application of gamification in educational environments. In classrooms, teachers use existing gamification services. However, this study advocates applying the leaderboard design principles suggested in this research.

• Applications for self-monitoring of gestational diabetes mellitus in pregnancy; part of the improvement of connected health in Europe

  From: JMIR mHealth and uHealth

  Date Submitted: May 1, 2019

  Open Peer Review Period: May 22, 2019 - Jul 17, 2019

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  Background: The rapid development of mobile application technology and personalized medicine also in Europe, stimulate the self-monitoring. Self-monitoring allows the patient to actively participate i...

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  Background: The rapid development of mobile application technology and personalized medicine also in Europe, stimulate the self-monitoring. Self-monitoring allows the patient to actively participate in the treatment process, with a positive impact on the result of the treatment. Mobile applications thus offer a new way to promote healthy behaviors, such as healthy diet, physical activity and measurement of blood glucose levels in the care for women with gestational diabetes. However, there are many factors, which make significant barriers preventing wide use of mobile applications in general medical praxis. Objective: The main aim of this study is to evaluate the most commonly used mobile apps used to manage gestational diabetes and compare them to each other. Methods: This paper presents a study, which investigates the mobile applications that can potentially support controlling of the blood sugar in pregnant women. After a broad overview of mobile applications on the Google Play Store and iTunes, we found 90 mobile applications that fit our keywords search terms and our inclusion criteria. Among these 90 applications, only 4 were designed for the management of gestational diabetes and not diabetes in general. All 4 were downloaded and analysed. Among the rest 86 applications that were designed to manage diabetes in general we downloaded, evaluated and compared to each other 5 applications with the highest download rate. Results: The characteristics of the most commonly used applications were described. Differentiations between useful mobile applications were investigated. Conclusions: Applications can provide support for women to act on a certain issue by themselves without visiting an obstetrician. Although most of the applications were very useful, we suggested improvements. The greatest policy concerns of connected health are quality, privacy and safety of the gathered data.

• Defining concepts in chronic subjective tinnitus symptomatology: qualitative study using an online discussion forum

  From: Journal of Medical Internet Research

  Date Submitted: May 19, 2019

  Open Peer Review Period: May 22, 2019 - Jul 17, 2019

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  Background: A minimum standard based upon consensus decision making recommends a core set of tinnitus-specific health complaints (outcome domains) which should be assessed and reported in all clinical...

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  Background: A minimum standard based upon consensus decision making recommends a core set of tinnitus-specific health complaints (outcome domains) which should be assessed and reported in all clinical trials since this enables comparisons to be made across studies as well as data pooling for meta-analysis. Objective: To further clarify how the outcome domain concepts should be defined for five of the core set: tinnitus intrusiveness, sense of control, acceptance of tinnitus, concentration, and ability to ignore. This step requires a clear and fully elaborated definition for each outcome domain, moving from an abstract or vague concept to an operationalised and measurable health-related construct, so that suitable measurement instruments can then be identified. Methods: A series of five focus-group-style semi-structured discussions were conducted via an online discussion forum, each open for two weeks and ending with a vote. Participants were 148 tinnitus experts who completed a preceding online Delphi survey which had generated the original set of minimum standards. Participants were healthcare users living with tinnitus, healthcare professionals, clinical researchers, commercial representatives and funders. Results: The online discussions led to a revision of all five original plain language definitions which had been used in the preceding online Delphi survey. Each revised definition was voted by 8-53 participants and reached the pre-specified threshold of 70% consensus for all except tinnitus intrusiveness. Although a single definition was not agreed for tinnitus intrusiveness, a majority of participants shared the view that the concept should be sufficiently broad to encapsulate a range of subdomains. Examples included tinnitus awareness, unpleasantness and impact on different aspects of everyday life. Thematic analysis of the five online discussion threads gave important insights into expert interpretations of each core outcome domain, generating an operationalised and measurable health construct in each case. Conclusions: The qualitative data gathered during the online discussion forum provided important in-depth understanding of the health concepts which had raised debate during earlier face-to-face meetings. The descriptive summaries and definitions provide sufficient operationalisation of those concepts to proceed to the second stage of Core Outcome Set development which is to identify and evaluate suitable measurement instruments. This work supports the use of online peer discussion forums in defining health concepts.

• Impact of a smartphone app to increase vegetable consumption and variety in adults: a large-scale community cohort study

  From: JMIR mHealth and uHealth

  Date Submitted: May 19, 2019

  Open Peer Review Period: May 22, 2019 - Jul 17, 2019

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  Background: Large scale initiatives to improve diet quality through increased vegetable consumption have had small to moderate success. Digital technologies have features which are appealing for healt...

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  Background: Large scale initiatives to improve diet quality through increased vegetable consumption have had small to moderate success. Digital technologies have features which are appealing for health-related behavior change interventions, and may overcome some of the limitations associated with traditional delivery approaches. Objective: This study describes the implementation and evaluation of a smartphone app, called VegEze, that aimed to increase vegetable intake among Australian adults. Methods: To better capture the impact of this app in a real world setting the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework was utilized. An uncontrolled, quantitative cohort study was conducted with evaluation conducted after 21 and 90 days of the program. The app was placed in the Apple® App Store® and accompanied by television, radio and social media promotion. Evaluation surveys were embedded into the app using ResearchKit®. The primary outcomes were vegetable intake (serves per day) and vegetable variety (types per day). Psychological variables (attitudes, intentions, self-efficacy and action planning) and app usage were also assessed. Descriptive statistics and multiple linear regression were used to describe the impact of the app on vegetable intake, and determine the user characteristics associated with increased intake. Results: Data were available from 5062 participants who completed the baseline survey, 1224 who completed the 21 day survey and 273 who completed the 90 day survey. The sample resided all around Australia, were mostly female (84.3%) with a mean age of 48.2 years (SD=14.1). The mean increase in intake was 0.48 serves, from 3.06 serves at baseline to 3.54 serves at the end of the 21 day challenge (t(1223)=8.71, P<.001). Variety of vegetables also increased by 0.35 types per day (t(1123)=9.59, P<.001). Participants with the highest app usage increased their vegetable intake by 0.63 (SD=2.02) serves per day compared to 0.32 (SD=1.69) for those with the lowest app usage. Based on multiple linear regression gender, age, BMI; psychological variables of self-efficacy, attitudes, intentions and action planning specific to vegetables; baseline vegetable intake and active days of app usage accounted for 23.3% of the variance associated with change in intake (F(9,1208)=42.09, P<.001). Baseline vegetable intake was the strongest predictor of change in intake (β=-0.495, P<.001), with lower baseline intake associated with greater change in intake. Self-efficacy (β=0.116, P<.001), action planning (β=0.066, P=.017), BMI (β=0.070, P=.009) and app usage (β=0.081, P=.002) were all significant predictors of change in intake. Conclusions: The VegEze app was able to shift intake by half a serve in a large sample of Australian adults. Testing the app in a real world setting and embedded the consent process allowed for greater reach, and efficient and robust evaluation. App usage was associated with successful behavior change, but further work to improve engagement is warranted. Clinical Trial: CSIRO Health and Medical Human Research Ethics Committee (CHM HREC) Low Risk Review Panel (Proposal #13/2017). Australian New Zealand Clinical Trials Registry (ACTRN12618000481279).

• A Randomized Controlled Trial of a Fully Automated Internet-Based Cognitive Behavior Therapy Intervention in a Community Population of Adults with Depression Symptoms

  From: Journal of Medical Internet Research

  Date Submitted: May 18, 2019

  Open Peer Review Period: May 21, 2019 - Jul 16, 2019

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  Background: Internet-based cognitive behavior therapy (iCBT) interventions can reduce depression symptoms; yet, large differences in their effectiveness exist. Objective: The aim of this study was to...

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  Background: Internet-based cognitive behavior therapy (iCBT) interventions can reduce depression symptoms; yet, large differences in their effectiveness exist. Objective: The aim of this study was to evaluate the effectiveness of an iCBT intervention called Thrive that is designed to enhance engagement when delivered as a fully automated intervention to a rural community population of adults with depression symptoms. Methods: Using no diagnostic or treatment exclusions, adults with depression symptoms were recruited from communities and randomized to the Thrive intervention group or the control group. Participants were evaluated at baseline, and 4 and 8 weeks for the primary outcome of depression symptom severity and secondary outcome measures of anxiety symptoms, work and social adjustment, psychological resilience, and suicidal ideation. Results: Over the 8-week follow-up period, the intervention group (n=181) had significantly lower depression symptom severity compared to control (n=161) (P<.001) with a moderate treatment effect size (d = 0.63). Moderate to near-moderate effect sizes favoring the intervention group were observed for anxiety symptoms (P <.001; d = 0.47), work/social functioning (P <.001; d = 0.39), and resilience (P <.001; d = 0.55). Although not significant, the intervention group was 45% less likely than the control group to experience increased suicidal ideation (OR = 0.55). Conclusions: These findings suggest that the Thrive intervention was effective in reducing depression and anxiety symptom severity and improving functioning and resilience among a mostly rural community population of US adults. The effect sizes associated with Thrive were generally larger than those of other iCBT interventions delivered as a fully automated, intervention. Clinical Trial: NCT03244878

• Readmission Risk Trajectories for Heart Failure Patients Using a Dynamic Prediction Approach: Observational Study

  From: Journal of Medical Internet Research

  Date Submitted: May 18, 2019

  Open Peer Review Period: May 21, 2019 - Jul 16, 2019

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  Background: Patients hospitalized with heart failure suffer the highest rates of 30-day readmission among any clinically-defined patient populations in the United States. Investigation into the predic...

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  Background: Patients hospitalized with heart failure suffer the highest rates of 30-day readmission among any clinically-defined patient populations in the United States. Investigation into the predictability of 30-day readmissions can lead to clinical decision-support tools and targeted interventions that can help care providers to improve individual patient care and reduce readmission risk. Objective: We developed a dynamic readmission risk prediction model that yields daily predictions for hospitalized heart failure patients toward identifying risk trajectories over time. We identified clinical predictors associated with different patterns in readmission risk trajectories. Methods: A two-stage predictive modeling approach combining logistic and beta regression was applied to electronic health record (EHR) data accumulated daily to predict 30-day readmission for a cohort of 534 heart failure patient encounters over 2,750 patient-days. Unsupervised clustering was performed on predictions to uncover time-dependent trends in readmission risk over the patient’s hospital stay. Results: Readmission occurred in 107 (20.0%) encounters. The out-of-sample AUC for the two-stage predictive model was 0.73 (±0.08). Dynamic clinical predictors capturing lab results and vital signs had the highest predictive value compared to demographic, administrative, medication and procedural data included. Unsupervised clustering identified four risk trajectory groups: decreasing risk (24.5% encounters), high risk (21.2%), moderate risk (33.1%), and low risk (21.2%). The decreasing risk group demonstrated change in average probability of readmission from admission (0.69) to discharge (0.30), while the high risk (0.75), moderate risk (0.61), and low risk (0.39) maintained consistency over the hospital course. Clinical predictors that discriminated groups included lab measures (hemoglobin, potassium, sodium), vital signs (diastolic blood pressure), and the number of prior hospitalizations. Conclusions: Dynamically predicting readmission and quantifying trends over patients’ hospital stay illuminated differing risk trajectory groups. Identifying risk trajectory patterns and distinguishing predictors may shed new light on indicators of readmission and the isolated effects of the index hospitalization.

• Automatic diagnosis of disc bulge and disc herniation based on lumbar MR images using deep convolutional neural networks

  From: Journal of Medical Internet Research

  Date Submitted: May 18, 2019

  Open Peer Review Period: May 21, 2019 - Jul 16, 2019

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  Background: Lumbar abnormalities often lead to the lower back pain which has keep plaguing people’s lives. Magnetic resonance imaging (MRI) is one of the most efficient techniques to detect lumbar d...

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  Background: Lumbar abnormalities often lead to the lower back pain which has keep plaguing people’s lives. Magnetic resonance imaging (MRI) is one of the most efficient techniques to detect lumbar diseases and widely used in clinic. How to interpret massive amounts of magnetic resonance (MR) images quickly and accurately is an urgent problem. Objective: The aim of this study is to present an automatic system to diagnosis of disc bulge and herniation which is time-saving and effective so that can reduce radiologists’ workload. Methods: The diagnosis of disorders of lumbar vertebral is highly dependent on medical images, therefore, we choose two most common diseases disc bulge and herniation as the research objects. The study is mainly about classification of the axial lumbar disc MR images using deep convolutional neural networks. Results: This system comprises of four steps. First step, automatic localizes vertebral bodies (including L1, L2, L3, L4, L5, and S1, L: Lumbar, S: Sacral) in sagittal images using the Faster R-CNN and 4-fold cross-validations show 100% accuracy respectively. Second step, automatically determine the corresponding disc of each axial lumbar disc MR images with 100% accuracy. In the third step, the accuracy to automatic localizes intervertebral disc region of interest (ROI) in axial MR images is 100%. The three classification (disc normal, disc bulge and disc herniation) accuracies in the last step in five groups (L1-L2, L2-L3, L3-L4, L4-L5, and L5-S1) are 92.7%, 84.4%, 92.1%, 90.4% and 84.2% respectively. Conclusions: The automatic diagnosis system was successful built which can classify images of disc normal, disc bulge and disc herniation. This system provides an online test to interpret lumbar disc MR images which will be very helpful in improving the diagnostic efficiency and standardizing diagnosis reports, also, the system can be promoted to detect other lumbar abnormalities and cervical spondylosis.

• Effects and Mechanisms of a WeChat-based Intervention on Suicide among People Living with HIV and Depression: A Path Model Analysis

  From: Journal of Medical Internet Research

  Date Submitted: May 18, 2019

  Open Peer Review Period: May 21, 2019 - Jul 16, 2019

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  Background: People living with HIV and depression (PLWHD) have high rates of suicide. Studies of mHealth interventions have shown feasibility, acceptability, and efficacy in improving mental health in...

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  Background: People living with HIV and depression (PLWHD) have high rates of suicide. Studies of mHealth interventions have shown feasibility, acceptability, and efficacy in improving mental health in PLWHD. However, few studies have examined the effects and mechanisms of mHealth interventions on suicide. Objective: This study was designed to examine the effects and mechanisms of a WeChat-based intervention, Run4Love, on suicide among PLWHD in China, while considering perceived stress and depressive symptoms as mediators. Methods: A sample of 300 PLWHD were recruited from the outpatient clinic of a large HIV/AIDS treatment hospital and were randomized to Run4Love group or control group. Data were collected at baseline, 3-, 6- and 9-month follow-ups. Path analysis modeling with longitudinal data was used in data analyses. Results: The Run4Love mHealth intervention had a direct effect on reducing suicide at 6-month follow-up (β = - .18, P = .02) and indirect effect through reducing perceived stress and depressive symptoms at 3-month follow-up (β = - .09, P = .001). A partial mediating effect between perceived stress and depressive symptoms accounted for 33% of the total effect. Conclusions: Through path analyses, we understood the mechanisms and effects of an mHealth intervention on suicide prevention. The findings underscored the importance of stress reduction and depression treatment in such a program. We call for more effective suicide prevention, especially mHealth interventions targeting the vulnerable population of PLWHD. Clinical Trial: Chinese Clinical Trial Registry - ChiCTR-IPR-17012606; http://www.chictr.org.cn/showproj.aspx?proj=21019 (Archived by WebCite at: https://www.webcitation.org/78Bw2vouF)

• Maximizing Data Utilization of Clinical Sequencing Data in Cancer : Implementation of International Standard (ISO/TS 20428)

  From: Journal of Medical Internet Research

  Date Submitted: May 15, 2019

  Open Peer Review Period: May 21, 2019 - Jul 16, 2019

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  Background: The analytical capacity and speed of next generation sequencing (NGS) technology has been improved. Lots of genetic variants correlating with various diseases have been discovered based on...

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  Background: The analytical capacity and speed of next generation sequencing (NGS) technology has been improved. Lots of genetic variants correlating with various diseases have been discovered based on NGS. Therefore, applying NGS to clinical practice results in precision or personalized medicine. However, as clinical sequencing reports in electronic health records (EHRs) are not standardized, clinical decision support systems have not been fully utilized. In addition, integrating genomic data with clinical data for translational research remains a significant hurdle. Objective: To apply international standards to clinical sequencing reports and to develop a clinical research information system to integrate standardized genomic data with clinical data. Methods: The authors applied the recently published ISO/TS 20428 standard to 367 clinical sequencing reports generated by panel (91 genes) sequencing in EHR and implemented a Clinical NGS Research System (CNRS) by extending the clinical data warehouse to integrate the necessary clinical data for each patient and developed a user interface including clinical research portal, and an e-CRF (electronic-Case Report Form). Results: A single clinical sequencing report with 28 items was restructured into four database tables and 49 entities. As a result, 367 patients’ clinical sequencing data were connected with clinical data in EHR such as diagnosis, operation, or death information. This system can support development of cohort or case-control datasets as well. Conclusions: The standardized clinical sequencing data could be further applied to translational research, not only for clinical practice.

• Evaluation of Mobile Apps Targeted to Patients with Spondyloarthritis for Disease Monitoring: Systematic App Review

  From: JMIR mHealth and uHealth

  Date Submitted: May 17, 2019

  Open Peer Review Period: May 21, 2019 - Jul 16, 2019

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  Background: There are many apps developed for patients with Spondyloarthritis in the market, but they are not objectively evaluated for their purposes and quality. Objective: To identify and evaluate...

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  Background: There are many apps developed for patients with Spondyloarthritis in the market, but they are not objectively evaluated for their purposes and quality. Objective: To identify and evaluate existing publicly available, high-quality apps for monitoring Spondyloarthritis disease activity that use validated measurement instruments. Methods: We did a review of apps available on Apple App store and Google Play store based on a combination of keywords, inclusion and exclusion criteria. Validated disease activity measurement instruments were identified. Information regarding app characteristics, including the presence of validated disease activity measurement were extracted. The Mobile App Rating Scale (MARS) was used to review the apps for user experience. Results: A total of 1,253 apps were identified in the app stores, and five apps met the criteria and were further analyzed. Two apps (MySpA and GRAPPA App) contained some of the validated disease activity monitoring instruments for specific spondyloarthritis subtypes. These two apps are also rated “good” on the MARS (with total mean scores ≥ 4/5), while the other apps scored poorly in comparison. Conclusions: There are two high-quality spondyloarthritis disease activity monitoring apps publicly available, but they only target two spondyloarthritis subtypes- ankylosing spondylitis and psoriatic arthritis. There is a lack of high-quality apps that can measure disease activity for other spondyloarthritis subtypes, and no available app that consolidates all validated disease activity instruments across subtypes.

• mHealth and Opportunities in Anti-Retroviral Adherence in HIV, A Diverse Group of Patients with Diverse and Unique Opportunities : A Narrative Review

  From: JMIR mHealth and uHealth

  Date Submitted: May 16, 2019

  Open Peer Review Period: May 21, 2019 - Jul 16, 2019

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  Background: Introduction: Antiretrovirals (ARVs) are key in the management of human immunodeficiency virus (HIV). While no cure exists, ARVs help patients live healthy lives and prevent transmission t...

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  Background: Introduction: Antiretrovirals (ARVs) are key in the management of human immunodeficiency virus (HIV). While no cure exists, ARVs help patients live healthy lives and prevent transmission to others. However, medication adherence to sometimes complex drug regiments is paramount to avoid the emergence of a drug-resistant virus. The goal of therapy is to reach an undetectable viral load. However, adherence is a common problem, stemming from such issues as mental health, chaotic home situations and busy work schedules. mHealth represents a new approach to improve medication adherence and multiple studies have been performed in this area. Objective: No current objective is listed in abstract. If needed can add the following: Objective: Our paper reviews the current implementations of mHealth in the management of HIV within different groups of patients. Methods: Methods: We used the PubMed database using various search terms to review the current implementations of mHealth in HIV care. Titles and abstracts were screened and 37 articles were fully reviewed. Results: Results: Upon a review of the literature, evidence was found for developing nations, intravenous and illicit drug users, and men who have sex with men. Conclusions: Discussion: There seems to be a role in developing nations; however, the optimal design of the interventions needs to be delineated. The evidence is less clear in other groups. Clinical Trial: Not Applicable

• Online information on electronic cigarettes – a comparative study of relevant websites from Baidu and Google search engines

  From: Journal of Medical Internet Research

  Date Submitted: May 16, 2019

  Open Peer Review Period: May 21, 2019 - Jul 16, 2019

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  Background: Online information on e-cigarettes may influence people’s perception and use of e-cigarettes. Objective: This study aimed to assess and compare types and credibility of web-based informa...

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  Background: Online information on e-cigarettes may influence people’s perception and use of e-cigarettes. Objective: This study aimed to assess and compare types and credibility of web-based information on e-cigarettes identified from Google (in English language) and Baidu (in Chinese language) search engines. Methods: We used key words “vaping” or “e-cigarettes” for Google search engine, and equivalent Chinese characters for Baidu search engine, and included the first 50 unique and relevant websites from each of the two search engines. The main characteristics, credibility of and claims made on included websites were systematically assessed and compared. Results: Relatively more included Baidu websites were owned by manufacturers or retailers than Google websites (33/50, 66% vs. 15/50, 30%; P<0.001). None of the Baidu websites, compared with 12 (24%) of the Google websites, were provided by public or health institutions. Baidu websites were more likely to contain e-cigarette advertising (P<0.001), and less likely to provide information on health education (P<0.001). The overall credibility of the included Baidu websites was lower than the Google websites (P<0.001). An age restriction warning was shown on all advertising websites from Google search engine (15/15), but only on 10 of the 33 (30%) advertising websites from Baidu search engine (P<0.001). Conflicting or unclear health and social claims were common on the included websites. Conclusions: Although conflicting or unclear claims on e-cigarettes were common on websites from both Baidu and Google search engines, there was a lack of online information from public health organisations in China. It is crucial to restrict e-cigarette marketing and reduce the attractiveness of e-cigarettes to young people by effectively implementing relevant regulations. Clinical Trial: Not applicable.

• Internet-based cognitive behavioural therapy programme tailored to patients with cardiovascular disease and depression: a randomised controlled trial

  From: Journal of Medical Internet Research

  Date Submitted: May 15, 2019

  Open Peer Review Period: May 19, 2019 - Jul 14, 2019

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  Background: Depression is a common cause of poorer wellbeing and prognosis in patients with cardiovascular disease (CVD). Yet there is a lack of effective intervention strategies targeting depression....

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  Background: Depression is a common cause of poorer wellbeing and prognosis in patients with cardiovascular disease (CVD). Yet there is a lack of effective intervention strategies targeting depression. Objective: To evaluate the effect of a nurse-delivered and tailored internet-based cognitive behavioural therapy (iCBT) programme aimed at reducing depression in patients with CVD. Methods: A randomised controlled trial. 144 CVD patients with at least mild depression (Patient Health Questionnaire-9 (PHQ-9) score ≥ 5) were randomised 1.1 to nine-week iCBT (n=72) or an active control participating in a Web-based discussion forum (ODF, n=72). The iCBT programme was adapted to fit patients with CVD. Feedback was provided by nurses with experience of CVD and a short introduction in CBT. The primary outcome, depression, was measured by the PHQ-9. Secondary outcomes were depression measured with Montgomery Åsberg Depression Rating Scale-self rating Scale (MADRS-S), Health-related Quality of life measured with Short Form 12 (SF-12) and EQ-VAS and adherence. Intention-to-treat analysis with multiple imputations was used. Between group differences of the primary and secondary outcomes was determined by analysis of covariance and sensitivity analysis was performed with mixed models. Results: iCBT had compared to ODF a significant and moderate treatment effect on the primary outcome depression (i.e. PHQ-9) (mean group difference -2.34 [95 % CI -3.58 to -1.10], P <0.001., Cohens d=0.62). In the secondary outcomes iCBT compared to ODF had a significant and large effect on depression (i.e. MADRS-S) (P<.001, Cohens d=0.86) and a significant and moderate effects on the mental component scale of the SF-12 (P<.001., Cohens d=0.66) and the EQ-VAS (P<.001., Cohens d=0.62). A total of 60% (n=43) in the iCBT group completed all seven modules, whereas 82% (n=59) completed at least half of the modules. No patients were discontinued from the study due to high risk of suicide or deterioration in depression. Conclusions: Nurse-delivered iCBT can reduce depression and improve HRQoL in CVD patients enabling treatment for depression in their own homes and at their own preferences of time. Clinical Trial: ClinicalTrials.gov, NCT02778074

• Exploring Patient Needs in Online Health Communities Using Text Mining--Taking Diabetes and Depression as Examples

  From: Journal of Medical Internet Research

  Date Submitted: May 14, 2019

  Open Peer Review Period: May 17, 2019 - Jul 12, 2019

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  Background: Online Health Community (OHC) refers to a forum where patients, their family members, doctors and caregivers communicate with each other. Patients who participate in OHCs can obtain benefi...

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  Background: Online Health Community (OHC) refers to a forum where patients, their family members, doctors and caregivers communicate with each other. Patients who participate in OHCs can obtain benefits for disease treatments and health management, so identifying the categories of patient needs and how they are satisfied are significant to determining theories of patient demand and community construction. Objective: (1) Explore the needs of patients in the Internet environment. (2) Distinguish the similarities and differences of patient needs among OHCs of different types and concerning different diseases. (3) Proposed a method for automatically identifying patient demands in Internet environments. Methods: This study used a combination of manual annotation and computer-aided method to mine value of 9936 posts collected from four OHCs in China. On one hand, we recruited 7 diabetes or depression medical experts to label text according to a theoretical framework, forming patient need theory in Internet environments, which is designed for the first two research goals. On the other hand, based on the corpus constructed by manual annotation, this research used Natural Language Processing (NLP) and Machine Learning (ML) to train a model for automatically identifying patient demands, which is planned to reach the third research purpose. Results: According to statistical results, the proportion of posts related to patient needs in OHCs was approximately 91%, and posts concerned with Emotional Support (18%), Information (28%) and Socialization (44%) needs were the top three most prevalent categories. However, when OHCs were divided according to user composition and disease type, patient needs were diverse: the chief demand was Socialization in Patient Interaction OHCs (65%), Diabetes OHCs (50%), and Depression OHCs (69%), while Information (96%) was the chief demand in Patient-Doctor Interaction OHCs. A model was trained to identify patient needs taking Linguistic Features (LF) and Category Keyword Features (CKF) as input and Random Forest as the classifier, of which the F1 value was higher than 0.80 on test set. Conclusions: Patient needs in the Internet environment mainly include Emotional Support needs, Information needs and Socialization needs. Differences in community type and disease type can lead to diverse patient needs in OHCs. It is practical to use computer-aided methods to identify patient needs in OHCs automatically.

• Examining the Accuracy of Optical Heart Rate Sensing Technology in Wearable Fitness Trackers for Young and Older Adults

  From: JMIR mHealth and uHealth

  Date Submitted: May 14, 2019

  Open Peer Review Period: May 17, 2019 - Jul 12, 2019

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  Background: Wearable fitness trackers are valuable tools that can record and enhance the physical activity of users. In recent years, the addition of photoplethysmography (PPG) devices, which employs...

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  Background: Wearable fitness trackers are valuable tools that can record and enhance the physical activity of users. In recent years, the addition of photoplethysmography (PPG) devices, which employs the optical heart rate sensors that can display real-time heart rates, has become popular and is an important parameter for monitoring and controlling exercise intensity. Although studies have highlighted the practical benefits of using optical heart rate monitors, the accuracy of readouts these commercial devices generate has not been widely studied, especially for different age groups and for yellow-skin tone ethnicity. Objective: This study aimed to examine the feasibility of applying two wearable fitness trackers with PPG to monitor real-time heart rates during moderate exercises for young and older adults. Methods: A total of 20 young adults and 20 older adults were recruited to this study. All participants were asked to undergo a series of sedentary and moderate physical activities by using indoor aerobic exercise equipment. Polar H7 chest strap heart rate monitor was used as the criterion measure to the two fitness trackers, Xiaomi Mi Band 2 and Garmin Vivosmart HR+ in this study. The real-time second-by-second heart rate data from both devices were recorded through broadcast heart rate mode. To critically analyze the results, multiple statistical parameters, including the mean absolute percentage error (MAPE), Lin’s concordance correlation coefficient (CCC), intra-class correlation coefficient, Pearson’s product correlation coefficient, and Bland–Altman coefficient were determined to examine the performances of the devices. Results: Both test devices exhibited acceptable overall accuracy as heart rate sensors based on several statistical tests. Notably, the MAPE values were below 10% (the designated threshold) in both devices (GarminYoung = 3.77%; GarminSenior = 4.73%; XiaomiYoung = 7.69%; XiaomiSenior = 6.04%). The reliability test of CCC scores for Garmin was found to be 0.92 (Young) and 0.80 (Senior), whereas the CCC scores for Xiaomi were 0.76 (Young) and 0.73 (Senior). However, our results obtained using the Bland–Altman analysis indicated that both of the test optical devices averagely underestimated the heart rate. Most importantly, this study documented some unexpected extreme readings reported by these devices when used on certain paThis study revealed that commonly used optical heart rate sensors, such as Garmin vivosmart HR+ and Mi band 2 reported in the current study, generally produce accurate heart rate readings regardless of the age of the users. However, users should be cautious to rely entirely on these readings to indicate exercise intensities, as these devices have a tendency to produce erroneous extreme readings which might lead to the misjudgment of real-time exercise intensity. Future studies should, therefore, emphasize the occurrence rate of such errors, as this will likely benefit the development of improved models of heart rate sensors. rticipants. Conclusions: This study revealed that commonly used optical heart rate sensors, such as Garmin vivosmart HR+ and Mi band 2 reported in the current study, generally produce accurate heart rate readings regardless of the age of the users. However, users should be cautious to rely entirely on these readings to indicate exercise intensities, as these devices have a tendency to produce erroneous extreme readings which might lead to the misjudgment of real-time exercise intensity. Future studies should, therefore, emphasize the occurrence rate of such errors, as this will likely benefit the development of improved models of heart rate sensors.

• Sustainability of mHealth effects on cardiometabolic risk factors: 5-year results of a randomized clinical trial

  From: Journal of Medical Internet Research

  Date Submitted: May 14, 2019

  Open Peer Review Period: May 17, 2019 - Jul 12, 2019

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  Background: Long-term effect of mHealth interventions has not been documented, especially in resource-constrained settings. Objective: This study aimed at assessing the 5-year effect of a mHealth inte...

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  Background: Long-term effect of mHealth interventions has not been documented, especially in resource-constrained settings. Objective: This study aimed at assessing the 5-year effect of a mHealth intervention on blood pressure levels and bodyweight in low-resource urban settings in Peru. Methods: After 5 years from randomisation, we attempted to contact the 212 individuals originally enrolled in the GISMAL Study in Peru. Primary outcomes were changes in systolic and diastolic blood pressure; and, in addition, hypertension incidence was also evaluated. Secondary outcome measures were changes in bodyweight and body mass index, and self-reported target behaviours. Study personnel collecting data were masked to group assignment. Linear mixed models were used to evaluate the effect of the intervention in primary and secondary outcomes in an intent-to-treat analysis. Results: Data from 164 (77.4%) out of 212 participants originally enrolled were available and analysed (80 in the intervention and 84 in the control group). The intervention did not result in changes in systolic (-2.54 mm Hg; 95% CI: -8.23; 3.15) or diastolic blood pressure (3.41 mm Hg; 95% CI: -0.75; 7.57) compared with the control group. The intervention reduced the risk of developing hypertension, but result was not significant (RR = 0.76; 95% CI: 0.45; 1.28). However, among secondary outcomes, those who received the intervention had a lower bodyweight (-5.42 kg; 95% CI: -10.4; -0.48) and BMI (-2.56 kg/m2; 95% CI: -4.46; -0.66). In addition, compared to controls, those who received ≥50% of the scheduled calls during the intervention had greater reductions of bodyweight (-6.23 kg; 95% CI: -11.47; -0.99) and BMI (-2.81 kg/m2; 95% CI: -4.77; -0.85). Conclusions: An mHealth intervention comprising motivational interview calls and SMS appears to have long-term effects on health. Although there were no effects on blood pressure levels, important reductions in bodyweight and BMI were seen five years after randomisation. Thus, mHealth appears to be a promising preventive strategy for non-communicable diseases in resource-constrained settings. Clinical Trial: N/A

• Telelactation among Rural Breastfeeding Mothers: Use, Experiences, and Satisfaction

  From: Journal of Medical Internet Research

  Date Submitted: Mar 8, 2019

  Open Peer Review Period: May 17, 2019 - Jul 12, 2019

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  Background: Telelactation services connect breastfeeding mothers to remotely located lactation consultants through audio-visual technology and can increase access to professional breastfeeding support...

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  Background: Telelactation services connect breastfeeding mothers to remotely located lactation consultants through audio-visual technology and can increase access to professional breastfeeding support in rural areas. Objective: To identify maternal characteristics associated with demand for and use of telelactation and to describe visit characteristics. Methods: We conducted a descriptive study within the context of a randomized controlled trial. Participant survey data and vendor EMR data were used to assess video call characteristics including timing, duration, and topics discussed and participant satisfaction. Recruitment occurred from 2016-2018 at a rural critical access hospital in Pennsylvania. Enrolled women (n=94) were given access to unlimited, on demand video calls with lactation consultants through a mobile phone application. Results: Forty-seven (50%) participants reported participating in one or more video calls, and 31 (33%) completed one or more calls that included a substantive discussion of a breastfeeding challenge. Participants who used telelactation were more likely to be working at 12 weeks post-partum (68% vs. 41%, p=0.02), less likely to have prior breastfeeding experience (39% vs. 65%, p=0.02), and less likely to have breastfed exclusively prior to hospital discharge (52% vs. 81%, p<.01). Most video calls (70%) occurred during the infant’s first month of life, and 41% occurred outside of business hours. The most common challenges discussed included: breast pain, soreness, and infection (30% of calls), use of nipple shields (25%), latch/positioning (24%). Most telelactation users (91%) expressed satisfaction with the help received. Conclusions: Telelactation is an innovation in the delivery of professional breastfeeding support. This research documents demand for and positive experiences with telelactation in an underserved population.

• Reimbursement of Apps for Mental Health: Current Practices and Potential Pathways

  From: JMIR Mental Health

  Date Submitted: May 16, 2019

  Open Peer Review Period: May 16, 2019 - Jul 11, 2019

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  Background: While apps and other digital and mobile health (mHealth) tools are helping improve the mental health of Americans, there is not a single channel through which they can all be reimbursed. O...

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  Background: While apps and other digital and mobile health (mHealth) tools are helping improve the mental health of Americans, there is not a single channel through which they can all be reimbursed. Objective: To shed light on the state of app reimbursement, we have documented ways in which apps can be reimbursed and surveyed stakeholders to understand current reimbursement practices. Methods: Individuals from over a dozen stakeholder organizations in digital behavioral and mental health, care delivery, and managed care were interviewed. A review of Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCSPCS) codes was conducted to determine potential means for reimbursement. Results: Interviews and the review of codes revealed that potential channels for app reimbursement include direct payments by employers, healthcare providers, patients, and insurers. Insurers are additionally paying for apps using channels originally designed for devices, drugs, and laboratory tests, as well as via value-based payments and CPT and HCSPCS codes. However, in many cases, it is possible to achieve the requirements of a CPT or HCSPCS code only if an app is used in conjunction with human time and services. Conclusions: Currently, many apps face significant barriers to reimbursement. CPT codes are not a viable means of providing compensation for the use of all apps, particularly those involving little physician work. As an alternative, apps have sought clearance from FDA for prescription use as digital therapeutics; a reimbursement mechanism with unproven sustainability. There is a need for simpler reimbursement mechanisms to cover standalone app treatment interventions.

• GDPR on the Edge: Health Data Protection in an EU Candidate Country – Example of Serbia

  From: Journal of Medical Internet Research

  Date Submitted: May 9, 2019

  Open Peer Review Period: May 16, 2019 - Jul 11, 2019

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  As of May 2018, all relevant institutions in EEA member countries have to comply with the European General Data Protection Regulation (GDPR) or face significant fines. In addition to EEA countries, th...

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  As of May 2018, all relevant institutions in EEA member countries have to comply with the European General Data Protection Regulation (GDPR) or face significant fines. In addition to EEA countries, this regulation has a notable effect on EU candidate countries which are undergoing the process of harmonizing their legislature with EU, as part of their accession process. The Republic of Serbia is an example of a country which is not a member of the EU but is significantly impacted by the GDPR. Serbia’s new Personal Data Protection Act mirrors the majority of provisions given in the GDPR. We outline the context for the implementation of the new Act in Serbia, present the experiences of delivering change in health data management across the health system so far, and outline the impact on the capability of candidate countries to conduct international health data research projects. GDPR has an extraterritorial application for non-EU data controllers who process the data of the EU citizens and residents. This primarily affects Serbian private practices which target EU citizens, although some visitors also end up in the public healthcare institutions. Serbia is a popular destination for medical tourism due to low prices, quality services, and geographical proximity. There are also ex-pat visitors, dual citizens, regular tourists from EU, business visitors, and those in transit to and from member countries. Serbia generally does not have well-established procedures to support international research collaborations around data created in Serbian healthcare institutions. In simpler endeavors, arrangements can be made with institution management and their ethics committees and then secured through contracts. Even then, smaller institutions that have not previously participated in similar ventures may require approval or support from health authorities. Larger studies that involve multi-site data, typically require the support of central health system institutions such as MoH, NHIF or the National Institute of Public Health, as well as any relevant research data aggregators and EHR vendors. Lack of framework for preparation, anonymization, and assurance of privacy preservation requires the researchers to rely heavily on local expertise and support. Given the current limitation of its health and data governance systems and potential issues with the forthcoming legislation, it remains to be seen whether the move toward the GDPR will be beneficial for the Serbian health system and medical research, with respect to the protection of personal data and privacy rights and medical research capacity. Although significant progress has been made so far, direct application of implementation methods designed for more advanced health data environments can be risky but can also stimulate the community to move forward. Serbia needs a strategic approach at the country level, systematic elimination of the problems with insufficient resources in the area of data protection, and further development of a modern personal data protection regulatory and institutional environment. This can only be achieved through a targeted educational effort among health workers and decision makers, aiming to improve awareness and develop the necessary skills and knowledge in the workforce. Privacy Act; Patient Data Privacy; Data Sharing; Information Disclosure; Ethical Issues; Medical Tourists; Healthcare Systems; Privacy policies; Privacy protections; Social aspects of security and privacy

• Validation of the iHealth Track Automated Blood Pressure Display for Self-Measurement in Patients with Chronic Kidney Disease: A Descriptive Investigation

  From: JMIR mHealth and uHealth

  Date Submitted: May 13, 2019

  Open Peer Review Period: May 16, 2019 - Jul 11, 2019

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  Background: Hypertension is a global population public health issue closely related to chronic kidney disorder (CKD). In people with CKD, strict checkpoint of blood pressure (BP) is a kingpin of thera...

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  Background: Hypertension is a global population public health issue closely related to chronic kidney disorder (CKD). In people with CKD, strict checkpoint of blood pressure (BP) is a kingpin of therapy. Objective: The objective of this research was determine to validate the iHealth Track monitor for BP surveillance in CKD patients conformable by the institution of the Hypertension International in European Society following of the protocol 2010 (HI-ES2010). Methods: Thirty-three patients who received hemodialysis in Plasencia participated in the study. Nine successive records were made conformable to the HI-ES2010. We calculated the differences between the reference standard device (Omron M3 Intellisense) and the test device (iHealth Track) for BP and heart rate (HR) values. For 99 total comparisons of paired measurements, we assorted differences into various categories (≤5 mmHg, ≤10 mmHg, and ≤15 mmHg for BP; ≤3 mmHg, ≤5 mmHg, and ≤8 mmHg beats per minute for HR). Results: In 90 of 99 systolic BP and 89 of 99 diastolic BP comparisons between devices, measurement differences were within 5 mmHg. In 81 of 99 HR comparisons between devices, measurement differences were within 3 bpm. The mean differences between the test and reference standard readings were 3.27 (SD 2.99) mm Hg for systolic BP, 3.59 (SD 4.55) mm Hg for diastolic BP, and 2.18 (SD 2.75) bpm for HR. We also observed that for both systolic and diastolic BP, 31 of 33 participants had at least two of three comparisons between devices with measurement differences less than 5 mmHg. For HR, 28 of 33 individuals had at least two of three comparisons between devices with measurement differences less than 3 bpm. Conclusions: To our knowledge, this is the novel study to show that iHealth Track meets the requirements of the HI-ES2010 in CKD patients. Therfore, the iHealth Track is suitable for use in renal patients. Clinical Trial: Not Applicable

• Awareness and experiences of cosmetic treatment providers with Body Dysmorphic Disorder in Saudi Arabia: A cross-sectional study

  From: Interactive Journal of Medical Research

  Date Submitted: May 13, 2019

  Open Peer Review Period: May 16, 2019 - Jul 11, 2019

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  Background: Body Dysmorphic Disorder (BDD) is defined as, constant obsession about one’s external appearance and flaws. Which is considered a psychological disorder, were people suffering from this...

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  Background: Body Dysmorphic Disorder (BDD) is defined as, constant obsession about one’s external appearance and flaws. Which is considered a psychological disorder, were people suffering from this issue might seek help from cosmetic procedure providers. Such as dermatologists or plastic surgeons. Objective: Nowadays, there is a huge increase in cosmetic procedures done worldwide and in Saudi Arabia. Yet there are no enough studies conducted in our region to assess the awareness of BDD among physicians who provide any kind of cosmetic procedures and treatment. In regard to their attitude toward such cases, and how would they manage it. Methods: Our study is a quantitative (observational) cross sectional study, conducted among all cosmetic procedure providers, such as Dermatologist, Otorhinolaryngologists who Provide cosmetic treatments, and Plastic Surgeons. A four paged questionnaire has been distributed among physicians, in governmental hospitals and also among physicians working in cosmetic clinics. The questionnaire was a close-ended one, which had four different sections. Then data were analyzed using Statistical Package for the Social Sciences (SPSS) version 22.0. Results: Total number of participants was 155, majority were males, by a number of 113 (72.9%), while 42 (27.1%) were female. 52 (33.5%) reported being totally familiar with the clinical picture of BDD. More than half of physicians reported that they have familiar with the diagnostic criteria of BDD during their practice by a number of 82 (52.9%). A number of physicians 63 (40.6%), estimated the prevalence of BDD in cosmetic practice to range from (1%-5%). Physicians also reported BDD to be more common among females. 76 (49%) of physicians sometimes share the knowledge about BDD with their patients if they are suspecting them to have it Conclusions: Recently, cosmetic treatments are more available to everyone, which lead to an influx of undiagnosed BDD patients electing to perform unnecessary cosmetic treatments. Therefore, physicians should have the clinical knowledge about BDD, on how to diagnose and how to manage. To avoid unnecessary costly procedures.

• A tablet app supporting self-management of people with dementia: Analysis of adoption and use patterns

  From: Journal of Medical Internet Research

  Date Submitted: May 13, 2019

  Open Peer Review Period: May 16, 2019 - Jul 11, 2019

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  Background: Assistive technology (AT) is fast emerging within dementia care and support. One area of application is AT to support people with dementia in compensating for cognitive symptoms and thereb...

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  Background: Assistive technology (AT) is fast emerging within dementia care and support. One area of application is AT to support people with dementia in compensating for cognitive symptoms and thereby promote their self-management. There is, however, generally little evidence for the applicability, usability and effectiveness of AT for people with dementia and a need to identify factors that can promote adoption. Objective: The aims of this study were (1) to evaluate the applicability and usability of an app, tailormade for people with dementia, (2) to explore factors affecting adoption, (3) to explore the possible influence of caregiver involvement and (4) contribute to process evaluation of the intervention. Methods: The ReACT app had been designed as a holistic solution to support memory and structure in daily living. The person with dementia had access to a personal user-account and family caregivers were given a parallel login. Written and online materials were provided to support self-applied implementation. A mixed methods design was applied to explore adoption and use-patterns, including background and disease-related data, qualitative data from a survey and log data. Adoption was defined as use of the app over a period of 90 or more days. Results: Data from 112 participants and 98 caregivers were included. Shorter time from diagnosis (U=595 P=0.046, r=.19) and caregiver having activated the app (p=.02; FET) had a significant impact on participant adoption status. Logistic regression analysis showed that if caregivers had activated the app the participant was 5 times more likely to become an adoptor (OR 5.1; 95% CI 1.29-19.99; P=.02). The overall predictive power was however low and there was quite wide variation in background and disease-related characteristics among adoptors. Level of experience and skills in tablet-use were not significantly different between adoptors and non-adoptors. Adoptors generally rated the app high on usefulness, satisfaction, and ease of using (rated on the USEdem questionnaire). Their scores were significantly higher compared to non-adoptors (U=5.5 P=0.02, r=.64). Analysis of use-patterns showed that all functionalities of the app were used among adoptors. Conclusions: Results confirmed the applicability and usefulness of the ReACT app and self-applied methods for implementation in a mixed group of people with dementia. The study provided insight into the importance of timely introduction and caregiver support for adoption of AT among people with dementia. It also underlined the high complexity of personal and contextual factors that influence adoption. These complex factors need to be considered when designing and implementing AT for people with dementia.

• Patient Satisfaction Outcomes Following Antibiotic Resistance Education for Adults in Primary Care: A Quasi-Experimental Study

  From: Journal of Medical Internet Research

  Date Submitted: May 12, 2019

  Open Peer Review Period: May 15, 2019 - Jul 10, 2019

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  Background: Antibiotics have saved many lives since their discovery, but today, due to their overuse, are becoming less effective. A portion of provider reimbursement from Medicare and Medicaid is ba...

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  Background: Antibiotics have saved many lives since their discovery, but today, due to their overuse, are becoming less effective. A portion of provider reimbursement from Medicare and Medicaid is based on patient satisfaction. Because of the previous effectiveness of antibiotics, patients have come to expect them from their provider when being seen for bronchitis, sinusitis, otitis media, and pharyngitis. Evidence suggests that educating patients, utilizing shared decision-making strategies, and communicating the reason for or against antibiotic prescriptions can produce positive outcomes when treating upper respiratory infections. Objective: The purpose of this evidence-based quality initiative which employs a quasi-experimental pre- and post- design is to determine if patient education and shared decision-making with regards to pharmacologic treatment for adults with upper respiratory infections will increase patient satisfaction in a primary care clinic setting in urban Kansas. Methods: Antibiotic resistance education was provided to 64 participants who are over the age of 18 and present to the clinic with upper respiratory complaints. Patient satisfaction will be measured with the Consumer Assessment of Healthcare Providers and Systems survey and compared to results from 61 participants who were treated for upper respiratory complaints prior to implementation of the standardized educational intervention. Results: Evidence suggests the two groups were not comparable (p=0.02). The evidence-based quality improvement initiative proved successful at increasing patient satisfaction in two areas, the antibiotic resistance education was recommended to the clinic for adoption as standard of care for patients with upper respiratory complaints. Conclusions: The EBQI has potential to decrease inappropriate antibiotic use and improve healthcare consumer satisfaction at the local level. A similar model of education and shared decision-making could be applied to other clinical problems in the future.

• Development of “My Retainers” mobile application: Triangulation of two qualitative methods

  From: Journal of Medical Internet Research

  Date Submitted: May 12, 2019

  Open Peer Review Period: May 15, 2019 - Jul 10, 2019

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  Background: Diligent wear of removable orthodontic retainers requires prolonged compliance and is invariably necessary to preserve optimal results. Patient-informed behaviour-change interventions repr...

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  Background: Diligent wear of removable orthodontic retainers requires prolonged compliance and is invariably necessary to preserve optimal results. Patient-informed behaviour-change interventions represent a promising and novel means of enhancing compliance with retainer wear. Objective: To describe the development of a patient-informed mobile application aimed to enhance retainer wear. Methods: Four aspects were considered during mobile application development: participant preferences; analysis of publicly-available retainer-related posts on Twitter; available interventions; and behaviour-change theories. Audio-recorded one-to-one interviews were conducted with a subset of participants to account for patient preferences in terms of features, design and content. A criterion-based purposive sample of participants wearing vacuum-formed retainers for at least 4 years was used. Thematic analysis of transcribed data was undertaken. Results: The need to facilitate communication with the treating clinician, responsive reminder and tracking systems, and access to useful and engaging written and visual information, in addition to other personalised and interactive features were considered important. Concerns related to retainer wear shared on Twitter informed an exhaustive list of frequently-asked questions. Application features were mapped to relevant theoretical constructs. Determinants of existing behavioural change theories were used to link application features to expected outcomes. Conclusions: A holistic process involving both patient and professional input can be useful in informing the development of mobile applications. The orthodontic application (“My Retainers”) will undergo further scrutiny in relation to its effectiveness in inducing behavioural change and concerning patient experiences prior to finalisation.

• Patient Perspectives on Usefulness of an Artificial Intelligence Assisted Symptom-Checker: A Cross-Sectional Survey Study

  From: Journal of Medical Internet Research

  Date Submitted: May 12, 2019

  Open Peer Review Period: May 15, 2019 - Jul 10, 2019

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  Background: Patients increasingly seek online symptom-checkers to obtain diagnoses. Little is known, however, about characteristics of patients who use these resources, their rationale for use, and wh...

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  Background: Patients increasingly seek online symptom-checkers to obtain diagnoses. Little is known, however, about characteristics of patients who use these resources, their rationale for use, and whether patients find them accurate and useful. Objective: To examine patients’ experiences using an artificial intelligence (AI) assisted online symptom-checker. Methods: An online survey was administered to US users of Isabel Symptom Checker within 6 months of their use and occurring from March 2, 2018 through March 15, 2018. User characteristics, experiences of symptom-checker use, experiences discussing results with physicians, and prior personal history of experiencing a diagnostic error were collected. Results: 329 usable/complete responses were obtained. Mean respondent age was 48.0 years (SD=16.7); most were women (n=230;75.7%) and white/Caucasian (n=271;89.1%). Patients used the symptom-checker to better understand their symptoms’ causes (n=232;76.3%), decide whether to seek care (n=101;33.2%) or where (e.g., primary or urgent care; n=63;20.7%), get medical advice without going to a doctor (n=48;15.8%), or better understand their diagnosis (n=39;12.8%). Most reported receiving useful information for their health problems (n=274;83.3%), with half reporting positive health effects (n=154;50.9%). Most perceived it to be useful as a diagnostic tool (n=253;76.9%), as providing insights leading them closer to correct diagnoses (n=231;70.2%), and reported they would use it again (n=278;84.5%). Patients who discussed findings with their physicians (n=103) sometimes felt physicians were disinterested (n=24;23.3%) and not open to discussing the tool’s results (n=21;20.4%). Patients who previously experienced diagnostic errors (missed or delayed diagnoses; n=181;55.0%) were more likely to use the symptom-checker to determine if they should seek care (26.5% vs 12.2%;p=.002), but more often felt physicians were disinterested in discussing the tool’s results (30.4% vs 8.8%;p=.04) than patients who had not previously experienced diagnostic errors. Conclusions: Despite ongoing concerns about symptom-checker accuracy, a large patient-user group perceived an AI assisted symptom-checker as useful for diagnosis. Formal validation studies evaluating symptom-checker accuracy and effectiveness in real-world practice could provide additional useful information about their benefit.

• The Role of Psychological Factors in Older Adults’ Readiness to Use eHealth Technology: Cross-Sectional Questionnaire Study

  From: Journal of Medical Internet Research

  Date Submitted: May 9, 2019

  Open Peer Review Period: May 13, 2019 - Jul 8, 2019

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  Background: Information and communication technology (ICT) use among older adults has been on the rise in recent years. However, the predictors and mechanisms behind older adults’ acceptance and use...

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  Background: Information and communication technology (ICT) use among older adults has been on the rise in recent years. However, the predictors and mechanisms behind older adults’ acceptance and use of ICT are not clear. Objective: The aim of the present study was to systematically describe ICT usage among Czech older adults and to evaluate the factors influencing their ICT use and readiness to use digital technology to promote health (eHealth readiness). The primary focus was on psychological factors and the role of older adults’ close persons. Methods: The research utilized cross-sectional survey data from a quota-based sample of Czech older adults (50+) and their close persons (N = 250 dyads). Structural equation modelling framework was used to evaluate relationships between psychological factors, ICT use and eHealth readiness. Results: Czech older adults’ use of ICT is low with the exception of cell phone usage (cell phone usage at 69.2%, other devices used by 20% of older adults or less). Apart from age (β = -.21, P < .001), eHealth readiness was predicted by ICT use (β = .65, P < .001). eHealth readiness was also indirectly affected by need for cognitive closure: individuals with a high need for closure perceived more barriers to ICT (β = .23, P = .013) and more reported barriers were linked to lower ICT usage (β = -.21, P = .001). The expected positive relationships between eHealth readiness of close persons and ICT use and eHealth readiness of older adults were not significant, but the total effect of eHealth readiness of close persons on eHealth readiness of older adults was positive and significant (β = .18, P = .015), indicating some level of influence of close persons on older adults’ attitudes and/or behaviors. Conclusions: The present study provided the first systematic examination of Czech older adults’ ICT usage and eHealth readiness. Novel predictors (need for cognitive closure and close persons’ variables) were evaluated and yielded actionable results. More research is needed to clarify the role of older adults’ close persons.

• Developing a Reproducible Microbiome Data Analysis Pipeline Using the Amazon Web Services Cloud for a Cancer Research Group

  From: JMIR Medical Informatics

  Date Submitted: May 9, 2019

  Open Peer Review Period: May 13, 2019 - Jul 8, 2019

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  Background: Cloud computing for microbiome data sets can significantly increase the working efficiencies and expedite the translation of research findings into clinical practice. Amazon Web Services (...

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  Background: Cloud computing for microbiome data sets can significantly increase the working efficiencies and expedite the translation of research findings into clinical practice. Amazon Web Services (AWS) cloud provides an invaluable option for microbiome data storage, computation, and analysis. Objective: The purpose of this study was to develop a microbiome data analysis pipeline by using AWS cloud and conduct a proof-of-concept test for microbiome data storage, processing, and analysis. Methods: A multidisciplinary team was formed to develop and test a reproducible microbiome data analysis pipeline with multiple AWS cloud services that can be used for storage, computation, and data analysis. The microbiome data analysis pipeline developed in AWS was tested by using two data sets: 19 vaginal microbiome samples and 50 gut microbiome samples. Results: Using AWS features, we developed a microbiome data analysis pipeline that included Amazon Simple Storage Service (S3) for microbiome sequence storage, Linux Elastic Compute Cloud (EC2) instances (i.e., servers) for data computation and analysis, and security keys to create and manage the use of encryption for the pipeline. Bioinformatics and statistical tools (i.e., QIIME 2 and RStudio) were installed within Linux EC2 instances to run microbiome statistical analysis. The microbiome data analysis pipeline was performed through command-line interfaces within the Linux operating system or in Mac OS™ systems. Using this new pipeline, we were able to successfully process and analyze 50 gut microbiome samples within 4 hours at a very low cost. Gut microbiome findings regarding diversity, taxonomy, and abundance analyses were easily shared within our research team. Conclusions: Building a microbiome data analysis pipeline with AWS cloud is feasible. This pipeline is highly reliable, computationally powerful, and cost effective. Our AWS-based microbiome analysis pipeline (MAP-AWS) provides an efficient tool to conduct microbiome data analysis. Clinical Trial: NA

• NIH Grants Proposing Specialized Smartphone Intervention Apps: 2014 to 2018

  From: JMIR mHealth and uHealth

  Date Submitted: May 8, 2019

  Open Peer Review Period: May 13, 2019 - Jul 8, 2019

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  Background: The widespread adoption of mobile and smartphones provides researchers with expanded opportunities for implementing behavioral and health-related interventions. The National Institutes of...

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  Background: The widespread adoption of mobile and smartphones provides researchers with expanded opportunities for implementing behavioral and health-related interventions. The National Institutes of Health (NIH) funds competitive technology-based grant applications to support health promotion consistent with its mission. Funded grants represent the state-of-the-art science and therefore are expected to anticipate the progression of health promotion and disease prevention research in the near future. Objective: The objective of this paper is to examine the different kinds of smartphone-based intervention apps funded through NIH Institutes during the five-year period between 2014 and 2018. Methods: We queried the public domain NIH Reporter to identify candidate grants that addressed mHealth and involved implementation of smartphone applications. From 1,524 potential grants, we identified 399 that met the requisite of including an intervention app. Grants from 20 Institutes under the NIH umbrella were included. Each grant’s abstract was analyzed to understand the rationale behind the app and focus of intervention, in addition year of funding, and first-year award amount, type of activity (e.g. R01, R34, etc.), specific strategy, intended outcome, and target population were also noted. Results: We identified 13 categories of strategies employed in the different intervention apps. Most grants included either one (36.6%) or two (37.8%) intervention approaches. These included cognitive and behavioral therapies (67 apps), enhanced motivation (49 apps), mindfulness training (17 apps), norm setting (7 apps), skills training (84 apps), gaming and gamification (56 apps), social support and social networking (58 apps), facilitating, reminding and referring (60 apps), education and information (84 apps), monitoring and feedback (191 apps), contingency management (23 apps), artificial intelligence (57 apps), and bionic adaptation (33 apps). The most frequently observed grant types included SBIR/STTR grants (40.9%) and R01s (26.1%). The number of grants funded increase through the five-year period from 60 in 2014 to 112 in 2018. Conclusions: Smartphone intervention apps are increasingly competitive for NIH funding. They utilize a wide diversity of intervention strategies and substantive foci that collectively have significant potential for use in applied health promotion settings.

• Developing SMS content to promote Pap triage: a qualitative exploration

  From: Journal of Medical Internet Research

  Date Submitted: May 8, 2019

  Open Peer Review Period: May 13, 2019 - Jul 8, 2019

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  Background: SMS interventions are effective in promoting a variety of health behaviors; however, there is scarce information regarding SMS use for cervical cancer screening and follow-up care. The ATI...

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  Background: SMS interventions are effective in promoting a variety of health behaviors; however, there is scarce information regarding SMS use for cervical cancer screening and follow-up care. The ATICA Study (Application of Communication and Information Technologies to Self-Collection, for its initials in Spanish) aims to evaluate a multi-component mHealth intervention to increase triage adherence among women with HPV+ self-collected tests in Jujuy, Argentina. Here, we describe the formative results used to design the content of the SMS to be tested in the trial. Objective: To understand cultural and contextual elements, women’s beliefs and perceptions regarding the use of SMS from the health care system, and women’s preferences about the message content. Methods: We conducted six focus groups, stratified by rural/urban residence and age. All participants were aged 30 or older and had performed HPV self-collection. Participatory techniques, including brainstorming, card-based classification and discussions were used to debate the advantages and disadvantages of messages. We openly coded the discussions for agreements and preferences regarding SMS content. Results: Forty-eight women participated in the FG. Participants viewed the use of SMS for notifying test result availability positively; however, the delivery of HPV results via SMS was deemed negative. Feedback on message content indicated it should strengthen communication between patients and the health care professionals, use a formal yet warm tone, and not include details regarding HPV results. Participants preferred messages addressed to recipients individually, which sacrifices confidentiality, but is crucial when cellphones are used by multiple family members. Conclusions: Results suggest SMS is accepted when notifying women about HPV result availability, but it should not replace face-to-face, doctor-patient encounters. Messages must be tailored and have a persuasive tone in order to motivate women to act on the information and adhere to triage. Clinical Trial: ClinicalTrials.gov, NCT03478397. Registered on March 20th, 2018.

• Transformation of the German Health Care System – Perception of the Progressing Digitization among Experts and the Public: A Mixed Method Study

  From: Journal of Medical Internet Research

  Date Submitted: May 12, 2019

  Open Peer Review Period: May 13, 2019 - Jul 8, 2019

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  Background: Health care systems worldwide are struggling to keep rising costs at bay with only modest outcome improvement among many diseases. Digitization with technologies like Artificial Intelligen...

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  Background: Health care systems worldwide are struggling to keep rising costs at bay with only modest outcome improvement among many diseases. Digitization with technologies like Artificial Intelligence or Machine Learning algorithms might address this. Although digital technologies have been successfully applied in clinical studies the effect on the overall health care system so far was limited. The regulatory ecosystem or data privacy might be responsible, but other reasons may also predominate. Objective: We analyzed how the digitization of the German health care market is currently perceived among different stakeholders and investigated reasons for its slow adaption. Methods: A Mixed Method study split into a qualitative Part A using the conceptual approach of the Grounded Theory and a quantitative Part B using the Delphi method was conducted. For Part A we interviewed experts in the health care system and converted the results into 17 hypotheses. The Delphi method consisted of an online survey, which was sent to the participants via e-mail and was available for three months. For the assessment of the 17 hypotheses, the participants were given a six-point Likert scale. The participants were grouped into patients, physicians, and providers of services within the German health care market. Results: There was a strong alignment of the hypotheses between experts (N=21) and survey participants together (N=733) with overall 70.5% agreement on 12 out of the 17 hypotheses. Physicians demonstrated the lowest level of agreement with the expert panel in 88% (15/17). Especially the hypotheses “H8: Digitization in the health care system will free up jobs” and “H6: Digitization in the health care system will empower the patients” were perceived to be in profound disagreement between physicians and the experts (P < .05 and P < .001, respectively). Conclusions: Despite the firm agreement among participants and experts regarding the impact of the digitization on the health care system, especially physicians demonstrated a more negative attitude. We assume that this might be a factor contributing to the slow adoption of digitization in practice. Physicians might struggle with changing power structures and therefore future measures to transform the market should involve them to a larger degree.

• An Effective Social Media Platform to Promote Hospital Branding

  From: Journal of Medical Internet Research

  Date Submitted: May 3, 2019

  Open Peer Review Period: May 11, 2019 - Jul 6, 2019

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  Background: Optimizing the use of social media to promote hospital branding is an important issue in the present digital era. In Taiwan only 51.1% of the hospitals have official FB fan pages. The numb...

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  Background: Optimizing the use of social media to promote hospital branding is an important issue in the present digital era. In Taiwan only 51.1% of the hospitals have official FB fan pages. The numbers of “likes” of these hospitals were also generally relatively low. Objective: The aim was to establish a special team for the purposes of promoting hospital branding in digital era. . Methods: A branding team, led by top administrators, was formed with 11 divisions to establish branding strategies. Furthermore, from August 2016 to 2018, the team implemented several action plans. Results: Compared with 2016, the numbers of “Likes” posted on FB fans page increased 61.2% in 2017, and 116.2% in 2018. Similarly, online visits to the hospital website increased 4.8% in 2017, and 33.1% in 2018. FB fans and website viewers were mainly within the age groups of 25 to 34 years and 35 to 44 years. Women constituted 60% of FB fans and website viewers. According to the FB insights-report, both numbers of posts of “Like” and post sharing increased in 2017 and 2018. Comment messages also grew from 2016 to 2018 (P=.018, for the trend). The most common type of posts varied over time: i.e., from media reports in 2016 to service convenience in both 2017 and 2018. “Like” in service convenience jumped from 2016 through 2018 (P=.045, for the trend). A total of 23,436 cumulative counts of “Likes” for postscripts was recorded at the end of 2018. This was the highest count recorded across all medical centers in Taiwan. Conclusions: Led by top administrators, our branding team had successfully implemented several strategies, which resulted in winning most popular number of FB fans among all hospitals of Taiwan. In this digital era, such strategy can help promoting the reputation of medical institute.

• Effectiveness of PUSH notifications from a mobile app for improving the body composition of overweight or obese women: Randomized Controlled Trial.

  From: JMIR mHealth and uHealth

  Date Submitted: May 10, 2019

  Open Peer Review Period: May 10, 2019 - Jul 5, 2019

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  Background: Technology and in particular, access to the Internet, from a mobile device, has forever changed the way we relate and execute our own behavior. In recent years, studies have been carried o...

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  Background: Technology and in particular, access to the Internet, from a mobile device, has forever changed the way we relate and execute our own behavior. In recent years, studies have been carried out to analyze the effectiveness of different actions via smarthpone in the field of health, telephone calls, SMS, telemedicine and, more recently, the use of PUSH notifications. We continue to explore ways to increase user interaction with mobile applications, one of the pending subjects in the field of mHealth. By analyzing the data that subjects produce during a clinical trial, we can extract patterns of behavior and design effective protocols in weight loss programs. Objective: For all of the above, a clinical trial is proposed to evaluate (1) the efficacy of PUSH notifications in an intervention aimed at improving the body composition of adult women who are overweight or obese, through a dietary intervention, (2) analyze the evolution of body composition based on PUSH notifications and prescribed physical activity. Methods: A randomized clinical trial of 3 groups was conducted. All received the same attention in face-to-face consultation, with a frequency of 30 minutes per week, for 6 months. All patients are fitted with an APP designed for this study and a pedometer. The control group does not have access to functionalities related to self-control of weight at home or gamification or prescription of physical activity. The intervention groups are assigned objectives to achieve in the degree of compliance with diet and physical activity, through exclusive access to specific functionalities of the APP. For the analysis of three or more means the ANOVA of repeated means was used to evaluate the effects of the intervention at baseline, at 3 and at 6 months. Results: Receiving notifications during the intervention increase the weight that is lost (ßestand. = -0.208) and helps maintain or gain muscle mass (ßestand. = 0.266). However, the most important impact is observed on body fat, increasing its loss to a large degree (ßestand. = -0.397). Conclusions: Based on these results, it is possible to conclude the positive effects of PUSH technology on mHealth interventions. Future interventions should extend the period of time of the tests and research the impact that different contents of the messages, times and frequencies of sending them have. Clinical Trial: ClinicalTrials.gov registration identifier NCT03911583

• Quality Evaluation of a Mobile Application as a Learning Aid for Nurses and Students to identify and Care for Stroke Patients

  From: Journal of Medical Internet Research

  Date Submitted: May 7, 2019

  Open Peer Review Period: May 10, 2019 - Jul 5, 2019

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  Background: Around the world there is a growing expansion in m-health due to the ease of access to mobile phones and broadband internet. The field of nursing care of the patient with stroke has prove...

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  Background: Around the world there is a growing expansion in m-health due to the ease of access to mobile phones and broadband internet. The field of nursing care of the patient with stroke has proven to be receptive to this technological evolution, both for the identification of risk factors in the population, as well as in the training and certification of professionals in the nursing care of stroke patients. In this way, nurses participate not only as developers of technologies for care, but also with scientific validation, with results of support to health services and training. Objective: To evaluate the efficacy of a mobile application as a learning aid for nurses and nursing students to identify and care for stroke patients in a region of southern Brazil. Methods: A study on the development and technological evaluation of the instructional design stages of an application was conducted for the period from July to November 2017 in a region of southern Brazil. This involved two clinical cases according to Problem Based Learning and Persuasive Technology. The quality evaluation was based on the Learning Object Review Instrument (LORI®). The resulting data were processed and analyzed using the R® programming language version 3.4.3. We used descriptive statistics (mean, median, minimum value, maximum value, and standard deviation) to compare both groups and a non-parametric test with a 5% significance level. Results: The mean of the variables was high (described as "very good"). The variables including content quality, learning goal alignment, motivation, feedback, and adaptation were notable with averages ranging from 4.91 (± 0.28) to 4.97 (± 0.16). Statistical analyses demonstrated that there was agreement between the nurse and student groups for the variables motivation (0.012), presentation design (0.019), re-usability (0.18) and standards compliance (0.45). Conclusions: It was determined that the mSmartAVC application satisfies international quality certification criteria and improves the decision-making and clinical evaluation of nurses and students.

• Development of a Smartphone App for Measuring Striking Response Time in Combat Sports: A Cross-Sectional Validation Study

  From: JMIR mHealth and uHealth

  Date Submitted: May 7, 2019

  Open Peer Review Period: May 10, 2019 - Jul 5, 2019

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  Background: The TReaction app purposes to determine strike response time with a low cost and easy application in combat sports. However, there is a need to verify the validity and accuracy of the resp...

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  Background: The TReaction app purposes to determine strike response time with a low cost and easy application in combat sports. However, there is a need to verify the validity and accuracy of the response time obtained by the TReaction app. Objective: To test the validity and reliability of the TReaction app in measuring the motor response time in combat sports. Methods: Two athletes performed 59 strikes to assess the response time from visual stimulus using the TReaction app simultaneously with a high speed camera. Accuracy of the measure was verified using a simulator programmed to discharge visual stimuli and obtain the response time. Person correlation, Student t test for dependent samples, and the Bland-Altman analysis were established. The accuracy was verified by the intraclass correlation coefficient (ICC). The Effect size (g) and the typical error of measurement (TEM) were calculated. The significance level was set at p<0.05. Results: No significant difference (p=0.556) was found between both systems. The methods presented a very strong correlation (r=0.993). A magnitude of the differences was trivial (g<0.25) and the TEM was 1.4%. These findings indicate the accuracy of the measures of changing computer screen and the smartphone flash to determine the beginning of the task, as well as the response time. Conclusions: Thus, our findings suggest that the TReaction app is valid to evaluate the response time in combat sports athletes.

• UBESAFE: prevention of HIV and others STI by geofencing and contextualized messages with a gamified App

  From: JMIR mHealth and uHealth

  Date Submitted: May 7, 2019

  Open Peer Review Period: May 10, 2019 - Jul 5, 2019

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  Background: Advances in the development of information and communication technologies have facilitated social and sexual interrelationships thanks to websites and Apps created to this end. However, th...

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  Background: Advances in the development of information and communication technologies have facilitated social and sexual interrelationships thanks to websites and Apps created to this end. However, these resources can also encourage sexual contacts without appropriate preventive measures in relation to HIV and other sexually transmitted infections (STI). How can users be helped to benefit from the advantages of these Apps while keeping in mind those preventive measures? Objective: To prevent STI by helping users to remember preventive measures in the risky situations. Methods: We have used the design and creation methodology and have developed a software system. This system has two parts: an Android OS application with emphasis on ubiquitous computing and gamification, as well as a server with a web page. First, a functional test with 5 men who have sex with men (MSM) allowed us to test the App with end-users. Also, a feasibility test with 4 MSM for a month allowed us to try the UBESAFE system with all its functionalities. Results: The main result is a system called UBESAFE that is addressed to MSM. The system has two main parts: 1) an App that sends preventive contextualized messages to users when: they use a contact application, or when they are near a point where sexual contacts are likely; and 2) a server part that was managed by the public health agency of Barcelona (ASPB), which preserves quality and pertinence of messages and places and offers instant help to users. To increase users’ adherence, UBESAFE uses a gamified system to engage users in the creation of preventive messages. Users increased the initial pool of messages and hot zones by more than 100% and 56.25% respectively. Conclusions: The system helped MSM who used it to become conscious about HIV and other STI. On the other hand, the system helped the ASPB to stay in contact with MSM and to detect behaviors that could benefit from preventive measures. All this has been done in a non-intrusive way since users used the App privately. Furthermore, the system has shown how important it is to make the users part of the creation process, as well as to develop Apps that work by themselves, i.e. that become useful to users.

• “Asking too much?”: A randomised N-of-1 trial exploring patient preferences and measurement reactivity to frequent use of remote multi-dimensional pain assessments in children and young people with Juvenile Idiopathic Arthritis

  From: Journal of Medical Internet Research

  Date Submitted: May 7, 2019

  Open Peer Review Period: May 10, 2019 - Jul 5, 2019

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  Background: Remote monitoring of pain using multi-dimensional mobile health (mHealth) assessment tools is increasingly being adopted into paediatric pain studies and in clinical pain care. This assess...

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  Background: Remote monitoring of pain using multi-dimensional mobile health (mHealth) assessment tools is increasingly being adopted into paediatric pain studies and in clinical pain care. This assessment method is valuable because it is challenging to comprehensively capture pain histories, particularly in children and young people with complex diseases where pain can be multisite and relapsing-remitting, such as Juvenile Idiopathic Arthritis [JIA]. With the growth of mHealth measures and more frequent assessment, it is important to explore patient preferences for the timing and frequency of administration of such tools, as well as consider whether certain administrative patterns can directly impact upon children’s pain experiences. Objective: To explore the feasibility and influence (in terms of objective and subjective measurement reactivity) of several time-sampling strategies in remote multi-dimensional pain reporting using My Pain Tracker (MPT) with children and young people with JIA. Methods: An N-of-1 trial was conducted in a subset of children and young people with JIA and their parents recruited to a UK cohort study, The Childhood Arthritis Prospective Study. Children were allocated to one of four groups. Each group followed a different schedule of completion of MPT for eight consecutive weeks. Each schedule included two blocks, each comprising four different randomised time-sampling strategies, with each strategy occurring once within each four week block. Children completed MPT according to time-sampling strategies; once-a-day, twice-a-day, once-a-week and as-and-when pain was experienced. Adherence to each strategy was calculated. Participants completed The PROMIS Pain Interference Scale at the end of each week to assess objective reactivity. Differences in pain interference scores between time-sampling strategies were assessed graphically and using Friedman tests. Participants took part in a semi-structured interview about their preferences for different time-sampling strategies and to explore subjective reactivity. Results: Fourteen children and young people (7-16 years) and their parents participated. Adherence to pain reporting was higher in less intense (once-a-week=62.5%) compared to more intense time-sampling strategies (twice-a-day=37.8%). There were no statistically significant differences in pain interference scores between sampling strategies. Qualitative findings from interviews suggested that children preferred once-a-day (42.9%) and as-and-when pain reporting (42.9%). Creating routine was one of the most important factors for successful reporting, whilst still ensuring that comprehensive information about recent pain was captured. Some children reported perceived changes in mood and fatigue in response to intense reporting. Conclusions: Important issues for the design of studies and care incorporating momentary assessment techniques were identified. We demonstrate that patient reporting preferences are key to accommodate and are important for research and care where long-term engagement with tools and data capture quality is key. Our findings support regular and frequent administration of such tools to capture pain patterns in children and young people with JIA, using daily reporting methods where possible.

• Sources of Health Information and Their Impact on Medical Knowledge Perception Among Saudi Population

  From: Journal of Medical Internet Research

  Date Submitted: May 7, 2019

  Open Peer Review Period: May 10, 2019 - Jul 5, 2019

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  Background: Having a reliable source for health information is critical to build a strong foundation of knowledge, especially with the current revolution of the internet and social media, which raises...

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  Background: Having a reliable source for health information is critical to build a strong foundation of knowledge, especially with the current revolution of the internet and social media, which raises many concerns of harmful effects on public health. There are no studies of how Saudi population seeks health information. Familiarity with the mostly used and trusted sources of health information among the public will help health authorities and public awareness accounts to disseminate health information accurately. Objective: This study aimed to investigate the different sources of health information that are used and trusted by the Saudi population and to assess the impact of these sources on their perception of medical knowledge and health decision-making. Methods: A cross-sectional study was conducted to meet the objectives. Four hundred and thirteen participants were sampled using the simple random method. Data were collected from both males and females older than 16 years who were attending primary care clinics at King Khalid University Hospital using a self-administered questionnaire. The data were analyzed using the SPSS software (IBM Corp., Armonk, NY, USA) and the single proportion test. Results: A total of 413 participants were included in this study; 24% of them were males and 49.9% had a bachelor’s degree. Doctors were chosen as the first source of information by 87.6% of the participants and they were completely trusted by most of the population (79.3%). The second most commonly used source was pharmacists (57.7%) and they were partially trusted by 65% of the participants. Internet searches, social media, and traditional medicine were not prioritized by most of the participants as the first nor second source of health information. The majority of the participants did not trust information obtained from social media, and WhatsApp was the most untrusted source by the study participants. Generally, almost half of the respondents (47.7%) acknowledged that various sources of information can often help them understand their health problems. Moreover, the majority of respondents (59.4%) did not doubt a doctor’s information due to the impact of other sources. Conclusions: Among the diverse sources, doctors were the most used and trusted source of health information. Although social media was less commonly used as a source of health information, some people, mainly males, trust the provided health information. This provides an insight into the level of accuracy and reliability of health information obtained from several sources by the Saudi population.

• Building a Medical Education Outcomes Center

  From: JMIR Medical Education

  Date Submitted: May 8, 2019

  Open Peer Review Period: May 10, 2019 - Jul 5, 2019

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  Background: Medical education and clinical data exist in multiple unconnected databases, resulting in three problems: 1) it is difficult to connect learner outcomes with patient outcomes; 2) learners...

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  Background: Medical education and clinical data exist in multiple unconnected databases, resulting in three problems: 1) it is difficult to connect learner outcomes with patient outcomes; 2) learners cannot be easily tracked over time through the education-training-practice continuum; 3) no standard methodology ensures quality and privacy of the data. Objective: The purpose of this project was to develop a Medical Education Outcomes Center (MEOC) to integrate education data and to build a framework to standardize the intake and processing of requests for using these data. Methods: An inventory of over 100 data sources owned or utilized by the medical school was conducted, and nearly two dozen of these data sources have been vetted and integrated into MEOC. In addition, American Medical Association (AMA) Physician Masterfile data of University of Minnesota Medical School (UMMS) graduates were linked to data from the National Provider Identifier (NPI) registry, to develop a mechanism to connect alumni practice data to education data. Results: Over 160 data requests have been fulfilled culminating in a range of outcomes analyses, including support of accreditation efforts. MEOC received data on 13,092 UMMS graduates in the AMA Physician Masterfile and could link 10,443 with NPI numbers and began to explore their practice demographics. Technical and operational work to expand MEOC continues. Next steps are to link educational data to clinical practice data through NPI numbers in order to assess the effectiveness of our medical education programs by the clinical outcomes of our graduates. Conclusions: MEOC provides a replicable framework to allow other schools to more effectively operate their programs and drive innovation. Clinical Trial: NA

• A Qualitative Study on Participants’ Experiences with a Community-based Mindful Walking Pilot Intervention Using Mobile Device Measurement

  From: JMIR Mental Health

  Date Submitted: May 6, 2019

  Open Peer Review Period: May 9, 2019 - Jul 4, 2019

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  Background: Wearable mobile devices have been increasingly used to measure outcomes of mindfulness interventions. Objective: This study documents participants’ experiences with a mindful walking (MW...

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  Background: Wearable mobile devices have been increasingly used to measure outcomes of mindfulness interventions. Objective: This study documents participants’ experiences with a mindful walking (MW) intervention and their experiences with reporting daily step counts using a mobile device. Methods: The pilot study involved a randomized MW intervention including 38 participants with inadequate physical activity. All participants were provided with a mobile device (“Fitbit”) to measure and report physical activity. The intervention group received a four-week MW intervention. All participants reported their experiences with Fitbit in responses to open-ended survey questions; those in the intervention group reported their experiences with MW. We used a qualitative thematic analysis of this survey-collected narrative dataset. Results: Participants’ reported experiences using the Fitbit device were mostly positive, with a majority of participants (63%) providing feedback that using the device was “enjoyable” and “helpful”. The common negative experience, reported by 16% of participants, was that the Fitbit was “uncomfortable to wear”. Perceived benefits of using the device included raising awareness about participants’ physical activity level and providing motivation to reach fitness goals. Participant feedback about the MW arm of the intervention included positive reports of benefits such as, “helping to focus on the present”, “coping with stressful emotions”, and negative feedback related to lacking the patience or ability to engage in meditation. Conclusions: Most participants reported step count data, demonstrating the feasibility of a mobile-device-assisted MW intervention. While most of the feedback about MW and the device was positive, some reported discomfort with wearing the device and lack of patience with meditation. These barriers should be addressed in future mobile health and mindfulness interventions. Clinical Trial: ClinicalTrials.gov NCT03856385, http://clinicaltrials.gov/ct2/show/ NCT03856385

• Issues Impacting Continuous Pulse Oximetry Monitoring and Wireless Clinical Notification System After Surgery

  From: JMIR Medical Informatics

  Date Submitted: May 6, 2019

  Open Peer Review Period: May 9, 2019 - Jul 4, 2019

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  Background: Background: Research has shown that introducing eHealth patient monitoring interventions can improve healthcare efficiency and clinical outcomes. VIGILANCE (The VItal siGns monItoring with...

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  Background: Background: Research has shown that introducing eHealth patient monitoring interventions can improve healthcare efficiency and clinical outcomes. VIGILANCE (The VItal siGns monItoring with continuous puLse oximetry And wireless cliNiCal notification aftEr surgery) was a randomized controlled trial (n=2049) designed to assess the impact of continuous vital sign monitoring with alerts to nursing staff on the incidence of respiratory resuscitations with naloxone, code blues, and intensive care unit transfers in a cohort of post-surgical patients in a ward setting. This report identifies and evaluates key issues and challenges associated with introducing wireless monitoring systems into complex hospital infrastructure during the VIGILANCE eHealth intervention implementation. Potential solutions and suggestions for future implementation research are presented. Objective: Objectives: (1) to identify issues related to deployment of the eHealth intervention system of the VIGILANCE study, and (2) to evaluate the influence of these issues on intervention adoption. Methods: Methods: During the VIGILANCE study, issues affecting the implementation of the eHealth intervention were documented on case report forms, alarm event forms, and a nursing user feedback questionnaire. These data were collated by the research and nursing personnel and submitted to the research coordinator. In this evaluation report, the clinical adoption framework was used as a guide to organize the identified issues and evaluate their impact. Results: Results: Using the clinical adoption framework, we identified issues within the framework dimensions of ‘people’, ‘organization’ and ‘implementation’ at the meso level, as well as standards and funding issues at the macro level. Key issues included: nursing workflow changes, patient withdrawal, wireless network connectivity, false alarms, monitor malfunction, probe issues, and wireless network standards. At the micro level, these issues affected the quality of the service in terms of support provided, the quality of the information yielded by the monitors, and the functionality, reliability and performance of the monitoring system. As a result, these issues impacted ‘access’ through decreased ability of nurses to make complete use of the monitors; ‘care quality’ of the trial intervention through decreased effectiveness; and ‘productivity’ through interference in the coordination of care, and thus decreased clinical adoption of the monitoring system. Conclusions: Conclusion: Patient monitoring with eHealth technology in surgical wards has the potential to improve patient outcomes. However, proper planning that includes engagement of front-line nurses, installation of appropriate wireless network infrastructure, and use of comfortable cableless devices are required to maximize the potential of eHealth monitoring.

• Patterns of sedentary time and quality of life in women with fibromyalgia: a cross-sectional study from the al-Ándalus project.

  From: JMIR mHealth and uHealth

  Date Submitted: May 6, 2019

  Open Peer Review Period: May 9, 2019 - Jul 4, 2019

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  Background: Sedentary time (ST) has been detrimentally associated with health outcomes in fibromyalgia. Previous evidence in general population showed that not only the total amount of ST but also the...

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  Background: Sedentary time (ST) has been detrimentally associated with health outcomes in fibromyalgia. Previous evidence in general population showed that not only the total amount of ST but also the pattern of accumulation of sedentary behaviors is relevant to health, being prolonged, unbroken periods (i.e. bouts) particularly harmful. Objective: To examine the association of the patterns of ST with health-related quality of life (HRQoL) in women with fibromyalgia, and to test if these associations are independent of moderate-to-vigorous physical activity (MVPA). Methods: Four-hundred-and-seven (51.4±7.6 years old) women with fibromyalgia participated. ST and MVPA were measured with triaxial accelerometry. Percentage of ST accumulated in bouts and frequency of sedentary bouts of different lengths (≥10, ≥20, ≥30, ≥60 min) were obtained. Four groups combining total ST and sedentary bout (≥30min) duration were created. We assessed HRQoL with the 36-item Short-Form health survey (SF-36). Results: Greater percentage of ST spent in all bouts lengths was associated with worse physical function, bodily pain, vitality, social function and physical component summary (PCS) (all, p<0.05). In addition, higher percentage of ST in bouts of ≥60 min was related to worse physical role (p=0.036). Higher frequency of bouts was negatively associated with physical function, social function, the PCS (≥30 min, and ≥60 min), physical role (≥60 min), bodily pain (≥60 min), vitality (≥20, ≥30 and ≥60 min) all p<0.05). Overall, for different domains of HRQoL these associations were independent of MVPA for higher bout lengths. Patients with high total ST and high sedentary bout duration had significantly worse physical function (mean difference=8.73 units; 95% CI: 2.31 to 15.15; independently of MVPA), social function (10.51 units; 2.59 to 18.44; not independent of MVPA) and the PCS (2.71 units; 0.36 to 5.06;not independent of MVPA) than those with low ST and low sedentary bout duration. Conclusions: Greater ST in prolonged periods (of any length) and higher frequency of ST bouts (especially in longer bout durations) are associated with worse HRQoL in women with fibromyalgia. These associations were generally independent of MVPA.

• Development of a Virtual Counseling Application Using Artificial Intelligence for Communication Skills Training in Nursing Education

  From: Journal of Medical Internet Research

  Date Submitted: May 8, 2019

  Open Peer Review Period: May 9, 2019 - Jul 4, 2019

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  Background: The ability of nursing undergraduates to communicate effectively with patients, healthcare providers, and family members is crucial to their nursing profession, because it can affect patie...

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  Background: The ability of nursing undergraduates to communicate effectively with patients, healthcare providers, and family members is crucial to their nursing profession, because it can affect patient outcomes. However, the traditional use of didactic lectures for communication skills training is ineffective, and the use of standardized patients is not time- or cost-effective. Given the ability of virtual patients to simulate an interactive and authentic clinical scenario in a secured environment with unlimited training attempts, it is an ideal platform for nursing students to hone their communication skills before their clinical posting. Objective: To develop and test the use of virtual patients in better preparing nursing undergraduates in communicating with real-life patients, family members, and other healthcare professionals during their clinical posting. Methods: The stages of creation of the virtual patients included preparation, design, and development, followed by a testing phase before official implementation. The initial voice chatbot was trained using a natural language processing engine, Google’s Dialogflow, and was later visualized into a three-dimensional avatar form using Unity 3D. Results: The virtual patients included four case scenarios, which were congruent with nursing undergraduates’ current semester learning objectives: 1) assessing the pain experienced by a pregnant woman, 2) taking the history of a depressed patient, 3) escalating a bleeding episode of a postoperative patient to the physician, and 4) showing empathy to a stressed-out fellow final-year nursing student. Conclusions: The creation of virtual patients to assist in nursing students’ communication skills training may provide an authentic learning environment that enhances students’ perceived self-efficacy and confidence in effective communication skills. However, given the infancy stage of this project, further refinement and constant enhancements are needed to train the virtual patients to simulate real-life conversations before official implementation. Future development of virtual patients can be enhanced from the experiences shared by the research team in this study. Clinical Trial: NA

• How mHealth Providers Meet the Emerging Demands of Consumers in China: A Survey from Patient-Users

  From: JMIR mHealth and uHealth

  Date Submitted: May 5, 2019

  Open Peer Review Period: May 8, 2019 - Jul 3, 2019

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  Background: Background: The adoption of mobile health information technology (mHealth), consisting primarily of electronic medical record (EMR) in hospitals and mobile health (mHealth) application amo...

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  Background: Background: The adoption of mobile health information technology (mHealth), consisting primarily of electronic medical record (EMR) in hospitals and mobile health (mHealth) application among consumers outside of healthcare settings, have been booming in China. There have been investigations on the impact of mHealth on improving the quality of healthcare. However, it remains unclear whether emerging mHealth providers, particularly mHealth providers, fill in emerging consumer needs in China. Objective: Objective: This study aims to survey prior knowledge, current usage, and future preference of mHealth applications among two distinct cohorts (online vs hospital visitor) that we surveyed in China. Methods: Methods: We categorized main mHealth features into 9 groups. We surveyed two Chinese cohorts: hospitalized patients (n = 299) and the general public outside the hospital using WeChat—a popular social networking APPs (n = 156), on mHealth usage and expectations on these 9 feature groups. The original survey was conducted in Chinese. We performed data analysis of user reponses in the survey using descriptive statistics techniques: t-test and chi-square fitness test. Results: Results: Although most of the survey participants show prior knowledge on some features of EMR, most of them (66%) have never used mHealth applications. In addition, the participants consider predictive analytic features as the most important ones for the mHealth applications. The responses vary according to different cohort demographics, in particular, age groups. Conclusions: Conclusions: Despite tremendous efforts in adopting EMR and developing mHealth applications, it is still too early to conclude that mHealth are readily adopted among patients in China. There are significant gaps among what the implementers offer, what providers expect, and what patients and consumers demands. Current Chinese mHealth applications implement features heavily focused on social networking and communication; however, it has been shown that patients do not consider these features as the top priority in mHealth applications. Instead, our study suggests that analytic features should be the future focus for successful mHealth application development in China.

• Geospatial-Temporal, Explanatory, and Predictive Models for Hospital-Based Outpatient Back Surgery

  From: Journal of Medical Internet Research

  Date Submitted: May 5, 2019

  Open Peer Review Period: May 8, 2019 - Jul 3, 2019

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  Background: Outpatient back surgery in the United States increased 60% from January 2012 through December 2017, yet the supply of neurosurgeons remained almost constant. During this time, adult obesit...

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  Background: Outpatient back surgery in the United States increased 60% from January 2012 through December 2017, yet the supply of neurosurgeons remained almost constant. During this time, adult obesity grew 5%. An obvious question is the relationship between the two, particularly when considering supply and demand. Objective: This research evaluates the demand and associated costs for hospital outpatient back surgery by geo-location over time to evaluate provider practice variation. The study then leverages hierarchical time series to generate tight demand forecasts on an unobserved test set. Finally, explanatory financial, technical / workload, geographical, and temporal factors as well as state-level obesity rates are investigated as predictors for the demand for hospital-based outpatient back surgery. Methods: Hospital data from January 2012 through December 2017 were used to generate geospatial, temporal maps and a video of CPT 63* claims. Hierarchical time series modeling provided forecasts for each state, the Census regions, and the nation for an unobserved test set and then again for the outyears of 2018 and 2019. Stepwise regression, lasso regression, ridge regression, elastic net, and gradient-boosted random forests were built on a training set and evaluated on a test set to evaluate variables important to explaining the demand for outpatient-based back surgery. Results: Widespread, unexplained practice variation over time is seen on the GIS multimedia mapping. Hierarchical time series provided accurate forecasts on a blind data set and suggest 6.5% growth of hospital-based outpatient back surgery in 2018 and 13% by 2019. The increase in payments by 2019 are estimated to be $323.9 million. Extreme gradient-boosted random forests beat constrained and unconstrained regression models on a 20% unobserved test set and suggested that obesity is one of the most important factors in explaining the increase in demand for hospital-based outpatient back surgery. Conclusions: Practice variation and obesity are factors to consider when estimating demand for hospital outpatient back surgery. Federal, state, and local planners should evaluate demand-side and supply-side interventions for this emerging problem. Administrators may use methods promulgated in this research to predict and anticipate growth in demand for specific services and respond through hiring action, agile shifting of internal workload, or external-contract activities for services outside the organization’s capacity.

• E-learning to improve suicide prevention practice skills: a randomized controlled trial among psychology undergraduate students

  From: Journal of Medical Internet Research

  Date Submitted: May 6, 2019

  Open Peer Review Period: May 7, 2019 - Jul 2, 2019

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  Background: Background: Despite increased evidence on the effectiveness of digital learning solutions in a variety of higher vocational education, including (para-)medical fields, online training of p...

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  Background: Background: Despite increased evidence on the effectiveness of digital learning solutions in a variety of higher vocational education, including (para-)medical fields, online training of practical skills in psychiatry and psychology in general, and in suicide prevention specifically, remains largely understudied. Objective: Objective: This study aims to determine the effectiveness of an e-learning module on suicide prevention guideline adherence, practical skills knowledge and provider’s confidence to have a dialogue about suicidal behavior in undergraduate psychology students. Methods: Methods: The e-learning consisted of video registrations of therapist-patient interactions with the aim to transfer knowledge about suicide prevention guideline recommendations. The program’s effects on guideline adherence, self-evaluated knowledge and provider’s confidence were assessed using online questionnaires prior to the program (baseline, T0), at 1 month (T1) and at 3 months after baseline (T3). Eligible 3th and 4th year undergraduate psychology students were randomly allocated to the e-learning (n=211) or to a waitlist control condition (n=187), with access to the intervention after one month (T1). Results: Results: Intention to treat analysis showed that the students in the intervention condition (n=211) reported higher levels of self-evaluated knowledge, provider’s confidence and guideline adherence than students in the waiting list control condition (n=187) after receiving the e-learning module, (all p-values <.001). When comparing the scores at one and three month follow up, after both groups had received access to the e-learning module, completers only analysis showed that levels of knowledge, guideline adherence and confidence within the intervention group stay constant (all p-values >.05), and that within the waiting list control group, ,the levels of all outcomes improved significantly (all p-values <.05). Overall the e-learning was evaluated fairly positive by the students. Conclusions: Conclusions: An e-learning on the prevention of suicide could be an effective first step in the improvement of clinical skill knowledge. Learning outcomes of a stand-alone module were found to be similar to a training that combined e-learning with a face-to-face training, with the advantages of flexibility and low costs.

• Standards to classify race and ethnicity: Meaningful information is lost in translation

  From: Journal of Medical Internet Research

  Date Submitted: May 3, 2019

  Open Peer Review Period: May 6, 2019 - Jul 1, 2019

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  Background: Data standards for collecting, storing, and indexing information on classification of social determinants of health, such as race and ethnicity, have significant ramifications in health eq...

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  Background: Data standards for collecting, storing, and indexing information on classification of social determinants of health, such as race and ethnicity, have significant ramifications in health equity research. Objective: We describe challenges encountered when working with multiple-race assessment in large health surveys in the Eastern Caribbean Health Outcomes Research Network (ECHORN), a collaborative of Barbados, Puerto Rico, Trinidad and Tobago, and U.S. Virgin Islands. Methods: We examined the data standards guiding research studies on race/ethnicity data collection and indexing, including Office of Management of Budget Directive 15 (OMB) and National Library Medicine’s Medical Subject Headings (MeSH), respectively, for a cohort study with multi-racial populations. Results: Among 1,211 participants in the ECHORN cohort study, 13% (n=117) selected Caribbean; 7.6% (n=58), Puerto Rican or Boricua; and 10% (n=122), multi-racial category. Over 18% selected two or more categories, with 15.2% (n=184) selecting two, and 2.6% (n=32) selecting three or more categories. With aggregation of ECHORN data into OMB categories, 24% of the participants are placed in the “more than one race” category. Moreover, searching for and retrieving articles related to multi-racial populations involves complicated keyword and synonyms searches and varies in number of articles retrieved (including terms such as biracial (n=863 articles), mixed race (n=6181articles), or multiracial (n=871 articles)). Conclusions: This analysis exposes the fundamental informatics challenges with current data standards, from data collection to indexing, that complicate meaningful collection and dissemination of accurate information for diverse and marginalized populations. Current standards should reflect the science of measuring race/ethnicity and the need for multi-disciplinary teams to improve evolving standards across the data lifecycle.

• Evaluation of the impact of four dissemination paths on key performance indicators of a social media-based breastfeeding campaign

  From: JMIR Nursing

  Date Submitted: May 4, 2019

  Open Peer Review Period: May 6, 2019 - Jul 1, 2019

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  Background: Social media utilization is globally on the rise, and the potential of social media for health behavior campaigns is widely recognized. However, as the landscape of social media evolves, s...

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  Background: Social media utilization is globally on the rise, and the potential of social media for health behavior campaigns is widely recognized. However, as the landscape of social media evolves, so do techniques used to optimize campaign dissemination. Objective: The primary aim of this study was to evaluate the impact of four material dissemination paths for a breastfeeding social media marketing campaign in Ghana on exposure and engagement with campaign material. Methods: Campaign materials (n=60) were posted to a Facebook and Twitter campaign page over 12 weeks (i.e. baseline). The top 40 performing materials were randomized to 1 of 4 re-dissemination arms (control simply posted on each platform, key influencers, random influencers, and paid advertisements). Key performance indicator data (i.e. exposure and engagement) were extracted from each Facebook and Twitter two days after the material was posted. A difference-in-difference model was used to exam the impact of the dissemination paths on performance. Results: At baseline, campaign materials received an average (SD) exposure of 1178 (670) on Facebook and 1071 (905) on Twitter (n=60). On Facebook, materials posted with paid advertisements had significantly higher exposure and engagement compared with the control arm (P < .001), and performance of materials shared by either type of influencer did not differ significantly from the control arm. No differences in Twitter performance were detected across arms. Conclusions: Paid advertisements are an effective mechanism to increase exposure and engagement of campaign posts on Facebook, which was achieved at a low cost. Clinical Trial: Key Words: Social Media, Campaign, Breastfeeding, Dissemination, Ghana 

• Mobile Apps for Management of Transparency-Mode Quality Report Cards on a Dashboard to Show the Performance of Case Mix Index for Hospitals in Taiwan

  From: JMIR mHealth and uHealth

  Date Submitted: May 3, 2019

  Open Peer Review Period: May 6, 2019 - Jul 1, 2019

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  Background: A quality report card is a report generated by a third-party evaluator that rates the performance of a specific health care provider. A dashboard is required to explore based on three prin...

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  Background: A quality report card is a report generated by a third-party evaluator that rates the performance of a specific health care provider. A dashboard is required to explore based on three principles—(1)anytime, anywhere, at a glance;(2)minimal interruption to workflow; and (3) protecting entity privacy—and 3 design features—(1)geographical layout; (2) entity-level alert; and (3) real-time summary data, particularly using mobile Apps to explain. However, few were successfully demonstrated in the literature. Objective: The aim of this study was to demonstrate a quality report card that can be shown on Google maps to investigate the performance of case mix index(CMI) for hospitals in Taiwan. Methods: The CMI data(from Q3 2013 to Q2 2016) were obtained from the website of Taiwan National Health Issuance Administration(NHIA). A total of 217 hospitals are eligible based on the data are complete. We used scale quality indicators (1) to assess the quality of the study data; (2) to create a dashboard-type quality report card that can be traced on the Google maps; (3) to select the hospital level that performs better in the trend and competition of CMI. Results: We found that (1) the CMI data fit the predictable requirements rather well(Chi-square = 10.09, df= 10, p =0.77); (2) the dashboard of quality report card shows on Google maps with multidisciplinary functionalities; (3)the level that regional hospitals earn the merit of the performance better in the CMI Growth/Improvement. Conclusions: The demonstration of a quality report card on CMI using Google maps can inspire other 44 quality indicators of NHIA in use for hospitals in the future. Clinical Trial: Not available

• Feasibility of ActivABLES to promote home-based exercise and physical activity of community-dwelling stroke survivors with support from caregivers: A mixed methods study

  From: Journal of Medical Internet Research

  Date Submitted: May 2, 2019

  Open Peer Review Period: May 6, 2019 - Jul 1, 2019

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  Background: Technical applications can promote home-based exercise and physical activity of community-dwelling stroke survivors to improve function and decrease physical inactivity and sedentary behav...

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  Background: Technical applications can promote home-based exercise and physical activity of community-dwelling stroke survivors to improve function and decrease physical inactivity and sedentary behavior. Informal caregivers are often able and willing to assist with home-based exercise and physical activity but may lack knowledge and practical resources. ActivABLES is an international collaboration which was established to promote home-based exercise and physical activity among community-dwelling stroke survivors, with support from their caregivers. Objective: The aim of this study is to investigate the feasibility of ActivABLES in terms of acceptability, demand, implementation and practicality. Methods: We conducted a mixed methods study with 10 community-dwelling stroke survivors, including five women and five men, with the median age of 72 years, who used ActivABLES for four weeks with support from their caregivers (seven women and three men, median age 68 years). Data collection included quantitative functional standardized measures of the stroke survivors before and after the 4-week use. Additionally, qualitative data was collected through individual semi-structured interviews with the stroke survivors and their caregivers after the 4-week use. Quantitative and qualitative data were also collected during the 4-week use. Descriptive statistics were used to analyze quantitative data and Wilcoxon signed rank test was used to analyze changes between the measures before and after the 4-week use. Qualitative data were analyzed with direct content analysis to identify subcategories to define the data further in context with the predetermined categories. Results: Acceptability was identified in four subcategories: appreciation, functional improvements, self-initiated activities and expressed potential use for future stroke survivors. Functional improvements of the stroke survivors were confirmed by quantitative and qualitative data and some mentioned changes in physical activity and self-initiated activities. All participants described ActivABLES to be feasible and to have potential for future stroke survivors. Demand was identified in three subcategories: reported use, interest in further use and need for follow-up. Most of the stroke survivors did follow the recommendation of using ActivABLES, confirmed by quantitative and qualitative data and showed interest in further use. Implementation was identified in three subcatagories: importance of feedback, variety of exercises and progression of exercises. Visual feedback was thought to be important and encouraging for continuing. About half of the stroke survivors felt that there was a lack of variation in exercises and about half used the progression of exercises. Practicality was identified in two subcatagories: need for support and technical problems. All participants agreed there was little need for support while using ActivABLES and the stroke survivors only needed minor assistance. All particants experienced some technical problems. Conclusions: The results from this study indicate that ActivABLES is feasible and can be a good asset for stroke survivors with slight or moderate disability to use in their homes.

• ActivABLES, a tangible interaction to promote home-based exercise and physical activity of community-dwelling stroke survivors: A development paper

  From: JMIR Rehabilitation and Assistive Technologies

  Date Submitted: May 2, 2019

  Open Peer Review Period: May 6, 2019 - Jul 1, 2019

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  Background: Novel technical solutions are called for to promote home-based exercise and facilitate engagement in physical activity among community-dwelling stroke survivors supported by their caregive...

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  Background: Novel technical solutions are called for to promote home-based exercise and facilitate engagement in physical activity among community-dwelling stroke survivors supported by their caregivers in the home environment. Lack of knowledge and resources on what to do and how to accomplish this has been demonstrated. Objective: To describe in detail the development of a technical intervention, ActivABLES, to promote home-based exercise and physical activity engagement of community-dwelling stroke survivors with support from their informal caregivers. Methods: Technical development process of ActivABLES was guided by Human-Centred Design and participatory design/co-design as well as the Medical Research Council (MRC) framework for the development and evaluation of complex interventions. The main steps included: (a) Synthesis of the evidence supported the inclusion of balance exercises, mobility and walking exercises, exercises for the upper arm and means to decrease sedentary behavior; b) Initial user studies with qualitative data collection from individual interviews with stroke survivors and focus group interviews with informal caregivers and health professionals; c) Preliminary testing of eight prototypes with seven stroke survivors and their informal caregivers which included introduction and testing of the prototypes; d) Feasibility study of six prototypes with ten stroke survivors and their informal caregivers which included use of ActivABLES for four weeks. Results: After the preliminary testing of eight prototypes, four prototypes were not further developed whereas four prototypes were modified further. In addition, two new prototypes were developed, leaving six prototypes constructed for use in the feasibility study. These included: 1) ActivFOAM, a soft mat for balance exercises, 2) WalkingSTARR, an iPhone application to facilitate walking, 3) ActivBALL, a soft ball for hand exercises, 4) ActivSTICKS, two linked plastic sticks for upper arm exercises and trunk rotation and 5) the ActivLAMP and 6) the ActivTREE which both give visual feedback (lights) for progress of daily exercise and physical activities. ActivFOAM, ActivBALL and ActivSTICKS are all connected to a tablet where exercise instructions are given. All the exercise prototypes can be connected to ActivLAMP and ActivTREE to give feedback on how much exercise the user has done. Settings can be individualized and recommended daily time and/or repetition can easily be changed as the user further progresses to higher activity levels. Conclusions: The development process of ActivABLES was guided by the human-centred design, with iterative testing of future users, and the MRC framework of complex intervention, with repeated process of development and testing. This process resulted in six prototypes which aim to promote home-based exercise and facilitate physical activity engagement of community-dwelling stroke survivors and were used in a feasibility study. Further research with a larger sample of stroke survivors and a more robust design is needed to substantiate these results.

• Cost and cost-effectiveness of StepCare: A stepped mental health care service in Australian general practice.

  From: Journal of Medical Internet Research

  Date Submitted: May 1, 2019

  Open Peer Review Period: May 6, 2019 - Jul 1, 2019

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  Background: The online ‘StepCare’ Service identifies adults with common mental disorders, recommends evidence-based treatments and monitors symptoms and risk, with feedback to patient and GP. Proo...

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  Background: The online ‘StepCare’ Service identifies adults with common mental disorders, recommends evidence-based treatments and monitors symptoms and risk, with feedback to patient and GP. Proof of concept study data indicated that the Service is acceptable and feasible in general practice. Objective: As part of a larger implementation study of StepCare, we conducted an economic evaluation of the Service from multiple stakeholder perspectives. The economic evaluation included (1) a trial-based cost and cost effectiveness analysis and (2) a modelled cost-consequence analysis. An Australian public finance perspective was used, with costs disaggregated to give transparency to the investment contributed by the various stakeholders. Methods: General practices, GPs, practice staff and adult patients (18 years and over) in two large Australian Primary Health Networks (PHNs), one urban, the other rural/remote, were invited to take part in the full implementation study. For the trial-based analysis, an incremental cost-effectiveness ratio (ICER) was calculated based on one of two metrics identified as appropriate proxy measures for better alignment with stepped mental health care: GP diagnosis rate for anxiety and depression. The expected costs over a twelve-month period associated with usual practice compared to a fully implemented stepped care model were calculated in the modelled extrapolation. Results: The trial-based analyses calculated the incremental cost of implementing StepCare to be $54 per person screened, with a cost per newly diagnosed person of $10,750. The modelled evaluation calculated that over a 12 month period, the StepCare Service (screening and treatment) was associated with mean costs of $294 AUD per person compared to (i) usual care assuming no active screening and a quasi-stepped approach to treatment, costing a mean of $535 AUD per person and (ii) usual care assuming no active screening and treatment-as-usual (ie not quasi-stepped) costing a mean of $442 AUD per person. That is, StepCare was associated with lower costs than either of the two comparator scenarios. Conclusions: Compared to current mental health care in general practice, StepCare is a cost-effective screening and patient management tool.

• Blended Face-to-face and Web-based Smoking Cessation Treatment: a description of patients’ user experience

  From: Journal of Medical Internet Research

  Date Submitted: May 1, 2019

  Open Peer Review Period: May 6, 2019 - Jul 1, 2019

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  Background: Blended treatment – a combination of Web-based and face-to-face (F2F) therapy – is a promising eHealth service, because it is expected that in blended treatment the strengths of one mo...

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  Background: Blended treatment – a combination of Web-based and face-to-face (F2F) therapy – is a promising eHealth service, because it is expected that in blended treatment the strengths of one mode of delivery will compensate for the weaknesses of the other. Objective: The aim of this study is to examine the key elements of the patients’ user experience (UX) in a blended smoking cessation treatment (BSCT) in routine care. Methods: Patients’ UX was collected by in-depth interviews (n=10) at an outpatient smoking cessation clinic in the Netherlands. Content analysis of semantic domains was used to analyze the patients’ UX. For the description of the UX, Hassenzahl’s UX model from a user perspective was applied examining the key elements of UX: (1) standards and expectations, (2) apparent character (pragmatic and hedonic attributes), (3) usage situation, and (4) consequences (appeal, emotions, behavior). Results: In general, the UX of BSCT was good. Patients had a positive-pragmatic standard and neutral-open expectation towards BSCT, and the pragmatic attributes (usability, utility) of both the Web-sessions and the F2F-sessions were mostly positive. However, for the hedonic attributes (stimulation, identification, evocation), Web-sessions differed from F2F-sessions: patients reported lower stimulation for the Web-sessions (“online won’t get through to me”), lower identification (“online is not my style”), and negative evocations (comparing the Web-sessions to e.g. “bookkeeping”). Ultimately, we found three types of combinations of appeal, emotions (e.g. satisfaction) and behavior (adherence; quitting): “positive”, “negative”, and “mixed”. Conclusions: This study aimed to provide insight in the user experience (UX) of a blended treatment. In the light of this study, the expectation that blended treatment combines “the best of both worlds” because the strength of one mode of delivery can compensate for the weaknesses of the other, can be supported. However, this was mainly found in only one way: F2F-sessions compensated for the weaknesses of Web-sessions. Further work needs to be done to investigate how the integration of F2F- and Web-treatment can be carried out to ultimately increase the effectiveness and efficiency of a blended treatment. This study provides a hint to explore this question by emphasizing the relevance of aspects of hedonism such as e.g. fun, joy or happiness which may be addressed to further improve UX and ultimately treatment effectiveness. Clinical Trial: trialregister.nl NTR5113

• Effectiveness of serious games to increase physical activity in children with a chronic disease: a systematic review with meta-analysis

  From: Journal of Medical Internet Research

  Date Submitted: May 1, 2019

  Open Peer Review Period: May 6, 2019 - Jul 1, 2019

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  Background: Physical activity (PA) is important for children with a chronic disease. Serious games may be useful to promote PA levels among these children. Objective: The primary purpose of the presen...

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  Background: Physical activity (PA) is important for children with a chronic disease. Serious games may be useful to promote PA levels among these children. Objective: The primary purpose of the present systematic review was to evaluate the effectiveness of serious games on PA levels in children with a chronic disease. Methods: PubMed, EMBASE, PsycINFO, ERIC, Cochrane Library and CINAHL were systematically searched from January 1990 to May 2018. Both randomized controlled trials and controlled clinical trials were included examining the effects of a serious game on PA levels in children with a chronic disease. Two investigators, independently, assessed all articles on intervention, methods, and methodological quality by using the Cochrane risk of bias tool. Both qualitative and quantitative analyses were performed. Results: Nine randomized controlled trials (886 participants) were included in this systematic review. Two included studies reported significant between-group differences in PA levels in favor of the intervention group. The meta-analysis on PA showed a non-significant effect on moderate to vigorous PA min/day between the intervention group and the control group (standardized mean difference 0.30, 95% CI -0.15 to 0.75, P=.19). The analysis on body composition showed that studies reported a reduction in Body Mass Index (BMI) in favor of the intervention group (standardized mean difference -0.24, 95%CI -0.45 to 0.04, P=.02). Conclusions: This review does not support the hypothesis that serious games improve PA levels in children with a chronic disease. The meta-analysis on body composition showed positive intervention effects by a significant reduced BMI scores in favor of the intervention group. A high percentage of non-use was identified in serious games and less attention was paid to behavior change theories and specific theoretical approaches to enhance PA in serious games. Small sample sizes, large variability between intervention designs and limited details about intervention contents were the main limitations. Research should find out which strategies enhance the effectiveness of serious games, possibly by incorporating behavior change techniques. Clinical Trial: Systematic review registration number:CRD42018070662

• A mobile application directory of occupational therapists who provide home modifications: Development and preliminary usability evaluation

  From: JMIR mHealth and uHealth

  Date Submitted: May 2, 2019

  Open Peer Review Period: May 6, 2019 - Jul 1, 2019

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  Background: Home modifications provided by occupational therapists (OTs) are effective in improving daily activity performance and reducing fall risk among community-dwelling older adults. However, th...

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  Background: Home modifications provided by occupational therapists (OTs) are effective in improving daily activity performance and reducing fall risk among community-dwelling older adults. However, the prevalence of home modification is low. One reason is the lack of a centralized database of OTs who provide home modifications. Objective: To develop and test the usability of a mobile application directory of OTs who provide home modifications in the US. Methods: In Phase 1, a prototype was developed by identifying OTs who provide home modifications through keyword web searches. Referral information was confirmed by phone or email. In Phase 2, community-dwelling older adults over the age of 65 and OTs currently working in the US were purposefully recruited to participate in a single usability test of the mobile app, Home Maddirs. Participants completed the System Usability Scale (SUS) and semi-structured interview questions. Interview data were coded and themes derived using a grounded theory approach Results: In Phase 1, referral information for 101 OTs across 49 states were confirmed. In Phase 2, six OTs (mean clinical experience ± SD: 4.3 ± 1.6 years) and six older adults (mean age ± SD: 72.8 ± 5.0 years) participated. The mean SUS score for OTs was 91.7 ± 8.0 (out of 100), indicating good usability. The mean SUS score for older adults was 71.7 ± 27.1, indicating considerable variability in usability. Additionally, the SUS scores indicated the app is acceptable to OTs and may be acceptable to some older adults. For OTs, self-reported barriers to acceptability and usability included the need for more information on the scope of referral services. For older adults, barriers included high cognitive load, lack of operational skills, and the need to accommodate sensory changes. For both groups, facilitators of acceptability and usability included perceived usefulness, social support, and multiple options to access information. Conclusions: Home Maddirs demonstrates good preliminary acceptability and usability to OTs. Older adults’ perceptions regarding acceptability and usability varied considerably, partly based on prior experience using mobile apps. Results will be used to make improvements to this promising new tool for increasing older adults’ access to home modifications.

• Predictors for switch from unipolar major depressive disorder to bipolar disorder: A nationwide population-based retrospective cohort study

  From: Journal of Medical Internet Research

  Date Submitted: May 2, 2019

  Open Peer Review Period: May 6, 2019 - Jul 1, 2019

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  Background: Unipolar major depressive disorder (MDD) and bipolar disorder are two major mood disorders. The two disorders have different treatment strategies and prognoses. However, bipolar disorder m...

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  Background: Unipolar major depressive disorder (MDD) and bipolar disorder are two major mood disorders. The two disorders have different treatment strategies and prognoses. However, bipolar disorder may begin with depression and could be diagnosed as MDD at the initial stage which may contribute to treatment failure. Previous studies indicated that a significant proportion of patients who were diagnosed with MDD will over time develop bipolar disorder. This kind of hidden bipolar disorder may contribute to the treatment resistance observed in MDD patients. Objective: In this population-based study, our aim is to investigate the rate and risk factors for a diagnostic change from unipolar MDD to bipolar disorder during a 10-year follow up. Furthermore, a risk stratification model was also developed for MDD to bipolar conversion. Methods: We conducted a retrospective cohort study involving patients who were newly diagnosed with major depressive disorder between January 1, 2000 and December 31, 2004 by using Taiwan National Health Insurance Research Database (NHIRD). All depression patients were observed until (1) diagnosed with a bipolar disorder by a psychiatrist, (2) death, or (3) December 31, 2013. All depression patients were divided into two groups, converted group and non-converted group, according to if the patients were diagnosed with bipolar disorder during the follow-up period. Six groups of variables within the first six months of enrollment, including personal characteristics, physical comorbidities, psychiatric comorbidities, health care usage behaviors, severity of disorder, and use of psychotropics, were extracted, and were put into CART analysis to generate the risk stratification model for MDD to bipolar conversion. Results: There are 2820 MDD patients enrolled in our study. During follow-up period, 536 patients were diagnosed with bipolar disorder (19.0%). The CART method identified 5 variables (kinds of antipsychotics use, kinds of antidepressant use, total psychiatric outpatient visits, kinds of benzodiazepine use within one visit, and use of mood stabilizer.) as significant predictors of risk of bipolar conversion. This CART risk tree was able to stratify patients into high, medium, and low risk for bipolar conversion. Conclusions: In our study, the CART method identified 5 variables as significant predictors of bipolar conversion. In a simple 2-to 4-step process, these variables permit identification of patients with low, intermediate, or high risk for bipolar conversion. The developed model can be applied to routine clinical practice and to facilitate early diagnosis of bipolar disorder.

• The effect of a mobile phone peer -to-peer mentorship program for newly diagnosed HIV positive youth in Khayelitsha, South Africa: a mixed methods study.

  From: Journal of Medical Internet Research

  Date Submitted: May 4, 2019

  Open Peer Review Period: May 6, 2019 - Jul 1, 2019

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  Background: Youth in South Africa are poor utilizers of HIV health services. Medecins Sans Frontieres has been piloting youth-adapted services at a youth clinic in Khayelitsha, including a peer virtua...

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  Background: Youth in South Africa are poor utilizers of HIV health services. Medecins Sans Frontieres has been piloting youth-adapted services at a youth clinic in Khayelitsha, including a peer virtual mentorship program over mobile phones, piloted from March 2015 to May 2016. Objective: This study evaluates the effect of the peer mentorship program on youths engagement with HIV services, as well as exploring the acceptability of the program to both mentors and mentees. Methods: ART initiation, retention in care and viral load suppression were compared between youth engaged in the virtual mentorship program and two matched controls. In-depth interviews were also conducted for 5 mentors and 5 mentees to explore acceptability and impact of the program. Results: 40 youth were recruited into the virtual mentorship program over the study period. Of these, data was obtained for 35, and 70 matched controls. There was no difference in baseline demographics (age, gender, CD4 count). Mentees had increased ART initiation (80% vs 42% in matched controls), and viral load completion (80% vs 36%), however no differences were found in viral load suppression or retention in care at 6 or 12 months. Mentors reported being motivated to participate in the program due to previous personal struggles with HIV and a desire to help their peers. Mentees reported fears of disclosure and lack of acceptance of their status as barrier to accessing services, but felt free to talk to their mentors, and valued the mentorship program, with a preference for phone calls. Conclusions: Peer mentorship in youth is acceptable to both mentors and mentees, and appears to increase linkage to care, and viral load completion rates.

• e-CLINICAL HIGH RISK FOR PSYCHOSIS: POTENTIAL OF DIGITAL INNOVATIONS FOR PREVENTIVE PSYCHIATRY

  From: JMIR Mental Health

  Date Submitted: May 3, 2019

  Open Peer Review Period: May 5, 2019 - Jun 30, 2019

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  e-Mental Health is an emerging area of research that has the potential to overcome some of the current barriers to progress in working with people at Clinical High Risk for Psychosis (CHR-P). This art...

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  e-Mental Health is an emerging area of research that has the potential to overcome some of the current barriers to progress in working with people at Clinical High Risk for Psychosis (CHR-P). This article provides an overview of how e-Mental Health could be utilised in the detection, prediction and treatment in the CHR-P population. Specifically, we evaluate e-detection, e-prediction and e-therapeutics for this clinical population. e-Mental Health holds great promise to improve current management of CHR-P individuals.

• Accuracy in energy expenditure estimation of the multisensory wristwatch Polar Vantage during various activities

  From: JMIR mHealth and uHealth

  Date Submitted: Apr 30, 2019

  Open Peer Review Period: May 3, 2019 - Jun 28, 2019

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  Background: Sport watches and fitness tracker provide a feasible option of energy expenditure (EE) estimation in daily life as well as during exercise. However, todays popular wrist-worn technologies...

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  Background: Sport watches and fitness tracker provide a feasible option of energy expenditure (EE) estimation in daily life as well as during exercise. However, todays popular wrist-worn technologies show only poor to moderate EE accuracy. Recently, the invention of optical HR measurement and the further development of accelerometers in wrist units have opened up the possibility of measuring EE. Objective: The aim of this study was to validate the new multisensory wristwatch Polar Vantage and its EE estimation in healthy individuals during low- to high-intensity activities against indirect calorimetry. Methods: Thirty volunteers (15 female; 29.5 ± 5.1 years; 1.7 ± 0.8 m; 67.5 ± 8.7 kg; VO2max of 53.4 ± 6.8 ml/min*kg) performed seven activities—ranging in intensity from sitting to playing floorball—in a semi-structured indoor environment for 10 minutes (min) each, with 2 min breaks in between. These activities were performed while wearing the Polar Vantage M wristwatch and the MetaMax 3B spirometer. Results: After EE estimation, mean ± standard deviations of 69.1 ± 42.7 kilocalories (kcal) and 71.4 ± 37.8 kcal per 10 min activity were reported for the MetaMax 3B and the Polar Vantage, respectively, with a strong correlation of r = .892 (P < .001). The systematic bias was 2.3 kcal (3.3%), with ± 37.8 kcal limits of agreement. The lowest mean absolute percentage errors were reported during the sitting and reading activities (9.1%), and the highest error rates during household chores (31.4%). On average, 59.5% of the mean EE values obtained by the Polar Vantage were within ± 20% of accuracy when compared to the MetaMax 3B. The activity intensity quantified by perceived exertion (odds ratio = 2.028, P < .001) and wrist circumference (odds ratio = −1.533, P = .03) predicted 29% of the error rates within the Polar Vantage. Conclusions: The Polar Vantage has a statistically moderate to good accuracy in EE estimation that is activity-dependent. During sitting and reading activities, the EE estimation is very good, whereas during non-steady activities that require wrist and arm movement, the EE accuracy is only moderate. However, compared with other available wrist-worn EE monitors, the Polar Vantage can be recommended, as it performs among the best.

• The Curation of Mental Health Recovery Narrative Collections: Systematic Review and Qualitative Synthesis

  From: Journal of Medical Internet Research

  Date Submitted: Apr 30, 2019

  Open Peer Review Period: May 3, 2019 - Jun 28, 2019

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  Background: Mental health recovery narratives are first-person lived experience accounts of recovery from mental health problems, which refer to events or actions over a period of time. They are readi...

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  Background: Mental health recovery narratives are first-person lived experience accounts of recovery from mental health problems, which refer to events or actions over a period of time. They are readily available, either individually in digital media hosting services such as YouTube, or in collections of recovery narratives published in books, health service booklets or online. Collection of recovery narratives have been used in a range of mental health interventions, including anti-stigma campaigns. Organisations or individuals who curate collections can therefore influence how mental health problems are seen and understood. No systematic review has been conducted of research into curatorial decision making. Objective: To produce a conceptual framework identifying key concerns in the curation of collections of mental health recovery narratives, and identifying and categorising curatorial choices and decisions. Methods: A conceptual framework was produced through a systematic review and qualitative evidence synthesis. Research publications were identified through searching of bibliographic databases (n=13), indexes of specific journals (n=3) and grey literature repositories (n=4). Informal knowledge about curation was identified through searching editorial chapters of electronically-available books (n=50), inspection of public documents provided by online collections (n=50), and prefaces of health-service booklets identified through expert consultation (n=3). Narrative summaries of included research articles were produced. A qualitative evidence synthesis was conducted on all included documents through inductive thematic analysis. Sub-group analyses were conducted to identify differences in curatorial concerns between online and printed collections. The review protocol was pre-registered (PROSPERO CRD42018086997). Results: 5,410 documents were screened. 23 documents were included. These comprised 1 research publication and 22 informal documents. Nine higher level themes were identified, which considered the intended purpose and audience of the collection, how to support safety of narrators, recipients and third parties, the processes of collecting, selecting, organising and presenting recovery narratives, ethical and legal issues around collections, and the relationship to society of the collection. Online collections placed more emphasis on (1) providing benefits for narrators (2) safety for recipients. Printed collections placed more emphasis on the ordering of narrative within printed material, and the political context. Conclusions: Only one research article was identified, despite extensive searches, and hence this review has revealed a lack of peer-reviewed empirical research regarding the curation of recovery narrative collections. The conceptual framework can be used as a preliminary version of reporting guidelines for use when reporting on healthcare interventions which make use of narrative collections. It provides a theory base to inform the development of new narrative collections for use in complex mental health interventions. Collections can serve as a mechanism for supporting collective rather than individual discourses around mental health.

• Anti-smoking ads, price promotions, urges to smoke, and purchases in a virtual convenience store

  From: Journal of Medical Internet Research

  Date Submitted: Apr 30, 2019

  Open Peer Review Period: May 3, 2019 - Jun 28, 2019

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  Background: Point of sale (POS) advertising is associated with smoking initiation, current smoking, and relapse among former smokers. Price promotion bans and anti-smoking advertisements (anti-ads) ar...

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  Background: Point of sale (POS) advertising is associated with smoking initiation, current smoking, and relapse among former smokers. Price promotion bans and anti-smoking advertisements (anti-ads) are too possible interventions for combatting these influences. Objective: The purpose of this analysis was to determine the relationship between anti- ads and price promotions (promos) and urges to smoke and tobacco purchases. Methods: This analysis examined exposure to graphic and supportive anti-ads and promos in a virtual convenience store as predictors of urge to smoke and buying tobacco products among 1,200 current cigarette smokers and 800 recent quitters recruited via an online panel. We used STATA to construct linear regression models for urge to smoke and logistic regression models for tobacco purchases, stratified by smoking status. Results: The only significant finding was a significant negative relationship between exposure to supportive anti-ads and urge to smoke among current smokers (Coeff = -5.04, 95%CI: -9.85, -0.22). All other analysis of anti-ads, promos, urges to smoke, and tobacco purchases were not significant for either current smokers or recent quitters at the P >0.05 significance level. Conclusions: The results of this analysis support the potential utility of supportive anti-ads at the POS to influence urge to smoke among current cigarette smokers.

• Mainz Inventory of Microstressors (MIMIS): Development and ecological validation of a microstressor scale for adults

  From: JMIR Mental Health

  Date Submitted: May 2, 2019

  Open Peer Review Period: May 2, 2019 - Jun 27, 2019

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  Background: Many of the existing scales for microstressor assessment do not differentiate between objective (i. e., observable) stressor events as opposed to stressful cognitions or concerns and often...

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  Background: Many of the existing scales for microstressor assessment do not differentiate between objective (i. e., observable) stressor events as opposed to stressful cognitions or concerns and often mix these items with other aspects of stress, such as perceived stressor severity, the evoked stress reaction or further consequences on health. This may result in spurious associations with other questionnaires measuring such constructs. Since most scales were de-veloped several decades ago, modern life stressors may not be represented. Objective: To develop a questionnaire that a) focuses on the retrospective assessment of objective microstressors over a one-week period and b) separates stressor occurrence from perceived stressor severity. Methods: Cross-sectional (N=109) and longitudinal studies (N=10 and N=70) were conduct-ed. In the longitudinal studies, Ecological Momentary Assessment (EMA) was used to com-pare stressor data, collected five times per day for 30 days, with retrospective reports (end-of-day, -week). Pearson correlations and multilevel-modelling were used in the analyses. Results: High correlations were found between the end-of-week, end-of-day and EMA data for microstressor occurrence (counts) (r ≥ .69 for comparisons per week, r ≥ .83 for cumulated data) and for mean perceived microstressor severity (r ≥ .74 for comparisons per week, r ≥ .85 for cumulated data). The end-of-week questionnaire predicted the EMA assessments suf-ficiently (counts: b= .03, 95% CI= .02 to .03, P<.001; severity: b= .67, 95% CI= .52 to .82, P<.001), the association did not change significantly over the period of four subsequent weeks. Conclusions: Our results provide evidence for the ecological validity of the MIMIS questionnaire. Clinical Trial: none

• Quality of Websites about Long-Acting Reversible Contraception

  From: Journal of Medical Internet Research

  Date Submitted: Apr 29, 2019

  Open Peer Review Period: May 2, 2019 - Jun 27, 2019

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  Background: Long-acting reversible contraception are recommended for those who wish to prevent unintended pregnancies. Use of the Web for information about contraception is widespread, but there is a...

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  Background: Long-acting reversible contraception are recommended for those who wish to prevent unintended pregnancies. Use of the Web for information about contraception is widespread, but there is a risk that patients come in contact with sources of low quality. Objective: The overarching aim was to investigate the quality of websites about long-acting reversible contraception. Methods: Swedish patient-oriented websites were identified through searches in Google (n=46 included websites). Reliability and information about treatment choices was assessed by two assessors with the DISCERN instrument, transparency was analyzed with the Journal of the Medical Association benchmarks, completeness was assessed with content analysis, and readability was analyzed with Readability Index. Results: The mean DISCERN was 44.1 (SD 7.7) for total score, 19.7 (SD 3.7) for reliability, 22.1 (SD 4.1) for information about treatment choices, and 2.3 (SD 1.1) for overall quality. A majority of the included websites had low quality concerning if it included information when the information was produced (87%), if it was clear which sources that were used to compile the publication (78%), and if it provided additional sources of support and information (66%). Less than half of the websites adhered to any of the JAMA benchmarks. We identified 23 categories of comprehensiveness. The most frequent was treatment mechanism, which was covered by 39 (85%) websites. The least frequent was when treatment may be initiated following an abortion, which was covered by 3 (7%) websites. Mean Readability Index was 42.5 (SD 6.3, Range 29-55) indicating moderate or difficult readability levels. Conclusions: The quality of patient-oriented websites about long-acting reversible contraception is poor. There is an undeniable need to support and guide laypersons that intend to use web-based sources about contraceptive alternatives, so that they may reach informed decisions based on sufficient knowledge.

• Contextual, Real-Time Micro-Nudges Improve Eating Mindfulness and are Associated with Weight Loss

  From: JMIR mHealth and uHealth

  Date Submitted: Apr 25, 2019

  Open Peer Review Period: Apr 30, 2019 - Jun 25, 2019

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  Background: Most obesity management interventions do not achieve sustained behavior change and, thus, do not result in long term weight loss. A promising approach to weight loss involves mindful eatin...

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  Background: Most obesity management interventions do not achieve sustained behavior change and, thus, do not result in long term weight loss. A promising approach to weight loss involves mindful eating coaching, which increases awareness of internal cues including hunger and satiety. The purpose of this study was to evaluate the use of a novel technology that promotes mindful eating and drinking behaviors by providing contextual, real-time micro-nudges on wrist-worn wearable devices. Objective: Evaluate the use of a novel technology, promoting mindful eating and drinking behaviors using contextual micro-nudges on a wrist-worn device, and assess how it facilitates behavior change and weight loss. Methods: Participants used the mindful eating technology for 5 weeks. The primary outcomes of interest collected at the end of the intervention were user acceptability and engagement. Secondary outcomes collected before and at the end of the intervention were mindfulness while eating, consumptions behaviors, and weight loss. Results: 17 overweight and obese people completed the intervention. They found the technology to be highly acceptable: 75% reported that using the wearable on their dominant hand felt natural; 88% found it convenient to keep their phone nearby and use the wearable all day; 75% did not find the wearable’s vibrations (haptic) associated with the micro-nudges to be disruptive to the meal experience; 88% enjoyed having the Klue metrics visible on their wearable at all times. On average, the duration of the intervention was 34.2 days (SD 1.2). On average, participants used the app for all but 1.8 (SD 2.0) days, 13.0 (SD 1.0) hours per day when active, received to 27.2 micro-nudges (notifications) per day and engaged in 13.9 daily interactive coaching moments. Moreover, 94% of participants significantly improved their scores on the validated Mindful Eating Questionnaire (P=.001). Similarly, 94% of participants reported improving at least one consumption behavior during the study and 77% reported improving three or more consumption behaviors (e.g., eating more mindfully, remaining well hydrated). Average weight loss was 1.3kg (SD 2.3, P=0.03). Conclusions: The novel technology evaluated in this study provided real-time micro-nudges on a wrist-worn wearable that were acceptable to users and used frequently. Technologies such as these that interact with the user in-the-moment as behaviors are developing may lead to sustained engagement and could have a significant role in increasing mindful eating and producing positive behavior changes associated with successful weight loss. Clinical Trial: Stanford e-Protocol #39068

• Patient and Provider Perspectives Regarding Criteria for Patient Prioritization in Rehabilitation Programs

  From: Journal of Participatory Medicine

  Date Submitted: Apr 25, 2019

  Open Peer Review Period: Apr 30, 2019 - Jun 25, 2019

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  Background: Queueing patients on waiting lists is a common practice to manage access to rehabilitation services. To increase fairness and equity in access, a strategy emerging from the literature is p...

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  Background: Queueing patients on waiting lists is a common practice to manage access to rehabilitation services. To increase fairness and equity in access, a strategy emerging from the literature is patient prioritization. The goal is for patients with the greatest needs to be treated first and for patient wait times to be determined objectively on the basis of explicit criteria. Selecting criteria, however, is a complex task because it is important to simultaneously consider the objectives of all stakeholders. Objective: The aim of this study was to compare service users’ and service providers’ perspectives regarding patient prioritization criteria in two rehabilitation programs. Methods: We conducted a multiple case study in two rehabilitation programs at the Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale in Quebec City (Canada), i.e. a driving evaluation program (DEP) and a compression garment manufacturing program (CGMP). We sent a web-based survey asking two groups (patients and providers) of informed stakeholders to individually produce a set of criteria. We then conducted an inductive thematic analysis where each group’s individual answers were coded and combined in a single set of criteria. Results: Stakeholders from the DEP identified a total of 22 criteria to prioritize patients while those from the CGMP listed 27 criteria. Providers shared 76% of the criteria mentioned by patients. Some criteria, such as age, occupation, functional level, pain, absence of caregiver, and time since referral, were considered important by both stakeholders in both programs. Conclusions: Patients and providers tended to have similar opinions about a majority of the criteria to prioritize patients in waitlists. Nonetheless, our study confirms that patients and providers base their choices on different types of knowledge and values, which explains some of the differences observed. Taking into consideration the opinions of all stakeholders concerning prioritization criteria is an important part of the decision-making process, based on a multiple constituency approach.

• Physical Activity Monitoring in Ischemic Stroke – a Feasibility Study

  From: JMIR mHealth and uHealth

  Date Submitted: Apr 25, 2019

  Open Peer Review Period: Apr 30, 2019 - Jun 25, 2019

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  Background: Continuous tracking of ambulatory activity in real-world settings using step activity monitors (SAMs) has many potential uses but feasibility, accuracy, and correlation with performance me...

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  Background: Continuous tracking of ambulatory activity in real-world settings using step activity monitors (SAMs) has many potential uses but feasibility, accuracy, and correlation with performance measures in stroke patients has not been well-established. Objective: To assess the feasibility of monitoring step counts in patients with recent mild ischemic stroke using a consumer-grade SAM, the Fitbit Charge HR™. Methods: Fifteen participants with recent mild ischemic stroke wore a Fitbit Charge HR™ for the first 90-days after discharge home and completed three performance measures from the National Institutes of Health Toolbox at discharge and 30 days: standing balance test, 2-minute walk endurance test, and 4-meter walk gait speed test. Accuracy of SAM was assessed by calculating differences in steps recorded on the SAM and a manual tally during 2-minute walk tests. Results: Participants had mean age of 54 years; median modified Rankin scale score = 1. Mean daily adherence with SAM use was 83.6%. Mean daily step count in the first week after discharge was 4,376. Daily step counts increased slightly during the first 30 days after discharge (average increase 52.5 steps per day; 95% CI: 32.2-71.8), and remained stable during 30-90 day period after discharge. Mean step count difference between SAM and manual tally was -4.8 steps (-1.8%). Correlations with 2-minute walk, standing balance, and 4-meter gait speed at discharge were 0.41 (95% CI -0.14, 0.75), -0.12 (95% CI -0.67, 0.64), and 0.17 (95% CI -0.46, 0.66), respectively. They were similarly poor at 30-days. Conclusions: The use of consumer-grade Fitbit Charge HR™ in patients with recent mild stroke is feasible with reasonable adherence and accuracy. There was poor correlation between step counts and gait speed, balance, and endurance. Further research is needed to evaluate the association between step counts and other outcomes of relevance to patients.

• User Experience Investigation of Seven Mobile EEG Devices

  From: JMIR mHealth and uHealth

  Date Submitted: Apr 24, 2019

  Open Peer Review Period: Apr 30, 2019 - Jun 25, 2019

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  Background: Registration of brain activity becomes more and more popular and offers a way to identify the mental state of the user, prevent inappropriate workload, and control other devices by means o...

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  Background: Registration of brain activity becomes more and more popular and offers a way to identify the mental state of the user, prevent inappropriate workload, and control other devices by means of brain-computer interfaces. However, the registration of the EEG is often related to user-acceptance issues regarding the measuring technique. In the meanwhile, emerging mobile EEG technology offers the possibility of gel-free signal acquisition and wireless signal transmission. Nonetheless, user experience research about the new devices is lacking. Objective: In this article we aimed to evaluate user experience aspects of emerging mobile EEG devices and in particular investigate wearing comfort and issues related to the research field of emotional design. Methods: We considered seven mobile EEG devices and compared them regarding their wearing comfort, type of electrodes, visual appearance, and subjects' preference for daily use. Twenty-four subjects participated in our study and tested every device independently of the others. The devices were selected in randomized order and worn on consecutive-day sessions of 60 min duration. At the end of each session, subjects rated the devices by means of questionnaires. Results: Results indicated a highly-significant change in maximal-possible wearing duration between the EEG devices (Χ^2=40.215, df=6, n=24, P<.001). Regarding the visual perception of devices' headset design, results indicated a significant change in subjects' ratings (Χ^2=78.663, df=6, n=24, P<.001). Results of subjects' ratings regarding the practicability of the devices indicated highly-significant differences between the EEG devices (Χ^2=83.185, df=6, n=24, P<.001). Ranking order and post-hoc tests offered more insight and indicated that pin electrodes had the smallest wearing comfort, in particular when coupled with a rigid, heavy headset. Finally, multiple linear regression for each device separately revealed that users were not willing to accept less comfort for a more attractive headset design. Conclusions: The study offers a differentiated look at emerging mobile and gel-free EEG recording technology as well as at the relation between user-experience aspects and device preference. Our research could be seen as a precondition for the development of usable applications with wearables and contributes to consumer health informatics and health-enabling technologies. Furthermore, our results provided guidance for the technological-development direction of new EEG devices related to aspects of emotional design.

• Usability of 60 Second Caregiver: A Weekly, Evidence-Based Health Letter for Caregivers

  From: Journal of Medical Internet Research

  Date Submitted: Apr 26, 2019

  Open Peer Review Period: Apr 29, 2019 - Jun 24, 2019

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  Background: Informal caregivers are family members or close friends who provide unpaid help to individuals with acute or chronic health conditions so that they can manage daily life tasks. The greates...

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  Background: Informal caregivers are family members or close friends who provide unpaid help to individuals with acute or chronic health conditions so that they can manage daily life tasks. The greatest source of health information is the internet for meeting the needs of caregivers. However, information on the internet may not be scientifically valid, it may be written in language that is difficult to read, and is often in very large doses. 60Second Caregiver is a health letter whose aim is to disseminate knowledge to caregivers in a user-friendly, weekly format, in order to improve their wellbeing. Objective: The main objective was to test a sample of 60Second Caregiver health letters in order to assess their usability and to optimize the design and content of the health letters. Methods: Usability research themes were assessed using semi-structured phone interviews, incorporating the Think Aloud method with retrospective questioning. Results: Usability was assessed in the context of five main themes: understandability and learnability, completeness, relevance, and quality and credibility of the health letter content, as well as design and format. Caregivers generally provided positive feedback regarding the usability of the letters. The usability feedback was used to refine 60Second Caregiver in order to improve the design and content of the series. Based on the results of this study, it may be of maximum benefit to target the series towards individuals who are new to caregiving or part-time caregivers, given that these caregivers of the sample found the letters more useful and relevant and had the most positive usability experiences. Conclusions: The findings assisted in the improvement of the 60Second Caregiver template, which will be used to create future health letters and refine the letters that have already been created. The findings have implications for who the 60Second Caregiver series should be targeting (i.e., newer or part-time caregivers) in order to be maximally impactful in improving mental health and wellbeing-related outcomes for caregivers, such as self-efficacy and caregiving knowledge. The results of this study may be generalizable to the examination of other electronic health information formats, making them valuable to future researchers testing the usability of health information products. In addition, the methods used in this study are useful for usability hypothesis generation. Lastly, our 60Second delivery approach can generate information useful for a set of similar products (e.g., weekly health letters targeted towards other conditions/populations).

• Exploring how professionals within Agile Healthcare Informatics perceive visualizations of Log File Analyses

  From: Journal of Medical Internet Research

  Date Submitted: Apr 25, 2019

  Open Peer Review Period: Apr 29, 2019 - Jun 24, 2019

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  Background: User-Centered Design (UCD) is seen as a vital determinant of a healthcare informatics’ success. Yet, an increasing number of software companies work according to the Agile software devel...

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  Background: User-Centered Design (UCD) is seen as a vital determinant of a healthcare informatics’ success. Yet, an increasing number of software companies work according to the Agile software development method, which is difficult to integrate with UCD practices. Log file analysis may provide opportunities for integrating UCD practices in the Agile process. However, research within healthcare information technology mostly has a theoretical approach and is often focused on the researcher’s interpretation of log file analyses. No studies have been reported on the Agile professionals’ interpretation of log file analyses, and therefore an opportunity exists for coupling these interpretations to concrete steps in the Agile development process. Objective: We propose a systematic approach to log file analysis (including pre-processing, analysis and various visualizations) in this study, and present these to developers to explore how they react and interpret them in the context of a real world healthcare information system, in an attempt to answer the following question: How may log file analyses contribute to increasing the match between the healthcare system and its users within the Agile development method according to Agile team members? Methods: This study consisted of two phases to answer the research question. In the first phase, log files were collected from a healthcare information system, and subsequently analyzed (summarizing sequential patterns, heatmapping, and clustering). In the second phase, the results of these analyses are presented to Agile professionals during a focus group interview. The interpretations of the Agile professionals are analyzed by open axial coding. Results: In the first phase, log file data of 17924 user sessions, and in total 176678 activities were collected. We found that the Patient Timeline is mainly visited, with 23707 (13.42%) visits in total. The page Change Conversation topic was least visited (n = 3; 0.0%). The main unique user session occurred in 5.99% of all user sessions, and consisted of ‘Insert Measurement Values for Patient’, ‘Patient Timeline’ followed by the page ‘Patient Settings’ and lastly ‘Patient Treatment Plan’. In the heatmap, we found that users often navigate to the pages ‘Insert Measurement Values’ and ‘Load Messages Collaborate’. Moreover, we found that there is a high probability that users repeatedly navigate from page ‘Address Book’ towards ‘Address Book’ again. Lastly, in the cluster analysis we found five clusters, namely the Information-seeking cluster (SS = 96.16), the Collaborative cluster (SS = 99.27), the Mixed cluster (SS = 193.40), the Administrative cluster (177.57), and the Patient-Oriented cluster (SS = 378.02). The total sum of squares within groups was 944.42 and the between sum of squares was 561.49. In the second phase, we found that the interpretations of these results by Agile professionals are related to stating hypotheses (n = 34), comparing paths (n = 31), benchmarking (n = 22), and prioritizing (n = 17). Conclusions: We found that analyzing log files provides Agile professionals valuable insights into users’ behavior. Therefore, we argue that log files analyses should be used within Agile development to inform professionals about users’ behavior. In this way, further UCD research can by informed by these results, making the methods less labor-intensive. Moreover, we argue that these translations to an approach for further UCD research will be carried out by UCD specialists, since they are able to infer which goals the user had when going through these paths when looking at the log data.

• Does teleconsultation reduce face to face visits? Evidence from the Catalan public primary care system

  From: Journal of Medical Internet Research

  Date Submitted: Apr 25, 2019

  Open Peer Review Period: Apr 29, 2019 - Jun 24, 2019

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  Background: eConsulta is a teleconsultation service between doctors and patients which is part of Catalonia’s public health system’s IT system. It has been in operation since the end of 2015 as a...

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  Background: eConsulta is a teleconsultation service between doctors and patients which is part of Catalonia’s public health system’s IT system. It has been in operation since the end of 2015 as a complement to the face-to-face consultations offered by the territory’s Primary Care Teams (PCTs) as one of the services offered in the Personal Health Folder. Objective: evaluate the relationship between the use of eConsulta and the number of face-to-face visits. Methods: 18 professionals from the Central Catalonia Health Region retrospectively categorized the cases managed via eConsulta (2,268), according to 13 typologies proposed by the authors, and indicated whether, in their opinion, they served to reduce the number of face-to-face visits. Results: the most frequent use of the e-consultation was for the management of test results (33%), queries for clinical reasons (17%) and the management of repeat prescriptions (12%). On average the conversations consisted of 1.57 messages (45% were only one message, the rest were conversations of mostly two and up to five interactions), with the patient initiating the majority of said conversations (60%). There was a broad consensus among doctors that eConsulta has a very high capacity to resolve patient queries (avoiding the need for a face-to-face visit in 88% of cases) for every type of consultation. Conclusions: the use of eConsulta is strongly associated with the reducing the number of face-to-face visits and is shown as a useful tool to avoid interactions with little added clinical value. Clinical Trial: The study was approved by the Ethical Committee for Clinical Research at the Foundation University Institute for Primary Health Care Research Jordi Gol i Gurina, with registration number P18/023.

• Predictors of patients’ loyalty towards doctors on online health communities

  From: Journal of Medical Internet Research

  Date Submitted: Apr 24, 2019

  Open Peer Review Period: Apr 29, 2019 - Jun 24, 2019

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  Background: Online health communities not only provide means for patients to seek care, but also to promote their relationship with doctors. However, little is known about the predictors of patient lo...

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  Background: Online health communities not only provide means for patients to seek care, but also to promote their relationship with doctors. However, little is known about the predictors of patient loyalty towards doctors on online health communities. Objective: This study aims to investigate what are the predictors of patient loyalty towards doctors in online health communities. Methods: Based on social-technical systems theory and attachment theory, we propose that social factors including emotional interaction, perceived expertise and social norm influence patient loyalty through their emotional attachment, while technical factors containing sociability, personalization and perceived security affect patient loyalty through functional dependence. To validate our proposed research model, we employed the survey method and collected 373 valid answers. Partial least square was used to analyze the data. Results: Our empirical analysis results show that all the social factors including emotional interaction (b=0.257, t=2.571, p<0.05), perceived expertise (b=0.288, t=3.412, p<0.01) and social norm (b=0.210, t=2.017, p<0.05) affect patients’ emotional attachment towards doctors significantly, while except sociability (b=0.110, t=1.152, p>0.05), technical factors like personalization (b=0.242, t=2.228, p<0.05) and perceived security (b=0.328, t=3.438, p<0.01) impact functional dependence significantly. Considering the effect of working mechanisms, both emotional attachment (b=0.443, t=4.518, p<0.001) and functional dependence (b=0.303, t=2.672, p<0.01) influence patient loyalty towards doctors on online health communities significantly. Conclusions: Patient loyalty towards doctors on online health communities is important for the effectiveness of doctors’ advice or service in online health communities. The research results, not only fill the gaps in the literature of the patient-doctor relationship and online health communities, but also provide many implications to establish patient loyalty on online health community and in physical context.

• Healthcare professionals’ perspectives on the secondary use of health records to improve quality and safety of care: a qualitative study in England

  From: Journal of Medical Internet Research

  Date Submitted: Apr 20, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: Background: Healthcare professionals (HCP) are often patients’ first point of contact in what concerns the communication of the purposes, benefits, and risks of sharing electronic health...

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  Background: Background: Healthcare professionals (HCP) are often patients’ first point of contact in what concerns the communication of the purposes, benefits, and risks of sharing electronic health records (EHR) for non-direct care purposes. Their engagement is fundamental to ensure patients’ buy-in and a successful implementation of healthcare data sharing schemes. However, their views on this subject were seldom evaluated. Objective: Objective: To explore HCP’ perspectives on the secondary uses of healthcare data in England. Specifically, we aimed to assess a) their knowledge on its purposes and b) the main concerns about data sharing processes. Methods: Methods: A total of 30 interviews were conducted between the 27th March and 7th April 2017 using an online interview platform, and following a topic guide with open-ended questions. The participants represented a variety of geographic locations across England (London, West Midlands, East of England, North East, Yorkshire and the Humber), covering both primary and secondary care services. The transcripts were compiled verbatim and systematically reviewed by two independent reviewers, using the framework analysis method to identify emerging themes. Results: Results: HCP were knowledgeable about the possible secondary uses of data and highlighted its importance for 1) patient profiling and tailored care, 2) research, 3) quality assurance, 4) public health, and 5) service delivery planning purposes. Main concerns towards data sharing included 1) data accuracy, 2) patients’ willingness to share their records, 3) challenges on obtaining free and informed consent, 4) data security, 5) lack of adequacy / understanding of current policies, and 6) potential patient exposure and exploitation. Conclusions: Conclusions: These results suggest a high level of HCP understanding about the purposes of data sharing for secondary purposes, however, some concerns still remain. A better understanding of HCP’ knowledge and concerns could inform national communication policies, and improve tailoring in order to maximise efficiency and improve patients’ buy-in.

• Analyzing Demographic Impact on Online Physician Ratings

  From: Journal of Medical Internet Research

  Date Submitted: Apr 21, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: Online doctor reviews are an important information source for prospective patients. In addition, they represent an untapped resource for studying gender bias in the doctor patient relatio...

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  Background: Online doctor reviews are an important information source for prospective patients. In addition, they represent an untapped resource for studying gender bias in the doctor patient relationship. Understanding bias is important because it may impact the value of online reviews to patients. Documenting bias is also important for improving the doctor patient relationship. Yet studies of bias are currently limited to smaller data sets and specific conditions. Objective: In this research, we explore 154,305 reviews from across the U.S. for all doctor specialties. Our analysis includes a qualitative and quantitative examination of review content and rating as they relate to doctor and reviewer gender. Methods: 154,305 reviews were downloaded from Google. For each review, the reviewer and doctor were assigned a gender based on name. Reviews were also coded by star rating (low or high) and content category (process, positive soft skills, negative soft skills). Our quantitative analysis made use of regression to model the relationships between the variables of interest (process, soft skills, physician gender, and reviewer gender). Results: Reviews for female physicians were overall significantly more critical (3.4 average rating for female and 4.0 average rating for male physicians). Reviews for female physicians were significantly more critical with respect to both process and soft skills, with negative comments on soft skills being twice as common for female (16.02%, 5,903 of 36,847) as for male physicians (8.80%, 6,529 of 74,189). Reviewer gender was not a strong predictor of review outcome or content, in general (p=0.046). The largest difference is in mentions of negative soft skills; 8.81% of female reviewers (5,978 of 67,857) and 7.79% of male reviewers (3,364 of 43,179). However there is a significant interaction effect between reviewer and physician gender. Female reviewers rate male physicians positively around 75.90% of the time (33,466 of 44,094), while male reviewers rate female physicians positively around 58.19% of the time (7,362 of 12,652). Our approach cannot identify causal relationships. Conclusions: Reviews for female physicians were more critical and focused more on soft skills than reviews for male physicians. Additionally, female reviewers are more likely to report on positive interpersonal skills than are male reviewers, and more likely to report experiences of disrespect and indifference in negative reviews than are male reviewers. This work complements existing smaller-scale studies of bias and suggest a need to include information about gender differences in review site summaries and search results. Clinical Trial: N/A

• Design and Evaluation of a Mobile Phone Based Gait Assessment Application for the Elderly: An Empirical Study among 140 Older Chinese Adults

  From: JMIR mHealth and uHealth

  Date Submitted: Apr 19, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: Gait disorder is common among older adults. With increases in the use of technology among older adults, a mobile application provides a solution for older adults to self-monitor their gait...

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  Background: Gait disorder is common among older adults. With increases in the use of technology among older adults, a mobile application provides a solution for older adults to self-monitor their gait quality in daily life. Objective: The objective of this study was to develop a gait-monitoring mobile application (Pocket Gait) and evaluate its acceptability and usability among potential older users. Methods: The application was developed to allow older adults to track their gait quality, including step frequency, step intensity (RMS), step regularity, step symmetry and step variability. One hundred and forty-eight community-dwelling older adults were recruited from two cities in China: Beijing and Chongqing. They walked in three ways (single task, dual task and fast walking) using a smartphone with the gait-monitoring application installed. Then, they completed an acceptability and usability survey after the walk test. User acceptability was measured by a questionnaire including four quantitative measures: perceived ease of use, perceived usefulness, ease of learning and intention to use. Usability was measured using the System Usability Scale (SUS). Interview were conducted with participants to collect open-ended feedback questions. Results: The acceptability of the gait-monitoring application was positive among older adults. Participants identified the usability of the system with an overall score of 59.7 (SD = 10.7) out of 100. Older adults from Beijing scored significantly higher SUS compared with older adults from Chongqing (p<.05). The age of older adults was highly associated with their SUS score (p<.05). Older adults identified improvements including larger font sizes, inclusion of reference values of gait parameters and inclusion of heart rate and blood pressure. Conclusions: The mobile application is a health management tool for older adults to self-manage their gait quality and prevent adverse outcomes. It will be important to take factors such as age and region into consideration when further designing a mobile phone-based gait assessment application. The feedback of the participants would help to design more elderly-friendly products.

• Disparities in Electronic Patient Portal Use in Prenatal Care: Retrospective Cohort Study

  From: Journal of Medical Internet Research

  Date Submitted: Apr 18, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: Electronic patient portals are websites that provide individuals access to their personal health records and allow them to engage through a secure online platform. These portals are becomi...

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  Background: Electronic patient portals are websites that provide individuals access to their personal health records and allow them to engage through a secure online platform. These portals are becoming increasingly popular in contemporary healthcare systems. Patient portal use has been found to be beneficial in multiple specialties, especially in management of chronic disease. However, disparities have been identified in portal use in which racial/ethnic minorities and individuals from lower socioeconomic status have been shown to be less likely to enroll and use patient portals than non-Hispanic white persons and persons with higher socioeconomic status. Electronic patient portal use by childbearing women has not been well studied, and data on portal use during pregnancy are limited. Objective: The objective of this study was to quantify use of an electronic patient portal during pregnancy and examine whether disparities exist related to patient demographics or clinical characteristics. Methods: Retrospective cohort study of women who received prenatal care at an academic medical center (2014-16). Clinical records were reviewed for portal use and patient data. Patients were considered enrolled in the portal if they had an account at the time of delivery; enrollees were compared to non-enrollees. Enrollees were further categorized based on the number of secure messages sent during pregnancy as active (≥1) versus inactive (0) users. Bivariable chi-square and multivariable Poisson regression models were used to calculate the incidence rate ratio of portal enrollment and, if enrolled, of active use based on patient characteristics. Results: Of 3450 women eligible for inclusion, 2530 (73%) enrolled in the portal. Of these enrollees, 1824 (72%) were active users. There was no difference in portal enrollment by maternal race and ethnicity on multivariable models. Women with public insurance (adjusted incidence rate ratio [aIRR], 0.60; 95% confidence interval [CI] 0.49 to 0.84), late enrollment in prenatal care (aIRR 0.78; 95% CI 0.69 to 0.89 for 2nd trimester and aIRR 0.50; 95% CI 0.39 to 0.64 for 3rd trimester), and high-risk pregnancy (aIRR 0.82; 95% CI 0.75 to 0.89) were significantly less likely to enroll. Conversely, nulliparity (aIRR 1.10; 95% CI 1.02-1.20) and having more than eight prescription medications at prenatal care initiation (aIRR 1.19; 95% CI 1.06-1.32) were associated with greater likelihood of enrollment. Among portal enrollees, the only factor significantly associated with active portal use (i.e. secure messaging) was nulliparity (aIRR 1.11; 95% CI 1.01-1.23). Conclusions: Among an obstetric population, multiple clinical and socioeconomic factors were associated with electronic portal enrollment, but not subsequent active use. As portals become more integrated as tools to promote health, efforts should be made to ensure that already vulnerable populations are not further disadvantaged with regard to electronic-based care.

• It’s a learning curve: A mixed method study on improving knowledge about pregnancy for Deaf South African women of reproductive age through an SMS-based information campaign

  From: JMIR mHealth and uHealth

  Date Submitted: Apr 18, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: Signing Deaf South Africans have limited access to health information and consequently limited knowledge about health. Maternal and neonatal mortality rates are high. Cell phone usage is h...

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  Background: Signing Deaf South Africans have limited access to health information and consequently limited knowledge about health. Maternal and neonatal mortality rates are high. Cell phone usage is high, making it a potentially important way of communicating about maternal and child health. Objective: The primary aim of this study was to assess whether an SMS-based health information campaign could improve knowledge about pregnancy, antenatal care and healthy living during pregnancy for signing Deaf South African women of reproductive age. A secondary aim was to evaluate the acceptability of such an intervention. Methods: The study was designed as a pre-test-post-test study. A baseline questionnaire assessed participants’ knowledge about pregnancy, antenatal care and healthy living during pregnancy before an SMS-based information campaign was conducted. After the campaign, an exit questionnaire was conducted, containing the same questions as the baseline questionnaire with additional questions about general acceptability and communication preferences. Results were compared between baseline and exit, using McNemar’s test and Wilcoxon signed-rank test. A focus group aimed to get further information on the impact and acceptability of SMSs. The focus group was analysed inductively. Results: The research showed a statistically significant improvement in overall health knowledge amongst participants. Despite this, some participants found the medical terminology difficult to understand. Several ways of improving SMS-campaigns for the Deaf were identified, including using MMSs (Multimedia Services) with a person signing messages and linking information campaigns to an interactive communication service that would enable Deaf people to pose questions. The focus group also suggested that SMSs might play a role in motivating healthy behaviour during pregnancy. Conclusions: The SMS-campaign was effective in improving Deaf women’s knowledge about pregnancy, antenatal care and healthy living during pregnancy amongst Deaf women of reproductive age and has potential to impact on healthy behaviour. This contrasts with a similar study with hearing pregnant women. This suggests that SMSs may be particular effective in improving Deaf people’s health knowledge. However, attention should be given to Deaf participants’ specific needs and communication preferences to optimise impact. The potential for using SMS-campaigns to impact on behaviour should be studied. Clinical Trial: The research was registered with the Pan African Clinical Trial Registry on December 1, 2015. Identification numbers: PACTR201512001352180.

• Just Because (most) Hospitals are Publishing Charges Doesn’t Mean Prices are More Transparent

  From: Journal of Medical Internet Research

  Date Submitted: Apr 18, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: Centers for Medicare and Medicaid Services (CMS) recently mandated that all hospitals publish their charge description masters (CDM) online, in a machine-readable format, by January 1, 201...

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  Background: Centers for Medicare and Medicaid Services (CMS) recently mandated that all hospitals publish their charge description masters (CDM) online, in a machine-readable format, by January 1, 2019. Additionally, CMS recommended that CDM data be made available in a manner that was consumer-friendly and accessible to patients. Objective: We examined all hospitals across the state of Pennsylvania to understand policy compliance and user friendliness of posted CDM data. Methods: A cross-sectional analysis was performed, quantifying hospital website compliance with recent CMS policies requiring hospitals to publish their CDM. Data was collected from all Pennsylvania hospital websites. Consumer-friendliness was assessed based on searchability, number of website clicks to data, and supplemental education accompanying CDM. Results: Most hospitals (80%) were compliant, but significant variation in data presentation occurred. Mean number of website clicks to CDM was 3.7 (standard deviation: 1.3; range: 1-8). 23.1% of compliant hospitals provided no supplemental educational with their CDM. Conclusions: While disclosure of charges has improved, the data are not sufficient to reasonably influence patient decision-making.

• Efficacy and safety of mHealth application and wearable device in physical performance for patients with hepatocellular carcinoma

  From: JMIR mHealth and uHealth

  Date Submitted: Apr 18, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: Despite the positive effect of exercise is quite predictable in hepatocellular carcinoma (HCC) patients, these patients are hesistant to start and build up exercise for one major reason: t...

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  Background: Despite the positive effect of exercise is quite predictable in hepatocellular carcinoma (HCC) patients, these patients are hesistant to start and build up exercise for one major reason: the vague fear of developing hepatic decompensation, a potentially fatal condition that can even lead to death. Integrating mobile healthcare (mHealth) with individualized exercise program could be a possible option for promoting physical capacity of HCC patients. Objective: The aim of this study was to evaluate the efficacy and safety of rehabilitation exercises individually prescribed via an mHealth application on physical fitness, body composition, biochemical profile, and quality of life in HCC patients. Methods: A total of 37 HCC patients were enrolled in a 12-week course with an mHealth application program targeted to HCC patients. At baseline, 6-week, and 12-week, participants’ physical fitness levels (6-minute walk test, grip strength test, 30-second chair stand test) were measured. Physical activity level (IPAQ), body composition (BMI, body fat percentage, muscle mass), biochemical profiles, and quality of life (EORTC QLQ-C30) were assessed at baseline and endpoint. At the 6-week midpoint, exercise intensity was individually adjusted. Results: Of the 37 patients, 31 completed the 12 weeks of intervention. Grip strength improved significantly after 12 weeks of intervention. The 30-second chair stand test and 6 minute walk test showed significant improvement after 6 and 12 weeks, and from 6 to 12 weeks. Muscle mass and IPAQ score increased significantly after 12 weeks of intervention without biochemical deterioration. Conclusions: Twelve weeks of mhealth care, including an individually prescribed rehabilitation exercise program, significantly improved physical fitness, body composition, and physical activity without any complication or biochemical deterioration in compensated HCC patients who had completed therapy.

• Comment on "Clinical Virtual Simulation in Nursing Education"

  From: Journal of Medical Internet Research

  Date Submitted: Apr 17, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  ...

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• Developing coherent assessment for a virtual patient: comparing the virtual patient’s assessment to clinical educators’ judgement

  From: JMIR Medical Education

  Date Submitted: Apr 17, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: Virtual patient software can be a useful tool to foster the development of medical history taking skills without the bedside setting’s inherent constraints. While virtual patients (VP) h...

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  Background: Virtual patient software can be a useful tool to foster the development of medical history taking skills without the bedside setting’s inherent constraints. While virtual patients (VP) hold the promise of contributing to the development of students’ skills, documenting and assessing skills acquired through VP remains a challenge. Objective: We propose outcome measures for medical history taking, articulate their implementation within a VP and then test the measures by comparing VP scores to the judgement of 10 clinician-educators (CE). Methods: We built, in the virtual patient software, four domains of medical history taking to be assessed (Breadth, Depth, Logical Sequence and Interviewing Technique). Ten CE watched the screen recordings of three students to assess performance first globally then for each of the four domains for the three students. Results: The scores provided by the VP were slightly higher but comparable to the ones given by the CE for the global performance and for Depth, Logical Sequence and interviewing technique. For Breadth, the VP scores were higher for two of the three students compared to the CE scores. Conclusions: Findings suggest that the VP assessment gives results akin to those that would be generated by CE. Developing a model for what constitutes a good history taking performance in specific contexts may provide insight about how CEs generally think about assessment.

• Attracting Users to Online Health Communities: Results of LungCancer.net Facebook Advertisement Campaigns

  From: Journal of Medical Internet Research

  Date Submitted: Apr 20, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: With growing numbers of adults turning to the Internet to answer health questions, online communities provide platforms with participatory networks to deliver health information and social...

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  Background: With growing numbers of adults turning to the Internet to answer health questions, online communities provide platforms with participatory networks to deliver health information and social support. To optimize the benefits of these online communities, however, these platforms must effectively market to attract new members and promote community growth. Objective: The objective of this study was to assess the engagement results of Facebook advertisements designed to increase membership in the LungCancer.net online community. Methods: In the fall of 2017, a series of five, weeklong Facebook advertisement campaigns were launched targeting adults over the age of 18 with an interest in lung cancer to increase the number of people who provided their email to join the LungCancer.net community. Results: Through the Facebook campaigns, 91,835 people were exposed to at least one study advertisement, and 863 new members joined the LungCancer.net community. Females ages 55 - 64 were the largest population reached by the campaign (34.29%), while females 65 and older were the largest population who joined the LungCancer.net community (35.57%). A total of $1742 was invested in the Facebook campaigns and 863 people joined LungCancer.net, resulting in a cost of $2.02 per new member. Conclusions: This research demonstrates the feasibility of using Facebook advertising to promote and grow online health communities, though more research is needed to identify the images, texts, advertisement methods/channels, and times of year that most effectively promote online community growth. Public health professionals should consider Facebook campaigns to effectively connect intended audiences to health information and support.

• Are Actual Behavior and Intention of Rating Physician Online Determined by Different Factors? A Cross-Sectional Study

  From: Journal of Medical Internet Research

  Date Submitted: Apr 17, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: Online physician rating (OPR) information is increasing popular among health consumers in China, but limited number of reviews generated by patients greatly hampered consumers’ usage. So...

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  Background: Online physician rating (OPR) information is increasing popular among health consumers in China, but limited number of reviews generated by patients greatly hampered consumers’ usage. So far, there has been little discussion about variables that influence OPR information generation from users’ perspective. Objective: To estimate the current level of OPR information generation in China and investigate the key factors that are associated with the actual behavior and intention of generating OPR information. Methods: An online cross-sectional survey of 589 valid Chinese health consumers was conducted in October 2018. We analyzed the impact of sociodemographic variables, health related variables, social cognitive variables and technology acceptance variables. Binary multivariate logistic regression and multiple linear regression models were separately performed for elaborating the characteristics of health consumers’ rating behavior and intention. The survey instrument was based on existing literature and pilot interview. Results: A total of 57.4% (338/589) of the sample used OPR information and 18.9% (111/589) had rated physician online. Factors that impacted physician rating behavior and intention were different. Actual physician rating behavior was mainly associated with experience of seeking physician information online (B=2.120, p<.001), experience of booking/consulting physician online (B=.715, p=.004), health information seeking ability (B=.225, p=.012), serious diseases (B=.674, p=.013), very good medical experience (B=.807, p=.004), lower levels of altruism (B=-.418, p=.009) and trust in OPR information (B=.406, p=.004). Furthermore, experience of booking physician online (β=.269, p=.004), rating habit (β=.185, p<.001), altruism (β=.432, p<.001), self-efficacy (β=.179, p<.001), trust in OPR information (β=.311, p<.001), perceived usefulness (β=.113, p=.011) and perceived ease of use (β=.093, p=.006) served as significant predictors for health consumers’ physician rating intention after they were aware of OPR information in our study. Conclusions: Health related variables played more important role in consumers’ physician rating behavior, while social cognitive variables and technology acceptance variables were more critical for consumers’ rating intention. We proposed some practical implications for PRWs and physician to promote OPR information generation.

• Characteristics of Patients Using Different Patient Portal Functions and the Impact on Primary Care Service Utilization and Appointment Adherence

  From: Journal of Medical Internet Research

  Date Submitted: Apr 16, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: Patient portals are now widely available and increasingly adopted by patients and providers. Objective: The objective of this study was to investigate the characteristics of primary care p...

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  Background: Patient portals are now widely available and increasingly adopted by patients and providers. Objective: The objective of this study was to investigate the characteristics of primary care patients using different patient portal functions and the impact of patient portal usage on patients’ primary care service utilization and appointment adherence. Methods: A retrospective observational study using a large dataset of primary care patients of University of Florida (UF) Health was conducted. A total of 4312 patient portal users and 17580 nonusers were identified during the study period July 2013 – June 2016. Patients were classified into different user subgroups based on their portal usage of messaging, laboratory, appointment, and medication functions. The association between patient demographics and portal usage were analyzed. Primary care service utilization and appointment adherence were measured by primary care office visits arrived, no-show, cancellation, and telephone encounter rates per quarter. Generalized linear models (GLM) were built to compare the time-dependent portal usage effects across different user subgroups and nonusers. Results: Five different user subgroups based on their dominant portal activities and usage frequency were identified. After adopting portals, patients with fewer active health problems used portal infrequently (silent users). Medicare (P = 0.04), White, and age 46-64 (P = 0.01) and 65 and older (P = 0.04) were positively associated with messaging usage. Age 19-30 (P < 0.001) was positively associated with appointment usage, and gender female (P = 0.01) was positively associated with laboratory usage. On the impact of portal usage, disease burden adjusted rate ratios (RR) between user subgroups and nonusers were obtained. The office visit and telephone encounter RRs of users to nonusers were significantly larger than 1 right after portal adoption (with P values less than 0.05), but were not significantly different 2 years after adoption, except for the silent users, whose office visit and telephone encounter rates were significantly smaller after around 1 year post portal adoption (with P values less than 0.05). Office visit cancellation rates were not changed, and no-show rates were significantly reduced or at least not changed post portal adoption. Patients who used messaging and laboratory functions more often exhibited a larger reduction in no-show among other user subgroups. Conclusions: Interestingly, a high propensity to adopt patient portals does not necessarily imply more frequent usage of portals. In particular, the number of active health problems was negatively associated with portal adoption but was positively associated with portal usage. For patients with fewer active health problems, their primary care service utilization was even lower after portal adoption; with a heavy disease burden, the utilization was temporarily increased but was not significantly changed after 2 years post adoption. Overall, appointment adherence was improved after portal adoption.

• Compassion apps for better mental health, a qualitative review.

  From: JMIR mHealth and uHealth

  Date Submitted: Apr 18, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: There is increasing empirical evidence for the positive mental health effects of compassion-based interventions. Although numerous smartphone apps offering compassion-based interventions (...

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  Background: There is increasing empirical evidence for the positive mental health effects of compassion-based interventions. Although numerous smartphone apps offering compassion-based interventions (‘compassion apps’) are now available for the general public, these apps have not been reviewed on their quality before. Objective: The current study focuses on rating existing compassion apps on their quality. Methods: Existing compassion apps were identified through searches in the Google Play store and App store. The 19 included apps were rated on their overall quality using the Mobile App Rating Scale and on their consistency with current evidence by comparing them to existing and studied compassion-based interventions. Results: Eight apps were identified that met the criteria of being consistent with existing and studied compassion-based interventions, and acceptable to good overall quality, and 11 apps that fail to meet one or both of these criteria. Conclusions: Good quality compassion apps are available but many of the available apps fail to meet certain quality criteria. It is recommended that future compassion apps are based on a clear definition of compassion, offer evidence- and theory based exercises and implement tools for increasing engagement.

• Who uses health apps among individuals with and without type 2 diabetes? A nationwide population-based survey

  From: JMIR Diabetes

  Date Submitted: Apr 15, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: Evidence suggests that mobile health app use is beneficial for the prevention and management of type 2 diabetes (T2D) and its associated complications; however, population-based research o...

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  Background: Evidence suggests that mobile health app use is beneficial for the prevention and management of type 2 diabetes (T2D) and its associated complications; however, population-based research on specific determinants of health app use in people with and without T2D is scarce. Objective: This study aimed to provide population-based evidence on rates and determinants of health app use among adults without diabetes and with T2D thereby covering a prevention perspective and a diabetes management perspective, respectively. Methods: The study population was comprised of 2327 adults without a known diabetes diagnosis and 1149 adults with known T2D from a nationwide telephone survey in Germany conducted in 2017. Rates of smartphone ownership and health app use were estimated based on weighted sample proportions. Among smartphone owners, determinants of health app use were identified for both groups separately in multivariable logistic regression models. Sociodemographic factors, diabetes-related, psychological and health-related factors, and health care utilization were selected as potential determinants. Results: Among participants without known diabetes, 74.7% (n = 1690) were smartphone owners. Of those, 49.3% (n = 717) used health apps, most often to improve regular physical activity. Among participants with T2D, 42.3% (n = 481) were smartphone owners. Of those, 41.1% (n = 171) used health apps, most commonly to target a healthy diet. Among people without known diabetes, determinants significantly (all P < .05) associated with an increased likelihood of health app use compared to their reference group were: younger age, 18-44 or 45-64 years (odds ratios (ORs) 4.36; 1.90); overweight or obesity (ORs 1.56; 1.96); hypertension diagnosis (OR 1.31); former or current smoking (ORs 1.52; 1.60); family history of diabetes (OR 1.34); other chronic diseases (OR 1.48); and having received health advice from a physician (OR 1.45). Poor perceived health (OR 0.72), a slight or high perceived diabetes risk (ORs 0.76; 0.24), and more optimistic bias about developing diabetes (OR 0.79) were significantly associated with a decreased likelihood of health app use. Among people with T2D, younger/middle age (18-64 years, OR 1.76), female gender (OR 1.71), using a blood glucose meter as well as a glucose sensor (OR 6.58), and more optimistic bias about developing diabetes complications (OR 1.43) were significantly positively associated with health app use. Conclusions: In terms of T2D prevention, age, diabetes-related risk factors, psychological and health-related factors, as well as health care factors may inform app development for specific target groups. Additionally, health professionals may encourage health app use when giving advice on health behaviors. Concerning T2D management, only a few determinants seem relevant for explaining health app use among people with T2D, indicating a need for more future research on which people with T2D use health apps and why.

• Pro-Breastfeeding Social Media Groups: Hidden Communities of Practice?

  From: JMIR Pediatrics and Parenting

  Date Submitted: Apr 11, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: In recent years, research around the intersection of motherhood, breastfeeding, and technology has grown significantly. These technological advancements elicit a need to better understand...

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  Background: In recent years, research around the intersection of motherhood, breastfeeding, and technology has grown significantly. These technological advancements elicit a need to better understand how communication and interaction between mothers within social media groups impacts breastfeeding-related outcomes. Objective: This study aimed to explore utilization of an existing pro-breastfeeding Facebook group, and how utilization influences breastfeeding-related knowledge, attitudes and behaviors. Methods: A mixed methods study was conducted exploring the experiences of participants within a Facebook pro-breastfeeding group. Participants recruited from within this social media group engaged in Online Focus Group Discussions (FGDs) (n=21) and additional individual interviews (n=12). Thematic analysis of qualitative data led to the conceptualization and contextualization of a breastfeeding community of practice (COP). A quantitative survey was then developed to assess the prevalence of these experiences amongst mothers within the group (n=314). Results: Qualitative findings showed an overall sense of community, elaborating on trust, interaction, and the promotion of breastfeeding. Quantitative results showed an extremely high exclusively breastfeeding rate at 6 months (69%), as well as a high percentage of mothers who initiated breastfeeding at some point (91.5%). Further findings show a large majority of mothers reported the group to exhibit specific aspects present within a COP. Conclusions: Results from this study suggest that this pro-breastfeeding Facebook formed an organic online COP. Interaction within the COP positively impacted breastfeeding outcomes. Further examination and exploration of breastfeeding COPs, including using this type of model as a method of lactation support or as a telemedicine framework, is a clear need. Results suggest pro-breastfeeding support groups that form a COP have the potential to positively influence breastfeeding-related outcomes. Ultimately, improved breastfeeding outcomes can lead to better quality of life for mother-infant dyads, including both physical and mental health outcomes.

• Longitudinal MRI as a potential correlate of Exploratory Data Analysis in the diagnosis of Alzheimer disease

  From: JMIR Biomedical Engineering

  Date Submitted: Apr 15, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: Alzheimer’s disease (AD) is a degenerative progressive brain disorder where symptoms of dementia and cognitive impairment intensify over time. Numerous factors exist which may or may no...

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  Background: Alzheimer’s disease (AD) is a degenerative progressive brain disorder where symptoms of dementia and cognitive impairment intensify over time. Numerous factors exist which may or may not be related to the lifestyle of a patient, can trigger off a higher risk for AD. Diagnosing the disorder in its beginning period is of incredible significance and several techniques are used to diagnose AD. A number of studies have been conducted for the detection and diagnosis of AD. This paper reports the empirical study performed on the longitudinal-based MRI OASIS data set. Furthermore, the study highlights several factors which influence in the prediction of AD. Objective: This study aims to examine the effect of longitudinal MRI data in demented and non-demented older adults. The purpose of this study is to investigate and report the correlation among various MRI features, in particular, the role of different scores obtained while MR image acquisition. Methods: In this study, we attempted to establish the role of the longitudinal magnetic resonance imaging (MRI) in exploratory data analysis (EDA) of AD patients. EDA was performed on the dataset of 150 patients for 343 MRI sessions [Mean age ± SD = 77.01 ± 7.64]. T1-weighted MRI of each subject on a 1.5-T Vision scanner was used for the image acquisition. Scores of three features, viz.- mini-mental state examination (MMSE), clinical dementia rating (CDR), and atlas scaling factor (ASF) were used to characterize the AD patients included in this study. We assessed the role of various features i.e. age, gender, education, socioeconomic status, MMSE, CDR, estimated total intracranial volume, normalized whole brain volume and ASF in the prognosis of AD. Results: The analysis further establishes the role of gender in prevalence and development of AD in older people. Moreover, a considerable relationship has been observed between education and socioeconomic position on the progression of AD. Also, outliers and linearity of each feature were determined to rule out the extreme values in measuring the skewness. The differences in nWBV between CDR = 0 (non-demented), CDR = 0.5 (very mild dementia), CDR = 1 (mild dementia) comes out to be significant i.e. p<0.01. Conclusions: A substantial correlation has been observed between pattern and other related features of longitudinal MRI data that can significantly assist in the diagnosis and determination of AD in older patients.

• How to design user-centered health apps. A proposal based on previous successful experiences

  From: Journal of Medical Internet Research

  Date Submitted: Apr 22, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: Different strategies encompassed within mHealth have shown themselves to be effective for maintaining good health or controlling certain diseases. However, there is usually a very high rat...

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  Background: Different strategies encompassed within mHealth have shown themselves to be effective for maintaining good health or controlling certain diseases. However, there is usually a very high rate of abandonment of health applications. Thus, it seems obvious that there is a need for involving the end users (whether they are health professionals, patients or both) in their design process as from the early stages to enable their needs and characteristics to be identified. In this sense, it is common knowledge that focusing on the user permits the consideration of valuable details aimed at making the correct fits between the patient, the technology, and the organization of attention. Objective: To propose a methodology, based on the review of previous successful user experiences in setting up health applications by using qualitative techniques (Focus Groups and Discussion Groups), that includes the participation of information technology and health professionals, and the patients themselves. Methods: An integrative review was made of studies in which a qualitative methodology was employed, Focus and/or Discussion Groups, for the design and development of Health Apps, consulting diverse databases (PubMed, Scopus and Proquest) with the following search strategy: “mHealth AND Apps AND Focus Group OR Discussion Group”. 44 papers were finally included in the review. Results: A proposal structured in 4 sessions of a variable duration was made in which information technology and health professionals and patients have to take part: Composing, Preparing and Organizing Contents (Session 1), Testing Structure and Usability (Session 2), Does the app fit the needs of end users? (Session 3) and Last Testing. Keep on Improving (Session 4). Throughout the sessions, it is proposed to study aspects like previous user experiences in mHealth, the barriers to the adoption of mHealth, interface contents, management and navigability, usability, perceived quality, security and privacy, the capacity to self-manage the disease with the app, ergonomy, glanceability, etc., and specific tools that have been seen to be useful in previous research for measuring these aspects are presented. Conclusions: These work sessions would be based on predominantly qualitative methodologies although, as they evolve, validated questionnaires permitting the assessment of the objectivity of certain technical aspects could be incorporated. With this proposal, a project centered on the end user could be effected, sparking, and responding to, their needs. However, this requires a validation that will be made via their implementation in development of Health Apps, with the subsequent measurement of results in terms of adherence and of an improvement in the clinical variables of the end users.

• Using Goal-directed Design to Create a Mobile Health App for Improving Patient Compliance with Hypertension Self-management: Development and Deployment

  From: Journal of Medical Internet Research

  Date Submitted: Apr 22, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: Hypertension is a lifestyle-induced chronic disease threatening lives of patients. The control of hypertension requires patients’ long-term self-management. Unfortunately, compliance wit...

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  Background: Hypertension is a lifestyle-induced chronic disease threatening lives of patients. The control of hypertension requires patients’ long-term self-management. Unfortunately, compliance with hypertension self-management is low, especially in developing countries. Improvement of patient compliance is premised on meeting their needs. Meanwhile, the use of mobile health is becoming popular in the self-management of chronic diseases. However, few mobile apps were specially designed to meet patients’ needs in hypertension self-management. Objective: The aim of this study was to develop a mobile health app for improving patient compliance with hypertension self-management and evaluate the effectiveness of the app in terms of patient compliance. Methods: The study contained 4 stages. Stage 1 to 3 was the development process. Goal-directed Design method was applied to guide the development. In order to improve the applicability of Goal-directed Design method in chronic disease management, we extracted elements of user models concerned with patient compliance and defined the concrete process for user modeling. In stage 1, personas of hypertensive patients were built using qualitative and quantitative methods. Clustering method based on questionnaires were used to divide patients into different groups. Qualitative interviews were conducted to identify the needs of different groups. In stage 2, several functional modules were defined based on the results from stage 1, in order to meet different groups’ needs. In stage 3, prototypes of functional modules were designed and implemented as a real app. Stage 4 was the deployment process, in which we conducted a pilot study to investigate patient compliance after using the app. Patient compliance was calculated through the number of blood pressure measurement. Besides, qualitative interviews were conducted to learn reasons for the compliance results. Results: In stage 1, patients were divided into 3 groups based on 82 valid questionnaires. 18 patients from different groups (7, 5 and 6) were interviewed and the needs of the groups were summarized as: to improve self-management ability, to enhance self-management motivation and to receive self-management support. In stage 2 and 3, 6 functional modules were designed and implemented based on the personas, and the usability of the app was improved through usability tests. In stage 4, 143 patients were recruited to use different versions of the app for 2 months, the results showed that patient compliance improved as functional modules were added, and finally maintained at a high level (the rate of 0.73). Interview results from 32 patients showed that the design of the app met different needs of patients so that patients were more complied with it. Conclusions: This study developed a mobile health app for hypertension self-management using Goal-directed Design method. The app proved to be effective in improving patient compliance with hypertension self-management.

• Recruiting ambulatory oncology practices and lessons learned

  From: Journal of Medical Internet Research

  Date Submitted: Apr 23, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: Practice-based research is essential to generating the data necessary to understand outcomes in ambulatory care. While there is increased interest in studying ambulatory care given rising...

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  Background: Practice-based research is essential to generating the data necessary to understand outcomes in ambulatory care. While there is increased interest in studying ambulatory care given rising patient volumes and complexity in those settings, little guidance is available on how best to recruit ambulatory practices for research. Objective: The purpose of this paper is to describe facilitators and barriers to recruiting ambulatory oncology practices into a large multi-site study. We also report lessons learned during the recruitment process. Methods: Using a mixed-method design, we sought to recruit 52 ambulatory oncology practices that participate in a state-wide quality improvement collaborative for the quantitative phase. We used four domains of the Consolidated Framework for Implementation Research to describe facilitators and barriers to recruitment. Results: We successfully recruited 28 of the 52 collaborative-affiliated practices, collecting survey data from 2,223 patients and 299 clinicians. Intervention attributes included multi-modal outreach and training activities to assure high fidelity to the data collection protocol. The implementation process was enhanced through interactive training and practice-assigned champions responsible for data collection. External context attributes that facilitated practice recruitment included partnership with a quality improvement collaborative and inclusion of a staff member from the collaborative on our team. Key opinion leaders within each practice who could identify challenges to participation and propose flexible solutions represented internal context attributes. Lessons learned included navigating diverse approaches to human subjects protection policies and delivering incentives to practices, among others. Conclusions: Our experience provides other researchers with challenges to anticipate and possible solutions to common issues. Using the Consolidated Framework for Implementation Research as a guide, we identified numerous recruitment barriers and facilitators, and devised strategies to enhance recruitment efforts. We conclude that researchers and clinicians can partner effectively to design and implement research protocols that ultimately benefit patients who are increasingly seeking care in ambulatory practices. Clinical Trial: N/A

• Effects of mobile app interventions on sedentary time, physical activity and fitness in older adults: systematic review and meta-analysis

  From: Journal of Medical Internet Research

  Date Submitted: Apr 17, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: High sedentary time, low physical activity (PA), and low physical fitness place older adults at increased risk for chronic diseases, functional decline and premature mortality. Interventio...

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  Background: High sedentary time, low physical activity (PA), and low physical fitness place older adults at increased risk for chronic diseases, functional decline and premature mortality. Interventions to reduce sedentary time, increase physical activity and improve fitness could potentially enhance the health and well-being of older adults. However, sustained positive changes in physical activity and sedentary time beyond twelve months have not been consistently achieved through traditional interventions. Mobile apps, applications that run on mobile platforms, may help promote active living. Objective: We aimed to quantify the effect of mobile app interventions on sedentary time, PA and fitness in older adults in this systematic review and meta-analysis. Methods: We systematically searched five electronic databases for trials investigating effects of mobile-app interventions on sedentary time, PA and fitness among community-dwelling older adults aged ≥55 years in September 2018. We calculated pooled standardised mean differences (SMD) in these outcomes between intervention and control groups after the intervention period. We performed a risk of bias assessment and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) certainty assessment. Results: Six trials (486 participants, 67% women; 68±6years) were included (five trials in meta-analysis). Mobile app interventions may be associated with decreases in sedentary time (SMD=−0.49, 95% confidence interval [CI] −1.02, 0.03), increases in PA (505 steps/day (95% CI -80.5, 1092) and increases in fitness (SMD=0.31, 95% CI -0.09, 0.70) in trials ≤3 months and with increases in PA (752 steps/day, 95% CI -146, 1652) in trials ≥6 months. Risk of bias was low for all but one study. The quality of evidence was moderate for PA and sedentary time, and low for fitness. Conclusions: Mobile app interventions have the potential to promote changes in sedentary time and PA over the short-term but results did not achieve statistical significance, possibly because studies were underpowered by small participant numbers. We highlight a need for larger trials with longer follow-up to clarify if apps deliver sustained clinically important effects. Clinical Trial: Prospero protocol CRD42018106195

• Counseling with guided use of a mobile well-being app for students with anxiety or depression: Clinical outcomes of a feasibility trial embedded in a student counseling service

  From: Journal of Medical Internet Research

  Date Submitted: Apr 15, 2019

  Open Peer Review Period: Apr 23, 2019 - Jun 18, 2019

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  Background: Anxiety and depression continue to be prominent experiences of students approaching their university counseling service. These services face unique challenges to ensure that they continue...

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  Background: Anxiety and depression continue to be prominent experiences of students approaching their university counseling service. These services face unique challenges to ensure that they continue to offer quality support to a growing student population and with less resource. The convenience and availability of mobile phone applications (apps) offer innovative solutions to address therapeutic challenges and expand the reach of traditional support. Objective: The primary aim of this study is to report on the outcomes of a feasibility trial in which guided use of a mobile phone well-being app was introduced into a student counseling service and offered as an adjunct to face-to-face counseling. Methods: The feasibility trial utilised a two-arm, parallel non-randomized design comparing counseling alone (Treatment As Usual) versus counseling supplemented with guided use of a mobile phone well-being app (intervention) for 38 university students experiencing moderate anxiety or depression. Students in both conditions received up to 6 sessions of face-to-face counseling within a 3-month period. Students who approached the counseling service and were accepted for counseling were invited to join the trial. Feasibility factors were evaluated including: recruitment duration, treatment preference, randomization acceptability and intervention fidelity. Clinical outcomes and clinical change were assessed with routine clinical outcome measures administered every counseling session and follow-up phases at 3- and 6-months after recruitment. Results: Both groups demonstrated reduced clinical severity by the end of counseling and this was particularly noticeable for depression and social anxiety, whereby students left the clinical boundary they reached at the intake assessment (baseline). By the 6-month follow-up, TAU clients’ (n = 18) anxiety had increased whereas intervention clients’ (n = 20) anxiety continued to reduce and this group difference was significant (GAD-7: (t(22) = 3.46, P = .002). This group difference was not replicated for levels of depression whereby students in both groups continued to reduce their levels of depression by a similar extent at the 6-month follow-up (PHQ-9: t(22) = 1.30, P = .21). Conclusions: Supplementing face-to-face counseling with guided use of a well-being app is a feasible and acceptable treatment option for university students experiencing moderate anxiety or depression. The feasibility trial was successfully embedded into a university counseling service without denying access to treatment and with minimal disruption to the service. This study provides preliminary evidence for using a well-being app to maintain clinical improvements for anxiety following the completion of counseling. The design of the feasibility trial provides the groundwork for the development of future pilot trials and definitive trials embedded in a student counseling service. Clinical Trial: Registration: This trial was registered on 20/06/2016 (Ref: ISRCTN55102899)

• Assessing the diagnostic capabilities of the app DemDx in an acute care setting

  From: JMIR Preprints

  Date Submitted: Oct 7, 2018

  Open Peer Review Period: Dec 30, 2018 - Dec 15, 2019

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  DemDx is a differential diagnosis app for students and junior doctors. Starting with a patient’s presenting complaint the app goes through a step-by-process through history, examination and investig...

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  DemDx is a differential diagnosis app for students and junior doctors. Starting with a patient’s presenting complaint the app goes through a step-by-process through history, examination and investigation findings to an increasingly refined differential diagnosis list until a single most likely diagnosis is reached. The aim of this project was to assess the accuracy of DemDx in an Emergency Department (ED) setting. Anonymised clinical records for 100 patients were retrospectively obtained from the ED in Beth Israel, Boston, USA. This contained the differential diagnoses from the clerking doctor, who performed the initial assessment (D1). The discharge diagnosis was used as the gold standard diagnosis (D2). D1 agreed with D2 in 74.44% of cases while DemDx agreed with D2 in 85.56% of cases (p=0.0003716). When the first, and thus most likely, differential was taken from D1 and DemDx, they agreed with D2 in 20 and 18.8% of cases, respectively (p=0.1428). This demonstration of the clinical accuracy of the app highlights how it can be a useful medical student education tool.